Haryana

StateCommission

A/1383/2018

TATA AIA LIFE INSURANCE CO. LTD. - Complainant(s)

Versus

DEEPAK SINGH - Opp.Party(s)

S.C.THATAI

05 Aug 2022

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                                                 

                                                         First Appeal No.1383 of 2018

                                                 Date of Institution: 20.12.2018

                                                               Date of Decision: 05.08.2022

 

1. Tata AIA Life Insurance Company Limited through Sh.Harsimran Singh, Manager (Legal), Regd. & Corporate Office : 14^th Floor, Tower A, Paninsula Business Park, Senapati Bapat Marg, Lower Parel Mumbai 400013.
2. Tata AIA Life Insurance Company Limited through Sh.Harsimran Singh, Manager (Legal), 1^st and 3^rd Floor, SCO 254, Ist Floor Sector-12, Part-1, Karnal 132001.

…..Appellants

Versus

Deepak Singh S/o Sh.Mahipal Singh R/o VPO, Zafarpur, Tehsil Barara, Distt. Ambala.

…..Respondent

CORAM:    S.P.Sood, Judicial  Member

                    Suresh Chander Kaushik, Member

                   

Present:-    Mr.S.C.Thathai, Advocate for the appellants.

                   Mr.Govind Chauhan, Advocate for the respondent.

 

                                                 ORDER

S P SOOD, JUDICIAL MEMBER:

          The present appeal No.1383 of 2018 has been filed against the order dated 14.11.2018 of the District Consumer Disputes Redressal Forum, Karnal (In short  now “District Commission”) in complaint case No.107 of 2017, which was allowed.

2.       The brief facts of the case are that the complainant purchased  an insurance policy of TATA AIA Life Mahalife Gold bearing No.C083770713 dated 27.12.2013 covering certain eventualities and paid a sum of Rs.93,209/- as annual premium.  As per the policy, if complainant became 100% disabled then said insurance company will pay a sum of Rs.10/- lacs.  On 01.04.2014, an accident took place when complainant alongwith his relatives had reached near Chandigarh marriage palace. His relative Rajbir Singh died away while still on the way of hospital, whereas he became permanently disabled and the doctor of Civil Hospital Ambala have issued a disability certificate to the complainant in this regard. DDR No.28(A) dated 01.04.2014 was registered in PS Mulana Distt. Ambala.  After this development complainant submitted relevant documents for seeking claim and OPs assured that they would release the insurance amount on the basis of disability certificate.  However despite his repeated requests to the OPs to pay Rs.10/- lacs but OPs did not oblige him.  Ultimately on 26.06.2015 the OPs repudiated his claim on the false and frivolous grounds. On 25.06.2015, the OPs transferred the installment amount in the bank account of complainant.  Faced with this situation, he sent legal notice dated 07.11.2016 but OPs did not respond. Thus there was deficiency in service on the part of the OPs, hence the complaint.

3.      O.Ps. filed the written version and submitted that  on 13.12.2013 complainant has submitted a duly signed proposal form for purchase of insurance policy and paid an advance initial premium of Rs.93,209/- vide cheque No.1 dated 12.12.2013.  The complainant has opted for two riders i.e. “Accidental Death and Dismemberment Rider” and waiver of premium rider.” But complainant concealed the material facts related to his treatment in Max Hospital Mohali prior to issuance of the policy.  On 29.01.2015 a Total & Permanent Disability claim form was submitted with the OPs as he had met with motor vehicle accident on 01.04.2014 resulting into a spinal cord injury rendering him permanently disabled totally. As per material record of PGI, Chandigarh, the complainant was a known case of coronary artery disease and had already underwent angiography previous year.  It also revealed that he got admitted in Max Super Speciality Hospital Mohali on 01.03.2013 for chest pain and had undergone angiography and was finally diagnosed with CAD-ACS Unstable Angine. He has also a history of bullet injury two years back. So forall these reasons the claim of the complainant was rightly repudiated vide letter dated 26.06.2015.  Thus there was no deficiency in service on the part of the OPs.  Besides this other objections about maintainability of complaint, accruing cause of action, concealment of material facts etc. were also raised and requested to dismiss the complaint.

4.      After hearing both the parties, the learned District Commission, Krnal has allowed the complaint vide order dated 14.11.2018. Relief para is reproduced below:-

“As a sequel to the foregoing discussion, we accept the present complaint and direct the OPs to pay Rs.10,00,000/- as insured amount to the complainant with interest @ 9% per annum from the date of filing the complaint till its realization. We further direct the OPs to pay Rs.5500/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses.”

5.      Feeling aggrieved therefrom, O.Ps.-appellants have preferred this appeal.

6.      This argument have been advanced by Sh.S.C.Thathai, learned counsel for the appellant as well as Sh.Govind Chauhan, learned counsel for the respondent.  With their kind assistance entire record of the appeal including that of the District Commission led on behalf of  the parties has also been properly perused and examined.

7.      Learned counsel for the appellants vehemently argued that the complainant has opted for two riders i.e. “Accidental Death and Dismemberment Rider” and waiver of premium rider.” The complainant has concealed the material facts related to his treatment in Max Hospital Mohali prior to issuance of the policy.  The insurance policy was issued on 27.12.2013, whereas he got admitted in Max Super Speciality Hospital Mohali on 01.03.2013 for chest pain and had undergone Angiography and finally diagnosed with CAD-ACS Unstable Angine. He has also a history of suffering a bullet injury two years back. Further argued that on 29.01.2015, the complainant had submitted the Total & Permanent Disability claim form, but, OPs did not pay the insured amount.  He met with motor vehicle accident on 01.04.2014 causing him a spinal cord injury, which rendered him disabled. As per material record of PGI, Chandigarh dated 01.04.2014, the complainant was a known case of coronary artery disease and underwent angiography previous year at Mohali. The claim of the complainant was rightly repudiated vide letter dated 26.06.2015. The complainant was not entitled for any relief as prayed for. He placed his reliance upon order of Hon’ble Supreme Court titled LIC of India Vs. Manish Gupta 2019(2) RCR (Civil) 906 and opinions of Hon’ble National Commission in  LIC Vs. Nita Bhardwaj 2014 (1) CPJ 409, LIC Vs. Maya Devi 2016 (2) CPJ 396 and LIC Vs. Ramamani Patra & Anr. 2015(3) CLT 487.

8.      In rebuttal, learned counsel for the complainant-respondent vehemently argued that he purchased insurance policy on 27.12.2013 and paid annual premium of Rs.93209/-  to the OPs and as per the policy if complainant became 100% disabled then said insurance company will pay a sum of Rs.10/- lacs to him. On 01.04.2014 accident took place and in this accident, one of his relatives  Mr.Rajbir Singh died away while being taken to the hospital.  He submitted all the  documents with the OPs, but, they illegally repudiated the claim of the complainant on  26.06.2015.  The
District commission rightly allowed the complaint. The complainant was entitled for the claim amount as prayed for. He placed his reliance upon order of Hon’ble National Commission titled Abdul Latheef and others vs LIC of India and Ors. Law Finder Doc Id#747264.

9.      It is not disputed that  On 27.12.2013, the complainant purchased the insurance policy alongwith two riders with the OPs. During the subsistence of the insurance policy, accident took place on 01.04.2014 and complainant suffered injuries and as per the report of doctors, he became totally disabled. Ex.C-7 of 17.09.2014 also shows the  same.  Perusal of Ex.OP-8 Angiography Report reveals that this procedure was carried out upon complainant on 01.03.2013.  Ex. OP-9 Discharge summary also reveals that date of admission of the complainant was 01.03.2013 in Max Hospital before the issuance of policy. The report also shows that complainant was admitted with the complaint of chest pain and treating doctor reported in the discharge summary that  flow of blood in coronary artery was slow. The report Ex. OP-8 and OP-9 did not reveal that complainant was suffering from any pre-existing disease.  He was admitted in the Max hospital following some discomfort which does not amount to pre-existing disease.  The case laws relied upon by the counsel for the appellants are not relevant because the facts and circumstances of the case are different to that of the present one. The case law relied by the respondent is relevant as in the case in hand the complainant consulted the doctors for chest pain and as per the medical literature, it is a condition of mind and not to be called as pre existing disease or non disclosure. The concealment of the facts is not  made out.  The repudiation of the claim is not justified. The complainant became 100% disabled due to accident. The learned District Commission rightly allowed the complaint. Since the opposite parties-appellants have paid Rs.93,146.11/- to the complainant on 25.06.2015, the complainant is entitled for the remaining claim amount i.e. Rs.9,06,854/-.  Rest of the impugned order is maintained. With the above modification, the appeal stands disposed off.

10.    The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant-respondent against proper receipt and identification in accordance with rules, after the expiry of period of appeal and revision, if any filed in this case.

11. Applications pending, if any stand disposed of in terms of the aforesaid judgment.

12. A copy of this order be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986/2019. The order be uploaded forthwith on the website of the commission for the perusal of the parties.

13. File be consigned to record room alongwith a copy of this order.

 

05th  August, 2022 Suresh Chander Kaushik                        S. P. Sood                                                    Member                                                         Judicial Member                            

 

S.K

(Pvt. Secy.)