| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C. No. 78 of 15-03-2018 Decided on : 9-12-2021 Roop Sat S/o Late Amarjit Singh Atam Parkash W/o Late Amarjeet Singh - Both R/o Village Balahar Vinju, Tehsil & District Bathinda. Amarjot Kaur D/o late Amarjit Singh now W/o Harmesh Singh R/o V. Rai Ke Kalan, Tehsil & District Bathinda. .......Complainants
Versus HDFC Life, Gurukashi Marg, Bathinda, through its Manager .......Opposite party
Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Kanwar Sandeep Singh, President Sh. Shivdev Singh, Member. Smt. Paramjeet Kaur, Member Present For the complainant : Sh. Jaswinder Singh Tugwali, Advocate For opposite party : Sh. Vinod Garg, Advocate. ORDER Kanwar Sandeep Singh, President The complainants Roop Sat & others (here-in-after referred to as complainants) have filed this complaint U/s 12 of Consumer Protection Act, 1986 (Now C.P. Act, 2019, here-in after referred to as 'Act') before this Forum (Now Commission) against HDFC Life (here-in-after referred to as opposite party). Briefly stated, the case of the complainants is that father of the complainant namely Amarjit Singh purchased life Insurance Policy vide policy No. 19242426 under Plan HDFC SL Progrowth Super-II from the opposite party and deposited Rs, 25000/- on 12-04-2017 as premium. It is alleged that on 23-11-2017 Amarjit Singh died and all the formalities were completed. The complainants submitted claim against the above said policy with the opposite party. The opposite party rejected the claim of the complainants on 06-01-2018 with the observation that life assured was suffering from Asthma prior to policy. It is pleaded that Life assured was not suffering from any disease and the opposite party wrongly rejected the claim of complainants. The complainants further alleged that they made repeated visits to the office of the opposite party and requested them to pay insurance claim, but to no effect. There is deficiency in service on the part of the opposite party in rejecting the claim. Hence, this complaint. On this backdrop of facts, the complainants have prayed for directions to the opposite party to pay claim amount of Rs, 5,00,000/- along with interest till the date of payment in addition to compensation of Rs,1,00,000/- for mental tension and harassment and Rs, 5500/- as litigation expenses. Upon notice opposite party appeared through counsel and contested the claim of the complainants by filing written reply raising legal objections that the complainant has concealed material facts and documents from this Commission as well as the opposite party. It is pleaded that the complainants have concealed the fact that the case of the complainants was got thoroughly investigated by the opposite party through KLCR Investigations Pvt Limited and it was found that the life assured Amarjit Singh was suffering from Asthma prior to the policy and this fact was not disclosed in the application dated 12-04-2017. He had been taking treatment from Dr. Baljinder Singh of Sadhu Singh Hospital for Asthma for the last three years. Had this information been provided to the opposite party at the time of applying for the insurance, the opposite party would have declined the application. Since, this vital information as not provided to the opposite party at the time of applying for the insurance policy, as such the opposite party did not admit any claim under the policy No. 19242426 The claim was repudiated vide letter dated 06-01-2018 due to incorrect information and non disclosure. It is further pleaded that it is mentioned in the policy that your policy is based on the application and declaration which you have made to us and other information provided by you/on your behalf. However, if any of the information provided therein is incomplete or incorrect,we reserve the right to vary the benefits, which may be payable and further if there has been non-disclosure of a material fact, section 45 of the Insurance Act applies. Thus, the opposite party was led to issue the above policy on the basis of false information and concealment of material facts regarding pre-existing disease which rendered the contract of insurance under the policy to be void ab-initio. However, a sum of Rs. 23,173.31 was paid by credit to the account of the complainant as fund value. Further legal objections are that the complainant has got no cause of action or locus standi to file the present complaint; that the complainant has not disclosed nor impleaded all the legal heirs of deceased Amarjit Singh in original complaint and that the complaint is not maintainable. On merits, the opposite party admitted purchase of policy by Sukhdev Singh in the name of Amarjit Singh and payment of premium. Sukhdev Singh and Amarjit were aware of the fact that deceased Amarjit Singh was suffering from Asthma but still, purchased the insurance in order to get wrongful gain. It is pleaded that sum assured was Rs. 2,50,000/- and not Rs, 5,00,000/- as claimed by the complainant. It is admitted that the claim was rejected vide letter dated 06-01-2018 as the life assured was suffering from Asthma prior to policy, but the same was not disclosed in the application for purchase of policy. It is denied that the complainant is entitled to any claim of Rs.5,00,000/- or compensation of Rs. 1,00,000/- or Rs, 5500/- as litigation cost, as alleged. After denying the all other averments of the complainant, the opposite parties prayed for dismissal of complaint. In support of their complaint, the complainant tendered into evidence affidavit of Roop Sat dated 23-07-2018 (Ex.C-1) photocopy of death certificate (Ex.C-2), photo copy of receipt (Ex.C-3) ,photo copy death claim (Ex.C-4), photocopy of Aadhar card (Ex.C-5) photo copy proposal forms ( Ex.C-6 to C-9) photo copy illustration (Ex.C-10 to C-12), photo copy letter (Ex.C-13), photocopy of policy documents ( Ex.C-14 to C-38) photocopy of death claim form (Ex.C-39 to C-51) photo copy of investigation report (Ex.C-52 to C-55), photocopy of Aadhar cards (Ex.C-56 & C-57)photo copy of prescription (Ex.C-58), photocopy of photographs (Ex.C-59 to C-62) and closed evidence. To rebut the evidence of the complainants, opposite party tendered into evidence photocopy of illustration (Ex.OP-1/1), photocopy of proposal form (Ex.OP-1/2) photocopy of policy documents containing pages 1 to 28 (Ex.OP-1/3) affidavit of Arpit Higgins, Manger Legal dated 25-04-2019 (Ex.OP-1/4) photocopy of letter ( Ex.OP-1/5 ) affidavit of Pardeep Aggarwal dated 13-1-2018 ( Ex.OP-1/6) photocopy of investigation report dated 22-01-2018 containing 1 to 7 pages ( Ex.OP-1/7) and closed evidence. We have heard learned counsel for the parties and gone through the record. These are undisputed facts between the parties that father of the complainant namely Amarjit Singh purchased life Insurance Policy vide policy No. 19242426 under Plan HDFC SL Progrowth Super-II (Ex. C-14) from the opposite party and deposited Rs. 25,000/- on 12-04-2017 as premium. On 23-11-2017 Amarjit Singh died, complainants submitted claim and opposite party repudiated the claim of the complainants on 06-01-2018 (Ex. C-4) with the observation that life assured was suffering from Asthma prior to policy and this fact was not disclosed in the application dated 12-4-2017. The plea of the opposite party is that the case of the complainants was got thoroughly investigated through KLCR Investigations Pvt. Limited and it was found that the life assured Amarjit Singh was suffering from Asthma prior to the policy and this fact was not disclosed in the application dated 12-04-2017. He had been taking treatment from Dr. Baljinder Singh of Sadhu Singh Hospital for Asthma for the last three years. Ex. OP-1/7 is the report of KLCR Investigation Pvt. Ltd., This document reveals that cause of death of Amarjit Singh, LA is mentioned as 'HEART ATTACK'. In the further details under the heading - “Suspicious Points”, the said Investigator has mentioned that during investigation in this case, we found insured had suffered from asthma problem for last three years. He had taken treatment from Dr. Sadhu Singh Hospital. The investigator has further mentioned that – we visited Dr. Sadhu Singh Hospital met with Dr. Baljinder Singh who confirmed that insured had taken day care treatment many time from last three years. Written Statement attached. Written Statement/Certificate issued by above said hospital on 19-1-2018, stamped and signed by Dr. Baljinder Singh, B.A.M.S.(Pb), wherein it is mentioned that deceased Amarjit Singh was under his observation for the last 3 years and he visited his hospital for day care. The above said evidence on the basis of which, the opposite party has repudiated the claim of complainants, does not reveal any chronic disease which has been concealed by deceased Amarjit Singh. Moreover, although it is not proved on file that deceased Amarjit Singh was suffering from Asthma yet Asthma is not the cause of his death as he died due to heart attack. The opposite party has not produced any evidence to prove that deceased Amarjit Singh ever admitted in any hospital and took treatment for Asthma. It has been specifically mentioned by the said Investigator that Cause of Death is Heart Attack. Ex. C-4 is the letter dated 6-1-2018 vide which the opposite party has conveyed to complainants that from investigations, it was established that Life Assured was suffering from Asthma prior to policy but the opposite party has neither brought on file any treatment record nor filed affidavit of treating doctor. Ex. C-4 nowhere reveals that patient was ever admitted for Asthma treatment. The opposite party has not brought on file any evidence to the effect that said disease, if any, had any nexus with the death of Life Assured. It seems that just to decline the claim of the complainants, the opposite party has manipulated things. Hon'ble State Commission, in CC No. 234 of 2017 decided on 22-3-2018 case titled Manish Goyal Vs. Max Bupa Health Insurance Company, has held that : “Insurance claim – Rejected on ground that insured not disclosed the pre-existing disease and doctor recorded the past history of illness – Age of insured was more than 45 years at the time policy issued – No medical examination got conducted by Insurance Company – Held, if the opposite parties themselves, failed to adhere the instructions issued by Insurance Regulatory and Development Authority of India (IRDAI), by putting the insured to thorough medical examination, being her age more than 45 years, and were interested in collecting premium from the complainant, as such, now at this stage, they cannot evade their liability. Complaint partly allowed.” Keeping in view the facts, circumstances and the evidence placed on file by the parties, this Commission is of the considered opinion that deceased Amarjit Singh was not suffering from Asthma or he concealed any pre-existing disease from the opposite party while obtaining Insurance Policy in question and the repudiation of claim of the complainants on this ground amounts to deficiency in service on the part of the opposite party. The complainants have claimed amount of Rs. 5,00,000/- being Sum Insured of Life Assured Amarjit Singh, but a perusal of policy schedule (Ex. C-14) reveals that Sum Insured is Rs. 2,50,000/- and as per Schedule of Benefits (Ex. C-15) Sum Assured in case of Death Benefit is Rs. 2,50,000/-. As per Ex. C-30 in case of Death Benefit - Sum Assured plus total fund value. The opposite party has already paid Rs. 23,173.31 being fund value to the complainants. Therefore, complainants are entitled to Sum Assured Rs. 2,50,000/- with interest alongwith some amount of compensation on account of harassment suffered at the hands of the opposite party without any fault on their part. In the result, this complaint is partly allowed with Rs. 10,000/- and cost and compensation. The opposite party is directed to pay Rs. 2,50,000/- to complainants (in equal shares) with interest @9% p.a from the date of repudiation i.e. 6-1-2018 till payment. The compliance of this order be made by the opposite party within 45 days from the date of receipt of copy of this order. The complaint could not be decided within the statutory period due to heavy pendency of cases.
Copy of order be sent to the parties concerned free of cost and file be consigned to the record. Announced : 09-12-2021 (Kanwar Sandeep Singh) President (Shivdev Singh) Member (Paramjeet Kaur) Member
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