Haryana

Karnal

CC/123/2019

Mrs. Nirmla Devi - Complainant(s)

Versus

DHFL Pramercia Life Insurance Company Limited - Opp.Party(s)

Virender Kumar

11 Apr 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                       Complaint No. 123 of 2019

                                                        Date of instt.05.03.2019

                                                        Date of Decision:11.04.2022

 

Mrs. Nirmla Devi wife of late Shri Ajay Kumar, resident of village Chirao, Tehsil and District Jhajhar.

 

                                               …….Complainant.

                                              Versus

 

1.     DHFL Pramercia Life Insurance Company Limited through its Branch Manager, SCO no.227, Second floor, Sector 12, Part ! Urban Estate, Karnal, Haryana-132001.

 

2.     DHFL Pramercia Life Insurance Company Limited through its Regional Manager, 4^th floor, Building no.9, Tower-B, Cyber City, DLF Phase 3, Gurugram-122002.

 

                                                                   …..Opposite Parties.

 

Complaint under Section 12 of the Consumer Protection Act, 1986 as amended under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

      Dr. Rekha Chaudhary….Member

 

 Argued by: Shri Virender Kumar, counsel for complainant.

                   Shri Abhishek Chaudhary, counsel for OPs.

 

                    (Jaswant Singh President)

ORDER:   

                

                The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 as after amendment under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that Shri Ajay Kumar husband of complainant got his life insured with the OPs, vide policy no.00487844 for a sum assured of Rs.4,23,500/- for the term of 15 years with effect from 31.03.2017 (date of proposal) to 31.03.2031 (date of maturity) for the said scheme/plan. The husband of complainant paid the premium of Rs.38500/- annually. Unfortunately, on 22.08.2017, the husband of complainant had died due to heart attack and information about his death was given to the OPs. After the death of her husband, complainant being nominee, has submitted the claim documents with the OP no.1, but claim submitted by the complainant has not been paid till date. As per the norms or terms and conditions of the Insurance Act, the OPs have to make the payment of the claim within stipulated period but the OPs knowingly and intentionally just to harass the complainant did not make the payment against the said claim to the complainant. OP no.1 has also issued a letter on 20.03.2018 to the complainant for submitting of the certain documents and accordingly the complainant has got submitted the requisite documents to the OPs, but OPs did not bother about the same and repudiated the claim of complainant, vide letter dated 30.05.2018, on the ground that life assured had concealed the true and material facts regarding his health at the time of obtaining the policy in question whereas deceased Ajay Kumar never suffered from any disease or did not conceal any facts regarding the income from the OPs. At the time of death, the husband of complainant was hale and healthy and deposited the premium as per terms and conditions of the policy, but the OPs intentionally did not pay the claim to the complainant. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that life assured has not disclosed the true and material facts regarding his health in the proposal form then the policy of the complainant stands null and void as per section 45 of the Insurance Act. As per terms and conditions of the policy, the husband of complainant has not disclosed true and correct information in the proposal form as he was suffering from and also undergoing treatment for chronic kidney disease. It is further pleaded that all the documents supplied by the insured at the time of insurance have not been found to be genuine as the circumstantial investigations provided the fraud being played upon the OP. The photographs of the insurer i.e. husband of complainant in the proposal form did not match with the identity proof provided by the complainant and also the husband of complainant has insured from multiple insurers. Due to the discrepancies in the proposal form, claim form and the identity proof, the OPs suspected possibility of fraud and initiated an investigation to enquire regarding the death of the insured, for considering the claim of the complainant as the said case was highly suspicious. Enquiry was conducted by the OPs and during investigation it was found that the insured was known case of Chronic Kidney Disease and this fact was confirmed by “Shri Ram Chand Memorial Hospitals Pvt. Ltd., 12 Ashoka Colony, Karnal. It is further pleaded that the insured had declared in the proposal form dated 30.03.2017 that the insured had not availed any other insurance as on that date, on the contrary, the husband of complainant had already availed the insurance policy issued by Bajaj and Aditya Birla sun Life Insurance which had commenced on 30.03.2017. The insured committed mis-statement while availing the insurance policies from the OPs and complainant has raised the claims against the said policies based on untrue facts. Thus, the claim of the complainant was rightly rejected by the OPs. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied by the OPs and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of policy document part-A Ex.C1, copy of policy schedule Ex.C2, copy of premium receipt Ex.C3, copy of claim form Ex.C4, copy of benefit of illustration DHFL Pramerica Smart Income Ex.C5, terms and conditions of the insurance policy Ex.C6, copy of repudiation letter dated 30.05.2018 Ex.C7, copy of letter dated 20.03.2018 by OP to complainant regarding condolence/additional information documents Ex.C8, copy of death certificate of life assured Ex.C9 and closed the evidence on 13.01.2020 by suffering separate statement.

5.             On the other hand, learned counsel for OPs has tendered into evidence affidavit of Mr. Parmal Singh, D.M.-Legal of DHFL Ex.RW1/A, authority letter Ex.R1, copy of insurance policies Ex.R2 to Ex.R4. copy of previous policy details Ex.R5, copy of death claim and death certificate Ex.R6, copy of Gram Panchyat order Ex.R7, copy of voter card of life assured Ex.R8, copy of Aadhar card of life assured Ex.R9, copy of PAN card of life assured Ex.R10, copy of Aadhar card of complainant Ex.R11, copy of PAN card of complainant Ex.R12, copy of ration card Ex.R13 and Ex.R14, bank statement of complainant Ex.R15, affidavit of complainant Ex.R16, copy of Gram Panchyat statement Ex.R17 to Ex.R19, copy of statement of complainant Ex.R20, photograph of complainant Ex.R21, copy of statement of complainant Ex.R22, copy of PAN card and Aadhar card verified report Ex.R23 to Ex.R27, copy of website of Election Commission Ex.R28, copy of death certificate of Ajay Kumar Ex.R29 repeated (Ex.53 and Ex.R67), medical record of Ajay Kumar Ex.R30 to Ex.R45, copy of statement of Gram Panchyat Ex.R46 and Ex.54, identity proofs Ex.R47 to Ex.R51 and Ex.R58 to Ex.62 claim investigation report Ex.R52, copy of statement of complainant Ex.55, copy of matriculation certificate of life assured Ex.R56, copy of statement of account of life assured Ex.57 and Ex.63, copy of email Ex.R64, copy death claim intimation form Ex.R65, copy of death claim form Ex.R66, copy of application by complainant to OP Ex.R68, copy of cancelled cheque of complainant Ex.R69 and closed the evidence on behalf of OPs n 12.01.2022 by suffering separate statement.

6.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties

7.             Learned counsel of complainant, while reiterating the contents of the complaint, has vehemently argued that husband of complainant namely Ajay Kumar (since deceased) had obtained a life insurance policy dated 31.03.2017 and the insured amount was of Rs.4,23,500/-. On 22.08.2017 the husband of complainant had died due to heart attack. Thereafter, complainant being nominee, applied for the insurance claim under the abovesaid policy with the OPs, but OPs refused to pay the same. He further argued that deceased life assured was not having any disease or medical history at the time of obtaining the policy and prayed for allowing the complaint.

8.             Per contra, learned counsel of OPs while, reiterating the contents of written version, has vehemently argued that at the time of obtaining the policy life assured had not disclosed in the proposal form that he had already availed the insurance policies from Bajaj Allianz and Aditya Birla sun Life Insurance from prior to purchase of the policy in question from the OPs. He further argued that during the claim investigation, it was found that the life assured was suffering from Kidney disease and was under treatment for the same. This fact was not disclosed by the life assured, at the time of obtainng of the policy. Learned counsel for the OP relied upon the judgment of Hon’ble Supreme Court in case titled as LIC of India and Anr. Versus Vidya Devi and Anr. 2013 (3) WBLR 674; Stanwant Kaur Sandu Versus New India Assurance Company Ltd. in civil appeal no.2776 of 2002 date of decision 10.07.2009 and Dineshbhi Chandarana and Anr. Versus Life Insurance Corporation and Anr. 20011 (1) CPR 63 and prayed for dismissal of the complaint.

9.             We have duly considered the rival contention of the parties.

10.           Admittedly, the life assured was insured with the OPs for the sum assured of Rs.4,23,500/- and the policy in question was issued on 31.03.2017. It is also admitted that the husband of complainant died during the subsistence of the insurance policy. It is also admitted that complainant is the nominee of the deceased life assured. The claim of the complainant has been repudiated by the OPs, vide repudiation letter Ex.C7, repudiation letter reproduced as under:-

“In the proposal form late Mr. Ajay Kumar had given a declaration that he had made complete, true and accurate disclosure of all the facts and circumstances as may be relevant for the acceptability of the proposal from. However, following questions numbers in the proposal form have been answered as “NO”

48 (ii) Have you ever suffered or are suffering from any of the following”

(3)    Symptoms/Ailment relating to Kidney, Prostate, Hydrocele, Urinary System-No.

It was found that late Mr. Ajay Kumar undergoing treatment for Chronic Kidney Disease prior to the date of application and this information was not disclosed in the said application.

In the proposal form late Mr. Ajay Kumar withheld his previous insurance details at the time of affecting the insurance.

Discrepancies are also noted in photographs and identity proof submitted at the time of proposal.

Also, it was found that late Mr. Ajay Kumar misrepresented his income and occupation details in the proposal form.

Disclosure of this information was material for the company to underwrite the risk on his life. If the true and correct facts pertaining to life insured’s Health Details. Previous insurance details and financial details were disclosed at proposal stage, our underwriting decisions would have been different.

Our liability as an insurer is subject to the terms and conditions of the policy of insurance under which such fraudulent act makes the Contract Void Ab initio. In the light of the above information, we are declining the death claim under above mentioned policy on grounds of fraud.

The premium paid excluding tax of Rs.38,506/-is being refunded towards the full and final settlement for the policy in question”.

11.           The claim of the complainant has been repudiated by the OPs on the ground of concealment of material facts with regard to pre-existing disease and with regard to not to disclose the previous insurance policy at the time of filling the proposal form.

12.           The onus to prove that the life assured was having pre-existing disease at the time filling of the proposal form lies upon the OPs, but OPs miserably failed to prove its version by leading any cogent and convincing evidence. The OPs relied upon the medical report Ex.R30 to R45. As per the abovesaid report the life assured was admitted in Shri Ram Chand Memorial Hospital Pvt. Ltd., Karnal, on 07.08.2017 and discharged on 18.08.2017. The policy in question was purchased by the life assured on 31.03.2017 i.e. very much prior to admission of the life assured. Moreover, in the medical record, it is nowhere mentioned that life assured was having any disease prior to admission in the said hospital and was under the treatment of any hospital. Hence, we found no substance in the contention of the OPs.

12.           The second ground for repudiation of the claim is that at the time of obtaining the present insurance policy, the life assured has already availed two insurance policies. It is evident from document Ex.R5, that life assured had availed two other insurance policies i.e. one from Bajaj Allianz on 03.03.2017 for the sum assured Rs.3,00,000/- and second from Aditya Birla Capital Insurance Company on 11.03.2017 and the sum assured Rs.10,00,000/-, but this fact has not been disclosed by the life assured at the time of obtaining the present insurance policy. All the three policies have been taken by the life assured in the month of March, 2017. Though OPs have failed to prove its version with regard to pre-existing disease of the life assured yet it creates the doubt in our mind that the life assured was having any disease at that time as the reason for obtaining three different policies within one month is best known to the policyholder. As per Section 45 of the Insurance Act, 1938 it is mandatory for a policyholder to declare the other policy or policies held by him/her in the claim form with the claiming insurer. In this regard, we are fortified with the observations of Hon’ble Supreme Court in case titled as Branch Manager, Bajaj Allianz Life Insurance Company Ltd. and others Vs. Dalbir Kaur in civil appeal no.3397 of 2020 decided on 09.10.2020 wherein Hon’ble Supreme Court held that a policy of insurance is governed by the principles of utmost good faith. The suppression of material facts by the insured/policyholder entitles the OP to repudiate the policy under section 45 of the Insurance Act. The said authority is fully applicable to the facts of the present case. In the present case life assured has concealed the true and material facts at the time of obtaining the policy in question. Hence, we are of the considered view that OPs have rightly repudiated the claim of the complainant. Thus, we found no deficiency in service on the part of the OPs while repudiating the claim of the complainant.

13.           Thus, as a sequel to abovesaid discussion, we found no merits in the present complaint and the same is hereby dismissed with no order as costs. The parties concerned be communicated the order accordingly, and the file be consigned to the record room, after due compliance.

Announced

Dated: 11.04.2022    

                                                               

                                                              President,

                                                 District Consumer Disputes

                                                 Redressal Commission, Karnal.

 

 

                 (Vineet Kaushik)       (Dr. Rekha Chaudhary)

                      Member                       Member