DISTRICT CONSUMER DISPUTES REDRESSAL FOR`UM, BATHINDA.

CC.No.268 of 12-06-2012

Decided on 21-11-2012

Darshana Devi aged about 58 years wd/o Sh. Parshotam Lal s/o Amar Nath r/o # 4645, Gali No.2, Nai Basti, Bathinda.

........Complainant

Versus

1.ICICI Prudential Life Insurance Co. Ltd., Regd. Office: ICICI Prulife Towers, 1089, Appasaheb Marathe Marg, Prabhadvi, Mumbai-400 025 (India), through its Managing Director/Chairman.

2.ICICI Prudential Life Insurance Co. Ltd., The Mall, Bathinda, through its Branch Manager.

.......Opposite parties

Complaint under Section 12 of the Consumer Protection Act, 1986.

QUORUM

Smt. Vikramjit Kaur Soni, President.

Sh.Amarjeet Paul, Member.

Smt. Sukhwinder Kaur, Member.

Present:-

For the Complainant: Sh.Rakesh Mangla, counsel for complainant.

For Opposite parties: Sh.Ashok Bharti, counsel for opposite parties.

ORDER

VIKRAMJIT KAUR SONI, PRESIDENT:-

1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act, 1986 as amended upto date (Here-in-after referred to as an 'Act'). In the instant complaint the complainant alleged that on the allurement of the various advertisements published in the newspaper and shown on T.V by the opposite parties and on approaching of their agent, the husband of the complainant Parshotam Lal has purchased the life insurance policy from them in July, 2010. The said agent has not disclosed any terms and conditions and exceptions attached to the said policy and took the signatures of the husband of the complainant on the various blank papers and blank printed forms and after obtaining all the requisite documents, husband of the complainant gave a cheque of Rs.50,000/- to the agent and he assured that the policy documents shall be supplied by the opposite parties to him within a day or so and disclosed the sum assured as Rs.2,50,000/-. The said agent also conveyed that in case the life assured did not agree with the terms & conditions of the said policy, a free look option will be given to him to cancel the said policy and the premium deposited by him shall be refunded to him. The complainant further alleged that the said agent did not ask any questions from her husband about his health or any treatment/consultation from any doctor. As per the general practice, they used to get the medical examination if the sum assured exceeds Rs.10 lacs. The policy documents containing terms & conditions were never supplied by the opposite parties despite repeated enquiries and all the times, they and their agent conveyed that the said policy shall be supplied very soon and free look period shall commence from the date of the receipt of the said policy. On 25.8.2010, the deceased life assured Parshotam Lal felt sudden severe chest pain and he was taken to Jindal Heart Institute & Infertility Centre where deceased life assured remained admitted till 26.8.2010 and on the same day the Jindal Heart Institute & Infertility Centre discharged him with an advise to transfer the patient to some higher centre for further management as his stay with their hospital was uneventful and accordingly, he was taken to DMC, Ludhiana and was got admitted in DMC on dated 27.8.2010 and the doctors of DMC prepared the LAMA summary on 28.8.2010 and discharged him on 28.8.2010 and ultimately, he died on 29.8.2010 at Bathinda, due to sudden severe chest pain. The claim was lodged with the opposite parties and the complainant has completed all the requisite formalities and during the investigation, their concerned official again obtained her signatures on the various blank papers and blank printed forms and assured her that her lawful claim shall be paid by them very soon. The opposite parties vide their letter dated 21.3.2011 has repudiated the claim of the complainant on the pretext that during processing, they have noticed 'Life Assured was suffering from Non Insulin Dependant Diabetes Mellitus since 2 years. Further, it is also noted that Life Assured underwent blood sugar tests in May 2010 & July, 2010, which were adverse' and the medical history, which was prior to the proposal, was not disclosed in the proposal form. The complainant alleged that the opposite parties never asked any questions regarding the health of the complainant's husband. The deceased life assured was never hospitalized about the alleged disease before issuing the cheque in favour of the opposite parties on account of the premium of the insurance policy in question. No terms and conditions or policy was issued by the opposite parties till the death of deceased life assured. The deceased life assured was not suffering from any such disease, but the opposite parties have failed to consider the fact that there was no nexus between the cause of the death of the deceased and the alleged disease from which the deceased life assured was alleged to have been suffering and concealed from the opposite parties prior to signing the alleged proposal form. The complainant has got served a registered legal notice to the opposite parties, but to no effect as neither they had made the payment of the claim amount nor replied the said legal notice. Hence the complainant has filed the present complaint to seek the directions to the opposite parties to pay the sum assured of Rs.2,50,000/- and Rs.50,000/- on account of fund value alongwith interest, cost and compensation.

2. Notice was sent to the opposite parties. The opposite parties after appearing before this Forum have filed their joint written statement and pleaded that the ICICI Prudential Pinnacle policy bearing No.14270729 was issued to the complainant on 1.8.2010 on the basis of the information provided by the Life Assured in the Proposal Form. Since the information provided by the Life Assured in the Proposal Form was established to be incorrect as such they have repudiated the claim of the complainant. The repudiation of the complainant was turned under the policy on the ground of misstatement of information, suppression of material information and furnishing of the false information in the proposal form. The Life Assured at the time of filling up the proposal form did not disclose the fact that he was suffering from Non Insulin Dependant Diabetes Mellitus since 2 years. The Life Assured underwent blood sugar tests in May 2010 and July 2010 which were adverse. The Life Assured had the knowledge of his adverse medical condition and suppressed the same from the opposite parties, which led to the issuance of the policy. The insurance contracts are contracts based on utmost good faith. As per the Contract, the insurer is bound to honour the claim under the said policy in the event of the death of the Life Assured provided the Life Assured at the time of applying for the said policy, had disclosed all the relevant information with regard to his health, habits, etc., which are the basis on which the insurer decides to cover the said life and at what rates. Since the Life Assured did not perform his duty to disclose all the material information, the contract of the Insurance between the opposite parties and the Life Assured is a void contract. The opposite parties further pleaded that under the provisions of Section 45 of the Insurance Act a life insurance policy can be called in question on the ground of concealment of the material facts within 2 years of the commencement of the said policy. In the instant case the Life Assured died within 28 days of the issuance of the said policy. The complainant has not approached this Forum with clean hands-'One who seeks equity must come with clean hands'. The opposite parties further pleaded that 'Declaration and Authorization' in the said proposal form signed by the deceased life assured in which he answered the question Nos.22(a):-'Yes'; 23(c):-'No'; 23(f):-'No' and 23 (h):- 'No'. In this way the husband of the complainant has suppressed the material facts regarding his health. The opposite parties further pleaded that the welcome kit including the welcome letter, copy of the proposal form, policy certificate and the policy documents etc. were duly dispatched on 4.8.2010 vide Blue Dart courier airway bill No.43667443455 and the same was duly received by the Life Assured on 6.8.2010. The complainant has herself annexed the welcome letter, premium receipts, proposal form and the policy documents with her present complaint clearly indicating that the Life Assured was in the receipt of the welcome kit and the same was retained by the Life Assured. The Life Assured died within 28 days from the issuance of the said policy. It has been mentioned in the History of Discharge Summary issued by Jindal Heart Institute & Infertility Centre dated 26.8.2010:- '60 year male patient known case of Non Insulin Dependant Diabetes Mellitus (NNDDM) since last 2 years was hospitalized in Cardiogenic shock/severe metabolics acidosis and gasping state'. Thus on the abovementioned ground the claim of the complainant was repudiated by the opposite parties.

3. The parties have led their evidence in support of their respective pleadings.

4. Arguments heard. The record alongwith written submissions submitted by the parties perused.

5. Admittedly, the complainant has purchased the ICICI Prudential Pinnacle policy bearing No.14270729 with the sum assured of Rs.2,50,000/- and premium was paid of Rs.50,000/- with premium frequency yearly. The proposal form signed by the deceased life assured on 31.7.2010 and the policy was issued on dated 1.8.2010. The husband of the complainant died due to the sudden severe chest pain on 29.8.2010 at Bathinda. The claim was repudiated by the opposite parties.

6. The complainant submitted that the agent of the opposite parties allured her husband to purchase the said insurance policy and he took the signatures of the deceased life assured on the various blank papers and blank printed forms without disclosing the contents and no terms and conditions were issued by the opposite parties. The deceased life assured Parshotam Lal felt sudden severe chest pain on 25.8.2010 and he was admitted to the Jindal Heart Institute & Infertility Centre till 26.8.2010 but he died on 29.8.2010 at Bathinda, the claim of the complainant repudiated vide letter dated 21.3.2011 on the ground that deceased life assured was suffering from pre existing disease but he was not suffering from any pre existing disease. The only basis on which the opposite parties have repudiated her claim is record of Jindal Heart Institute & Infertility Centre wherein she opined that the deceased might be suffering from Non Insulin Dependant Diabetes Mellitus since 2 years but the opposite parties have not filed any affidavit of the alleged doctor to prove that the deceased life assured is suffering from any such disease from the last 2 years.

7. The submissions of the opposite parties are that the husband of the complainant has concealed the material facts regarding his health as the Life Assured at the time of filling up the proposal form did not disclose the fact that he was suffering from Non Insulin Dependant Diabetes Mellitus since 2 years. The Life Assured underwent blood sugar tests in May 2010 and July 2010 which were adverse. The Life Assured had the knowledge of his adverse medical condition and suppressed the same from the opposite parties. The opposite parties issued the insurance policy whereas the insurance contracts are contracts based on utmost good faith. Thus the claim of the complainant was repudiated.

8. A perusal of record shows that the complainant has filled and signed the application (proposal form) and has given the details as under:-

The 'Important Guidelines' at the top of the Proposal Form duly signed by the Life Assured reads as under:-

“Insurance is a contract of utmost good faith requiring of the proposer and the Life to be assured not only to disclose all material facts but also not to suppress any material facts in response to the questions in the Proposal Form....”

The complainant has also signed the 'Declaration and Authorization' in the said proposal form. The relevant portion of this reads as under:-

“I/We further declare that the answers given by me/us to all the questions in the proposal form as to the state of health and habits of the life to be assured are true and complete in every respect and I/We have not withheld any material information or suppressed any fact.... I/We undertake to notify the Company of any changes of the state of health of the life to be assured or as to his occupation subsequently to the signing of this proposal and before the acceptance of risk by the Company....I/We also understand that in case of any mis-statement or suppression of material information the Company has the right to repudiate the claim under the policy.”

The husband of the complainant gave answers in negative to the relevant questions asked to him regarding his health vide Ex.R8. The relevant portion of this document reads as under:-

“In this connection, we have noted that in the proposal for insurance received by us on July 31,2010 (copy of the proposal form enclosed), relevant questions were answered as follows:-

The above policy was issued on August 01,2010. The Life Assured expired within 28 days of the policy issuance on August 29,2010.

After careful evaluation of the records, obtained by us, during the claim processing, it is noted that Life Assured was suffering from Non Insulin Dependant Diabetes Mellitus since 2 years. Further, it is also noted that the Life Assured underwent blood sugar tests in May 2010 & July 2010 which were adverse.

The above medical history, which was prior to the proposal, was not disclosed in the proposal for insurance.”

Further a perusal of record shows that the Life Assured was suffering from Non Insulin Dependant Diabetes Mellitus since 2 years and has underwent blood sugar tests in May 2010 & July, 2010, which were on the negative side. The report of Krishna Clinical Laboratory dated 5 May, 2010 Ex.R5 shows 'Biochemical Tests Fasting Sugar (70-110) 125 mg/dl (prior to policy issuance)' and the report of Krishna Clinical Laboratory dated 12.7.2010 Ex.R6 shows ' Biochemical Tests Fasting Sugar (70-110) 137 mg/dl (prior to policy issuance)'. A further perusal of Ex.R7 dated 26.8.2010 reveals:-

“Diagnosis:-NIDDM

CAD/IWMI.

Cardiogenic Shock/CHB.

Severe Metabolic Acidosis.

Procedure:- 2D ECHO n 25.8.2010

TPI done on 25.8.2010

Medication:-1. Tab.Prax 10mg once a day.

2. Tab Ecosprin 150 mg once a day.

3. Tab. Avas 20 mg once a day.

4. Tab Pantocid 40 mg once a day.

5. Inj. Adrenalin 1/V infusion.

6. Inj.H.Actrapid S/C S/S.

History:-60 year old male patient known case of NIDDM (last 2 years)/Non HTN was hospitalized in Cardiogenic shock/severe metabolic acidosis and gasping state. Associated with ECG (IWMI, CHB). Patient was intubated with initial resuscitative measures and put on mechanical ventilation with other supportive treatment. And shifted to cath lab for TPI.

Course In The Hospital:- TPI done on 25.8.2010. Patient managed with I/V inotropes, haparin,fluids, Gp2b/3a inhibitor (tirofiban), antiplatelets, antiaginals. Patient gradually improved on treatment, and was gradually weaned off ventilator on 2^nd day of higher center for further management.”

The history of the patient given in Ex.R7 reveals that the patient is the known case of NIDDM for last 2 years, Non HTN was hospitalized in Cardiogenic shock/severe metabolic acidosis and gasping state. Associated with ECG (IWMI, CHB). Patient was intubated with initial resuscitative measures and put on mechanical ventilation with other supportive treatment. And shifted to cath lab for TPI.

9. Thus from the facts, circumstances and evidence placed on file it is proved that the husband of the complainant has suppressed the material facts from the opposite parties. The insurance contracts are based on utmost good faith i.e. ubremma fides but the husband of the complainant has replied the questions regarding his health falsely. The support can be sought by the law laid down by the Hon'ble Supreme Court of India in case titled Satwant Kaur Vs. New India Assurance Company Ltd., 2004 (4) CLT 398 wherein it was held:-

“(i) Contract of Insurance-Expression 'material fact'-Any fact which would influence the mind of a prudent insurer in deciding whether to accept or not to accept the risk is a 'material fact'-If the proposer has knowledge of such fact, he is obliged to disclose it particularly while answering question in the proposal form-Any inaccurate answer will entitle the insurer to repudiate his liability because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering into a Contract of Insurance.

(ii)Consumer Protection Act, 1986,Section 2(1) (g)-Insurance Act, 1938, Section 45-Mediclaim policy-Insurance claim-Repudiation-Suppression of material fact-The provision of Section 45 of the Insurance Act, 1938 applies only in a case of life insurance policy and not in case of mediclaim policy- Insured at the time of taking policy not disclosing that he was suffering from chronic Diabetes and Renal failure and died within three weeks of taking the policy-A clear case of suppression of material facts in regard to the health of the insured-Respondent insurer was fully justified in repudiating the insurance contract.”

Further the reliance can be sought by the precedent laid down by the Hon'ble National Consumer Disputes Redressal Commission, New Delhi in case titled Life Insurance Corporation of India Vs. Francis Antony D'souza, 2012 (2) CLT 176 wherein it was held:-

“Insurance claim Repudiation-Suppression of material facts-In the proposal form the insured had replied all questions pertaining to her personal medical history in negative-The evidence produced by the Petitioner in the form of the OPD medical history of the deceased/insured clearly and undeniably confirms that the insured had in fact regularly visited a doctor for about 70 days with complaints of difficulty in swallowing for which she was treated-Death of insured within five months of taking the insurance policy-There was clearly non-disclosure of facts by the insured-Petitioner-Insurance Company justified in repudiating the insurance claim of the Respondent and, therefore, committed no deficiency in service-Order of the State Commission liable to be set aside.”

The reliance can also be sought by the precedent laid down by the Hon'ble National Consumer Disputes Redressal Commission, New Delhi in case titled LIC of India Vs. Premlata Aggarwal, 2012 (2) CLT 182 wherein it was held:-

“.....The insured had suppressed material information-He violated the well-established and fundamental principle of an insurance policy which is a contract entered into good faith and binding on both the parties-As per the terms and conditions of the insurance policy repudiation of claim held to be justified....”

Further the reliance can also be sought by the precedent laid down by the Hon'ble State Consumer Disputes Redressal Commission, Panchkula in case titled LIC of India Vs. Kulwant Kaur, 2012 (2) CLT 591 wherein it was held:-

“ Consumer Protection Act, 1986,Section 2(1) (g)-14(1) (d) and 15 Insurance Act, 1938, Section 45-Insurance claim-Repudiation-Suppression of material facts-Certificate issued from PGIMS, Chandigarh reflects that the life assured was diagnosed as a case of Hypthyoidism in PGI in the year 1990 but this fact was not disclosed by him in the proposal form while giving personal statement-The life assured died within nine months from the date of obtaining the Insurance Policy and therefore the provisions of Section 45 of the Act, 1938 attracted-In view of the documentary evidence produced the opposite parties have sufficiently proved their case-Impugned order passed by the District Forum allowing the complaint liable to be set aside and the complaint dismissed.”

10. The husband of the complainant has suppressed the material facts from the opposite parties regarding his health. Moreover Life Assured had died on 29.8.2010 at Bathinda, due to sudden severe chest pain after 28 days of the commencement of the said policy and attracted the provisions of section 45 of the Insurance Act, 1938.

11. Therefore in view of what has been discussed above there is no deficiency in service on the part of the opposite parties. Hence this complaint is dismissed.

12. The parties are left to bear their own costs.

13. A copy of this order be sent to the parties concerned free of cost and file be consigned to the record room.

Pronounced in open Forum:-

21-11-2012

Vikramjit Kaur Soni

President

Amarjeet Paul

Member

Sukhwinder Kaur

Member