Delhi

East Delhi

CC/137/2018

HIMANSHU - Complainant(s)

Versus

HDFC STANDRED LIFE INS. - Opp.Party(s)

18 Jul 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO. 137/2018

In the Matter of:-

	Himanshu S/o Late shri krishan kumar wadhera R/o H.No. 244-22, Gali No.3 School Block, Talab Chowk, Mandawali, New Delhi-110092 Also at: 183, Tanda Nagar, Johripur, Dayalpur North East, Delhi-110094	….Complainant
Versus
1	HDFC Standard Life Insurance Company Ltd. SN G1 to G9 Ground Floor, GE Sagar Plaza PN-19, Vikas Marg, Laxmi Nagar Delhi-110092.	……OP1
2	HDFC Standard Life Insurance Company Ltd. R/o Lodha Excelus, 13th Floor, Appolo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai-400011	…….OP2
3	HDFC Standard Life Insurance Company Ltd. Branch Office:- B-3/6, Ground Floor, Asaf Ali Road, Next to HP Petrol Pump, New Delhi-110002	…..OP3

 

  Date of Institution: 24.04.2018

Judgment Reserved on: 08.07.2022

Judgment Passed on: 18.07.2022

QUORUM

Sh. S.S. Malhotra (President)

Ms. Ritu Garodia (Member) – on leave

Sh. Ravi Kumar (Member)

 

Order By: Shri S.S. Malhotra, President

 

JUDGEMENT

1. Complaint pertains to deficiency in service on the part of OP in repudiating the claim of complainant. w.r.t. not paying the insured amount to the extent of Rs.6,65,000/- for which his father had obtained the policy of OP w.e.f. 18.05.2017 to 17.05.2027. 
2. Brief facts as stated by the complainant in the complaint are that his father Shri Krishan Kumar Wadhera took an Insurance Policy vide policy No. 19287042 namely HDFC SL ProGrowth Plus and paid Rs.95,000/- as premium for 10 years and  the said policy was effective from 18.5.2017 to 17.5.2027 and he was assured that in case of any mishappening, the complainant or his beneficiaries/nominee(s) would be entitled to get insured amount  Rs.6,65,000/- The father of the complainant fell ill on 27.1.2018 and was taken to Max Super Spatiality Hospital where he was under the treatment of Doctor Ketki Siroha but unfortunately his father expired on the same day due to hypoglycemia. The OP was informed about this fact who required certain documents i.e. death certificate, claim form & documents related to treatment, which were provided to OP in due time but the OP transferred only an amount of Rs.85577/- and repudiated the claim of the complainant on the ground that the father of the complainant had expired due to low sugar and this facts was concealed by the complainant at the time of filling up of the proposal form and therefore, the claim was rejected. Complainant issued a legal notice dated 3.4.2018 to OP demanding actual insured amount alongwith interest @18% p.a. and other charges. The said legal notice was duly served upon the OP but OP in its reply denied to pay the actual claim amount to the complainant. Ultimately, having no option left, the complainant has filed the present complaint claiming deficiency of service with the prayer to direct the opposite party to pay the claim amount of Rs.6,65,000/- to the complainant alongwith interest @18 per annum till realization, pay Rs.5,00,000/- on account of  deficiency in service, mental agony and harassment, pay litigation charges Rs.50,000/- and any other relief(s), which this Hon'ble Commission may deem fit and proper.
3. The OP was served and has filed its reply taking preliminary objections inter alia stating that the complaint is not maintainable as the complaint doesn’t qualify the ingredients of a valid complaint as envisaged in section 2(1)(c) of the CPA, 1986, there is no cause of action that have ever arisen in favour of the complainant or against the OP, the complainant has not come to this Forum with clean hands and has concealed true facts and he had not disclosed in the claim form w.r.t the fact that his father was suffering from diabetes at the time of filling of the policy proposal form. The deceased father of complainant had obtained the policy by misrepresentation and by concealing actual facts pertaining to his health as the patient was suffering from diabetes and urinary tract infection disease prior to Risk Commencement Date (RCD) [i.e. Pre-existing Disease] which was not declared in the proposal form and thus obtained the subject insurance policy on the basis of false declaration and concealing/suppressing actual and material facts regarding his health. Hence, the said claim made by the complainant has rightly been repudiated by the Opposite Parties vide letter dated 21.3.2018. Thus, the present complaint deserves to be dismissed. On merit almost all the facts stated in preliminarily objection are reiterated and it is prayed the complaint be dismissed.
4. The complainant has filed rejoinder to the written statement and has denied the contents of preliminary objection by stating that the complainant has filed this complaint being aggrieved. Complainant is a consumer within definition under section 2(1)(c) of the Consumer Protection Act. It is denied that there is no cause of action or that the deceased father of the complainant had concealed material facts regarding his health. It is stated that his father had never been suffering from any ailment like diabetes or urinary infection. It is also denied that any doctor has given any certificate w.r.t. pre-existing ailment of diabetes and OP have failed to file any document to prove that deceased father of complainant was suffering from pre-existing ailment.
5. As far as merits are concerned, ‘the contents of written statement are denied and it is prayed that complaint of the complainant be allowed.
6. The complainant has filed his own evidence by way of affidavit and the OP has filed its evidence by way of affidavit of shri Ankush Saini, Dy. Manager-Legal of the OP stating that death claim filed by the complainant is not payable owing to suppression of material facts by the DLA.  Along with the evidence a copy of authorization letter has been exhibited as OPW1/1, copy of policy document exhibited as Ex.OPW-1/2, true copies of the documents establishing pre-existing disease of the Life Assured, filed on record are collectively exhibited as Ex.OPW-1/3 (colly), copy of repudiation letter dated 21.3.2018 exhibited as Ex.OPW-1/4, copy of the reply dated 7.4.2018 exhibited as Ex.OPW-1/5.  The OP credited the fund value of Rs.85,577/- to the account of the complainant. The death claim for Rs.6,65,000/- was repudiated by the OP vide letter dated 21.3.2018 for suppression and concealment of material facts regarding his health by the DLA in the proposal form. It is further stated that OP have correctly informed the complainant that the death claim is not payable to the complainant in the facts and circumstances of the case. In view of the facts and circumstances of the case, the OP have acted in accordance with the terms and conditions of the policy.
7. The Commission has heard the arguments and also gone through the written arguments filed by the parties.
8. The facts in nutshell are that father of the complainant got a policy from the OP which was valid on the date when he fell ill and which was valid for a period of 10 years and when his father fell ill and was taken to Hospital,  where his father could not survive and his death claim for an amount of Rs.6,65,000/- i.e. insured amount was denied on the ground that the father of the complainant has concealed the material fact with respect to pre existence ailment of hypoglycemia, and since it was a pre existing ailment which was not disclosed by the complainant and as such the claim was repudiated.
9. Apart from this bald allegation the OP has not filed any document on record which may show and co-relate that the father of the complainant had been suffering from this disease on the date when the insurance policy was taken.  What is the basis of the information with the OP that the father of the complainant had been suffering from some ailment previously or at least on the date of taking the policy has not been explained.  In the repudiation letter dated 21.03.2018 the only averment which the OP has made is that from the investigation it was established that the insured was suffering from diabetes and urinary tract infection prior to the policy which was not disclosed by the insured How and by whom, such investigation was conducted and who informed the OP with respect to such ailment or what certificate of which doctor the OP got during their investigation have not been placed on record to get their document appreciated.  Not only this, such facts have not been disclosed by the OP in the written statement and in absence of corroborating of such investigation with the prescriptions etc. (current, new or previous) of the father of the complainant as might have been issued by the hospital where the insured was admitted,  the contention of OP cannot be appreciated nor the same would help the OP to prove its contention and therefore it appears that such a bald statement have been made by the OP without any basis.  The disease like infection or diabetes have been otherwise classified as common life Diseases and then non-mentioning of such ailment  in the proposed form have already been held to be not prejudication.  Therefore, the Commission is of the opinion that comp. has been able to prove that there is deficiency and service by the OP in repudiating the insurance claim of the comp. in not refunding the amount of Rs.6,65,000/-. 

1. However, it is a matter of record that OP has refunded an amount of Rs.85,577/- to the Complainant therefore, this court hereby orders as follows:

• OPs would pay Rs.579423/- to the Complainant along with interest @ 9% p.a. from the date of filing the complaint,
• OPs would also pay Rs. 25,000/- as compensation towards mental pain and agony and also Rs. 11,000/- litigation expenses. 

This order be complied with within 30 days from the date of receipt of the order.

3. opy of the order be supplied / sent to the parties free of cost as per rules.

File be consigned to Record Room.

Announced on 18.07.2022

 

On leave

(Ritu Garodia) Member

(Ravi Kumar) Member

(S.S. Malhotra) President