Charanjit Singh, President

1        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 34, 35 and 36 against the opposite parties on the allegations that the opposite parties are doing the business of insurance through network of branches across India, including the Branch office at Tarn Taran and Amritsar i.e. opposite parties. As the opposite parties are dealing in the Life Insurance Policies and for that purpose, they had spread out number of agents in the field for covering the life risks of common man and the opposite parties usually allures and gives attractive offers to the common man at the time of giving policies and further assures the applicant and his family members that if any untoward incident occurred the opposite parties i.e. the company will give all the benefits and the sum assured at the door step as the family will have to go nowhere and the services will be availed while sitting at home and the agents of the opposite parties i.e. the company as well as it’s officials, use to give lucrative offers to common people in order to secure their business. The Life Insurance Corporation presents the LIC’S JEEVAN LABH’ policy as an insurance policy. The opposite parties i.e. company’s officials and agents approached the husband of the complainant and gave lucrative offers for having a life insurance policy and had told about the above policy to the husband of the complainant and the husband of the complainant was attracted to the offers made by the opposite parties/ its’ agents but never disclosed all the terms and conditions of the policy. The husband of the complainant was approached by an agent of the opposite parties and upon the assurance that the insurance services provided by the opposite parties are the best in their field. Thereafter, as per the assurance of the opposite parties, husband of the complainant had availed one life insurance policy bearing policy No. 148180209 for a sum of Rs. 4,00,000/- and date of commencement of the said policy was on 15.4.2021, date of maturity 15.4.2042 for the premium of Rs. 13,726/- as half yearly rests. Hence the husband of the complainant being a policy holder/ customer of the opposite parties, as such, complainant and her husband are consumer within the purview of the Consumer Protection Act. Neither the terms nor conditions were ever supplied nor explained to the complainant and her husband at the time of issuance of the said insurance policy. On 10.8.2022 the insured namely Major Singh was got admitted in Hospital at Amritsar and on the same day he was declared as dead by the doctors. Thereafter, wife of the deceased namely Rupinder Kaur visited the office of the opposite parties in order to inform the opposite parties regarding the death of the insured Major Singh. The officials of the opposite parties told to the complainant regarding the submission of the relevant documents with regard to the death of insured Major Singh and later on the complainant submitted all the requisite documents to the opposite parties and further requested to the officials of the opposite parties to relinquish the said claim to the complainant so that she may get financial support from the above said claim and for the bright future of her family. Thereafter, number of times the complainant visited the offices of opposite parties at Amritsar and Tarn Taran in order to know about the status of claim of the insurance policy but the opposite parties linger on the matter on one false pretext or the other. On dated 2.6.2023 the complainant astonished when she received a letter from the opposite parties where the opposite parties have specifically rejected the claim of the policy on the ground of non-discloser of the material facts as well as for intimation.  The complainant further requested the opposite parties that the claim which has been filed by her with regard to the above said policy was within the limitation. The opposite parties have rejected the claim on biased and false pretext and the opposite parties in highly arbitrary manner credited the amount of Rs. 41,178/- in the joint bank account of complainant and deceased Major Singh on dated 13.6.2023 without any basis and reason i.e. the amount of instalments which was deposited by the deceased husband of the complainant. Neither the terms nor conditions were ever supplied nor explained to the complainant at the time of issuance of insurance policy.  The husband of the complainant availed this policy on 15.4.2021 and the date of death of Major Singh is 10.8.2022 and this fact clearly reveals that the husband of complainant remained alive about the period of 1½ years after the insurance of the above said policy.  The above said act of the opposite parties i.e. the company is an unfair trade practice as the company has declined the genuine right/ legal claim of the complainant, who is an innocent lady and victim of cruel fate and husband of the complainant had given hard earned money to the opposite parties i.e. the insurance company. The company has disbursed only the amount of Rs. 41,178/- i.e. the amount of instalments which was deposited by the deceased husband of the complainant and rest of the claim was repudiated by the opposite parties in a very unbussiness like and arbitrary manner and no other amount was paid thereafter. The company had issued the policy to the deceased life assured after making thorough inquiries and required medical check-ups and more over it was duty of the company to collect every required information by making investigation at the time of issuance of the policy. It is higher degree of deficiency in services on the part of the company, who has repudiated the claim of the complainant without any reasonable basis. At the time of issuance of the policy all the necessary information related to the insured Major Singh were taken by the officials of the opposite parties and officials who collected the information and relevant documents, had verified the facts regarding the health of the deceased through medical examination by the empanelled doctors of the company and personal investigation conducted by them regarding any ailment or severe disease, any surgery, operation or any medical assistance obtained or not and hence the correct information was given to the officials of the opposite parties i.e. the company and prayed that the present complaint may kindly be allowed. The complainant has prayed the following relieves:-

1. The opposite parties may kindly be directed to reimburse the amount of Rs. 4,00,000/- to the complainant as the complainant is legally entitled to recover the same as per the policy.
2. It is further prayed that an amount of Rs. 1,00,000/- as compensation and Rs. 22,000/- as litigation expenses on account of mental and physical harassment caused to the complainant at the hands of the opposite parties, in the interest of justice, equity and fair-play.

Alongwith the complaint, the complainant has placed on record his affidavit Ex. C- 1, Self attested copy of the Insurance Policy Ex. C-2, Self attested copy of installment deposit receipt (Proposal deposit receipt) Ex. C-3, Self attested copy of renewal premium receipt Ex. C-4, Self attested copy of the rejection letter dated 2.6.2023 Ex. C-5, Self attested copy of joint bank account Ex. C-6,  Self attested copy of Adhar Card of complainant Ex. C-7, Self attested copy of Adhar Card of Major Singh Ex. C-8, Self attested copy of death certificate of Major Singh Ex. C-9.

2        Notice of this complaint was sent to the opposite parties and opposite parties appeared through counsel and filed written version by interalia pleadings that the present complaint is not maintainable.  The complainant has not come to the court with clean hands, as such, she is not entitled to the relieves claimed in the present complaint. Claim of the complainant with respect to the policy No. 148180209 of the deceased Major Singh was repudiated by the opposite party vide repudiation letter dated 2.6.2023 on the basis of treatment record of EMC Super Specialty Hospital, Amritsar where the said Major Singh remained hospitalized with a past history of Type 2 Diabetes Mellitus for the last 6-7 years and old Pulmonary Koches (Tubeculosis) for the last 3-4 years and died on 10.8.2022. While proposing for the policy No. 148180209, he had not disclosed about his ill health. These facts were not disclosed by the deceased Major Singh with the sole intention of defrauding the Corporation i.e. opposite party as the intimation regarding his illness was in his exclusive knowledge which he concealed intentionally at the time of proposal. The complainant has filed death claim with the corporation on 1.12.2022 i.e. after a period of 3 months and 21 days from the date of death i.e. on 10.8.2022 as such, the claim is barred by limitation clause of the terms and conditions of the policy in question and limitation clause is applicable as per point No. 4 on page No. 2 of policy bond. The stipulated period for lodging the death claim is 80 days from the date of death.  The complainant has no cause of action. No lucrative offers were given by the agents of the opposite parties to the deceased life assured and only features of the plan were shared with him by them when he approached for purchasing an insurance policy.  The life assured Major Singh had purchased a life insurance policy from Tarn Taran branch bearing Policy No. 148180209 and date of commencement of risk under the said policy was 15.4.2021 and date of maturity as 15.4.2042 with half yearly premium of Rs. 13,726/-.  The amount of Rs. 41,178/- was paid to the complainant through credit in the bank account of nominee/ complainant being the refund of the premiums towards the full and final settlement of the death claim. Apart from explaining at the time of proposal, complete terms and conditions being the part of the policy bond, were duly supplied to deceased life assured. The complainant has submitted the said policy Bond containing all the terms and conditions related to the policy in question, with the corporation at the time of lodging the claim. Hence this falsifies the version of the complainant that terms and conditions were not supplied by corporation .  Life assured Major Singh had died on 10.8.2022 and the policy in question had not completed three years from the date of commencement of Risk i.e. 15.4.2021 to date of death of the life assured. As such, the opposite party examined the death claim keeping in view of provisions of Section 45 of the Insurance Act, 1938 and an investigation as conducted by Sh. Rajesh Kumar, Manager, LIC of India Branch Office, Tarn Taran and while thoroughly examining the said claim thread-bare, the opposite party came to know that the said Major Singh life assured remained admitted in EMC Super Specialty Hospital Amritsar on 10.8.2022 with a past history of Type 2 Diabetes Mellitus for the last 6-7 years and old Pulmonary Koches (T.B) for the last 3-4 years before his death and he died on the same day i.e. 10.8.2022. The opposite party has also taken expert medical opinion of Dr. Anil Khanna M.D. Divisional Medical Refree (DMR), LIC of India Amritsar who opined that deceased life assured was suffering from Type 2 Diabetes Mellitus for the last 6-7 years and old Pulmonary Koches (T.B) for the last 3-4 years before his death. LA was suffering from these diseases at the time of taking insurance policy and diabetic patients are more prone to severe and life threatening infections. The above said facts were in the exclusive knowledge of deceased life assured, which he willfully did not disclose at the time of effecting insurance with the opposite party and hence suppressed the material information about his ill health, which was very much necessary and indispensable for the opposite party to know and consider the same at the time of proposal. The above said facts of his ill health were not disclosed by the deceased Major Singh at the time of proposal. In the proposal form relating to the above said policy No. 148180209, the said Major Singh life assured has answered the following questions, as noted herein below

          The aforesaid answers given by the said Major Singh in the Proposal Form were false as can be clearly seen from the treatment record of EMC hospital, Amritsar where he remained admitted with a past history of Type-2  Diabetes Mellitus for the last 6-7 years and old Pulmonary Koches for the last 3-4 years and died on 10.8.2022. This suppression of extremely material facts related to the proposer Major Singh, which and a great bearing on the consideration and acceptance of risk on his life, was clearly done by the said Major Singh with sole intent to defraud the opposite parties i.e. Corporation, as the information regarding his illness was in his exclusive knowledge which he concealed intentionally at the time of proposal. Based upon the proposal, the risk understood by underwriter of the corporation was altogether different from the risk actually involved in acceptance of the proposal. The corporation was grossly misled by suppression of extremely material facts regarding health of the proposer Major Singh thus violating the principle of ‘Uberrima Fidei’. Had the correct facts been disclosed in the Proposal Form, the proposal would not have been accepted and the insurance would not have been granted by the opposite party/ corporation. Hence the above said claim under policy No.  148180209 was repudiated by the opposite party vide letter dated 2.6.2023 on the basis of treatment record of EMC Hospital Amritsar in a lawful manner. The policy in question has run for 1 year 3 months and 25 days from date of commencement of risk to date of death of life assured not for a period of 1½ years.  The claim has been repudiated lawfully for the reason that the material medical information was willfully withheld by the deceased Major Singh.  No special medical reports were conducted at the time of proposal, as the same were not required as per the then prevalent rules of underwriting. Only a simple and Basic Medical Examiner’s report / questionnaire was required which was filled by the empanelled Doctor of the Corporation after ascertaining the answers to the questions from the proposer.  The opposite parties have denied the other contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite party has denied the other contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite parties have placed on record affidavit of Sudeep Kumar Sharma Manager (L & HPF) Divisional Office, LIC of India, Amritsar Ex. OPs 1 & 2/1,Self  attested photocopy of proposal form related to P.No. 148180209 Ex. OP  1 & 2/2,  Self attested copy of policy bond bearing Policy No. 14818029 Ex. OP  1 & 2/3, Self attested photocopy of status report of Policy bearing No. 148180209 Ex. OP  1 & 2/4, Self attested photocopy of claim enquiry Report conducted by Sh. Rajesh Kumar Manager LIC of India Branch Office, Tarn Taran Ex. OP  1 & 2/5, Self attested photocopy of Medical opinion of Dr. Anil Khanna DMR LIC of India, Amritsar Ex. OP  1 & 2/6,  self attested photocopies of treatment record of deceased Major singh at EMC Hospital, Amritsar Ex. OP  1 & 2/7, Self attested photocopy of claim Form No. 3783-A submitted by complainant bregarding policy bearing No. 148180209 Ex. OP  1 & 2/8, Self attested photocopy of repudiation letter dated 2.6.2023 Ex. OP  1 & 2/9, Self attested photocopy of Medical Examiners Report dated 10.4.2021 Ex. OP  1 & 2/10, Self attested photocopy of F.No. 3816 issued by EMC Hospital, Amritsar Ex. OP  1 & 2/11, Death  intimation letter from Claimant Ex. OP  1 & 2/12.

3        The complainant has filed rejoinder to the written version filed by the opposite parties and denied all the pleas taken in the written version and reiterated the stand as taken in the complaint and it was pleaded that deceased Major Singh was got admitted in EMC Hospital on 10.8.2022 and on the same day he has died due to cardiac arrest (Heart Attack) and even EMC hospital did not get any medical test of the deceased Major Singh so how they can gave conclusion that Major Singh is suffering from Type 2 Diabetes for the last 6-7 years and tuberculosis for the last 3-4 years within one day. The said EMC Hospital has given wrong and bogus medical report of the deceased Major Singh because on 10.8.2022 when Major Singh has been got admitted in the said EMC hospital they are not doing proper treatment of Major Singh and doing embezzlement in medicines as such a big dispute arose there between the family members of deceased Major Singh and staff members of EMC Hospital and due to this reason they gave the wrong and bogus medical report of Major Singh. In this respect family members of the complainant have also moved one complaint/ application No. 8374 dated 28.8.2022 before civil Surgeon Amritsar with regard to fact of not doing proper treatment of Major Singh and doing embezzlement in medicines. As soon as the complainant has got all the relevant documents to lodge death claim of the deceased Major Singh, she has immediately lodged the same to the opposite parties as such the death claim is lodged within time by the complainant. 

4        We have heard the Ld. Counsel for the complainant and opposite parties and have carefully gone through the record.

5        Ld. Counsel for the complainant contended that the husband of the complainant was approached by an agent of the opposite parties and upon the assurance that the insurance services provided by the opposite parties are the best in their field. As per the assurance of the opposite parties, husband of the complainant had availed one life insurance policy bearing policy No. 148180209 for a sum of Rs. 4,00,000/- and date of commencement of the said policy was on 15.4.2021, date of maturity 15.4.2042 for the premium of Rs. 13,726/- as half yearly rests. The husband of the complainant being a policy holder/ customer of the opposite parties, as such, complainant and her husband are consumer within the purview of the Consumer Protection Act. Neither the terms nor conditions were ever supplied nor explained to the complainant and her husband at the time of issuance of the said insurance policy. On 10.8.2022 the insured namely Major Singh was got admitted in Hospital at Amritsar and on the same day he was declared as dead by the doctors. Thereafter, wife of the deceased namely Rupinder Kaur visited the office of the opposite parties in order to inform the opposite parties regarding the death of the insured Major Singh. He further contended that the officials of the opposite parties told to the complainant regarding the submission of the relevant documents with regard to the death of insured Major Singh and later on the complainant submitted all the requisite documents to the opposite parties and further requested to the officials of the opposite parties to relinquish the said claim to the complainant so that she may get financial support from the above said claim and for the bright future of her family. Thereafter, number of times the complainant visited the offices of opposite parties at Amritsar and Tarn Taran in order to know about the status of claim of the insurance policy but the opposite parties linger on the matter on one false pretext or the other. He further contended that on 2.6.2023 the complainant astonished when she received a letter from the opposite parties where the opposite parties have specifically rejected the claim of the policy on the ground of non-discloser of the material facts as well as for intimation.  The complainant further requested the opposite parties that the claim which has been filed by her with regard to the above said policy was within the limitation. The opposite parties have rejected the claim on biased and false pretext and the opposite parties in highly arbitrary manner credited the amount of Rs. 41,178/- in the joint bank account of complainant and deceased Major Singh on 13.6.2023 without any basis and reason i.e. the amount of instalments which was deposited by the deceased husband of the complainant. He further contended that neither the terms nor conditions were ever supplied nor explained to the complainant at the time of issuance of insurance policy.  The husband of the complainant availed this policy on 15.4.2021 and the date of death of Major Singh is 10.8.2022 and this fact clearly reveals that the husband of complainant remained alive about the period of 1½ years after the insurance of the above said policy.  The above said act of the opposite parties i.e. the company is an unfair trade practice as the company has declined the genuine right/ legal claim of the complainant, who is an innocent lady and victim of cruel fate and husband of the complainant had given hard earned money to the opposite parties i.e. the insurance company. The company has disbursed only the amount of Rs. 41,178/- i.e. the amount of instalments which was deposited by the deceased husband of the complainant and rest of the claim was repudiated by the opposite parties in a very unbussiness like and arbitrary manner and no other amount was paid thereafter. The company had issued the policy to the deceased life assured after making thorough inquiries and required medical check-ups and more over it was duty of the company to collect every required information by making investigation at the time of issuance of the policy. It is higher degree of deficiency in services on the part of the company, who has repudiated the claim of the complainant without any reasonable basis and prayed that the present complaint may kindly be allowed.

6        Ld. Counsel for the opposite parties contended that the present complaint is not maintainable.  The complainant has not come to the court with clean hands, as such, she is not entitled to the relieves claimed in the present complaint. Claim of the complainant with respect to the policy No. 148180209 of the deceased Major Singh was repudiated by the opposite party vide repudiation letter dated 2.6.2023 on the basis of treatment record of EMC Super Specialty Hospital, Amritsar where the said Major Singh remained hospitalized with a past history of Type 2 Diabetes Mellitus for the last 6-7 years and old Pulmonary Koches (Tuberculosis) for the last 3-4 years and died on 10.8.2022. While proposing for the policy No. 148180209, he had not disclosed about his ill health. These facts were not disclosed by the deceased Major Singh with the sole intention of defrauding the Corporation i.e. opposite party as the intimation regarding his illness was in his exclusive knowledge which he concealed intentionally at the time of proposal. The complainant has filed death claim with the corporation on 1.12.2022 i.e. after a period of 3 months and 21 days from the date of death i.e. on 10.8.2022 as such, the claim is barred by limitation clause of the terms and conditions of the policy in question and limitation clause is applicable as per point No. 4 on page No. 2 of policy bond.  The stipulated period for lodging the death claim is 80 days from the date of death.  The complainant has no cause of action. No lucrative offers were given by the agents of the opposite parties to the deceased life assured and only features of the plan were shared with him by them when he approached for purchasing an insurance policy.  The life assured Major Singh had purchased a life insurance policy from Tarn Taran branch bearing Policy No. 148180209 and date of commencement of risk under the said policy was 15.4.2021 and date of maturity as 15.4.2042 with half yearly premium of Rs. 13,726/-.  An amount of Rs. 41,178/- was paid to the complainant through credit in the bank account of nominee/ complainant being the refund of the premiums towards the full and final settlement of the death claim. Apart from explaining at the time of proposal, complete terms and conditions being the part of the policy bond, were duly supplied to deceased life assured. He further contended that the complainant has submitted the said policy Bond containing all the terms and conditions related to the policy in question, with the corporation at the time of lodging the claim. Hence this falsifies the version of the complainant that terms and conditions were not supplied by corporation.  He further contended that life assured Major Singh had died on 10.8.2022 and the policy in question had not completed three years from the date of commencement of Risk i.e. 15.4.2021 to date of death of the life assured. As such, the opposite party examined the death claim keeping in view of provisions of Section 45 of the Insurance Act, 1938 and an investigation as conducted by Sh. Rajesh Kumar, Manager, LIC of India Branch Office, Tarn Taran and while thoroughly examining the said claim thread-bare, the opposite party came to know that the said Major Singh life assured remained admitted in EMC Super Specialty Hospital Amritsar on 10.8.2022 with a past history of Type 2 Diabetes Mellitus for the last 6-7 years and old Pulmonary Koches (T.B) for the last 3-4 years before his death and he died on the same day i.e. 10.8.2022. The opposite party has also taken expert medical opinion of Dr. Anil Khanna M.D. Divisional Medical Refree (DMR), LIC of India Amritsar who opined that deceased life assured was suffering from Type 2 Diabetes Mellitus for the last 6-7 years and old Pulmonary Koches (T.B) for the last 3-4 years before his death. LA was suffering from these diseases at the time of taking insurance policy and diabetic patients are more prone to severe and life threatening infections. The above said facts were in the exclusive knowledge of deceased life assured, which he willfully did not disclose at the time of effecting insurance with the opposite party and hence suppressed the material information about his ill health, which was very much necessary and indispensable for the opposite party to know and consider the same at the time of proposal. The above said facts of his ill health were not disclosed by the deceased Major Singh at the time of proposal.  He further contended that the answers given by the said Major Singh in the Proposal Form were false as can be clearly seen from the treatment record of EMC hospital, Amritsar where he remained admitted with a past history of Type-2  Diabetes Mellitus for the last 6-7 years and old Pulmonary Koches for the last 3-4 years and died on 10.8.2022. This suppression of extremely material facts related to the proposer Major Singh, which and a great bearing on the consideration and acceptance of risk on his life, was clearly done by the said Major Singh with sole intent to defraud the opposite parties i.e. Corporation, as the information regarding his illness was in his exclusive knowledge which he concealed intentionally at the time of proposal. Based upon the proposal, the risk understood by underwriter of the corporation was altogether different from the risk actually involved in acceptance of the proposal. The corporation was grossly misled by suppression of extremely material facts regarding health of the proposer Major Singh thus violating the principle of ‘Uberrima Fidei’. Had the correct facts been disclosed in the Proposal Form, the proposal would not have been accepted and the insurance would not have been granted by the opposite party/ corporation. Hence the above said claim under policy No.  148180209 was repudiated by the opposite party vide letter dated 2.6.2023 on the basis of treatment record of EMC Hospital Amritsar in a lawful manner. The policy in question has run for 1 year 3 months and 25 days from date of commencement of risk to date of death of life assured not for a period of 1½ years.  The claim has been repudiated lawfully for the reason that the material medical information was willfully withheld by the deceased Major Singh.  No special medical reports were conducted at the time of proposal, as the same were not required as per the then prevalent rules of underwriting. Only a simple and Basic Medical Examiner’s report / questionnaire was required which was filled by the empanelled Doctor of the Corporation after ascertaining the answers to the questions from the proposer and prayed that the present complaint may be dismissed.

7        The combined and harmonious reading of documents and pleadings is going to prove on record that the husband of the complainant has obtained the life insurance policy from the opposite party bearing policy No. 148180209 for a sum of Rs. 4,00,000/- and date of commencement of the said policy was 15.4.2021 and date of maturity 15.4.2042 for the premium of Rs. 13,726/- as half yearly rests. Three installments of the premium has been given by the life assured which is clear from the document i.e. status report of policy Ex. OP1 & 2/4 in which it has been mentioned that an amount of Rs. 13,726/- has been paid on 15.4.2021, Rs.13,726/- has been paid on 2.11.2021 and Rs. 13,726/- has been paid on 22.4.2022. In this way three premiums have been given to the opposite parties against the insurance policy No. 148180209.  The opposite party after admitting the death of life assured and after admitting the insurance policy has made the payment of Rs. 41,178/- to the complainant through credit in the bank account of nominee/ complainant being the refund of the premiums towards the full and final settlement of the death claim.  The opposite party has repudiated the claim of the complainant vide repudiation letter dated 2.6.2023 Ex. OP1 & 2/9 which is reproduced as follows:-

“1     This has reference to your claim intimation under the above mentioned policy on the life of your deceased husband-Sh. Major Singh, received by us on 01.12.2022 from you.

2        The claim has been intimated after 3 months & 21 days from the date of death-10.8.2022. The claim was required to be intimated within 90 days from the date of death.

3        In this connection we have to inform you that above stated policy has not completed three years from the date of risk which is 15.4.2021 to date of death of the life assured on 10.8.2022. As such we have examined the claim keeping in view of provisions of Section 45 of the Insurance Act, 1938 and further Insurance Laws (Amendment) Act, 2015.

4        We have further examined the case for ex-gratia consideration, though the claim is barred by limitation clause.

5        We further note that had the claim been intimated before the expiry of limitation period as defined in policy conditions, it would have been found non admissible due to the reasons below:

           Section 1- Details of the Life to be assured

6       We may, however, state that aforesaid answers were false. As per treatment record of EMC Hospital, Amritsar, the life assured was suffering from T2D and Pumonary Koches for last 5-6 years which was in his knowledge and not disclosed at the time of taking insurance.

7        This suppression of material facts, which have had a bearing on the granting of risk, was clearly done with intent to mislead the corporation.

8        Hence, it has been decided to reject all the liabilities under the policy.

9        However, it has been decided to refund the premium received under the policy towards full and final settlement of your claim.

10      However, if you disagree with our above decision and feel that we have not considered any particular facts and circumstances in support of your claim, you may send your appeal against the decision in the forum of insurance Ombudsman within three months from date of receipt of this letter for review of your claim alongwith all the supporting documents, at the following address:-

          The Insurance Ombudsman,

          SCO 101-103, 2^nd Floor,

Batra Building,

Sector -17-D,

Chandigarh-160017”

          As per repudiation letter the opposite party has repudiated the claim of the complainant on the ground that the claim has been intimated after 3 months and 21 days from the date of death.  The opposite party cannot repudiate the claim on the ground of intimation of delay. But it is not justified as per law. This delay in the opinion of this Commission is not such a delay which could compel the insurance company to close or repudiate the claim of the complainant. Otherwise also, a circular dated 20.9.2011 was issued by IRDA, referred to all the insurance companies, which reads as under:-

“Circular

To:    All Life Insurers and non-life insurers

Re:    Delay in claim intimation/ documents submission with respect to

i)       All life insurance contracts and

ii)      All Non-life individual and group insurance contracts.

          The Authority has been receiving several complaints that claims are being rejected on the ground of delayed submission of intimation and documents.

          The current contractual obligation imposing the condition that the claims shall be intimated to the insurer with prescribed documents within a specified number of days is necessary for insurers for effecting various post claim activities like investigation, loss assessment, provisioning, claim settlement etc. However, this condition should not prevent settlement of genuine claims, particularly when there is delay in intimation or in submission of documents due to unavoidable circumstances. The insurers’ decision to reject a claim shall be based on sound logic and valid grounds. It may be noted that such intimation clause does not work in isolation, and is not absolute. One needs to see the merits and good spirit of the clause, without compromising on bad claims. Rejection of claims on purely technical grounds in a mechanical fashion will result  in policy holders losing confidence in the insurance industry, giving rise to excessive litigation.

Therefore, it is advised that all insurers need to develop a sound mechanism of their own to handle such claims with utmost care and caution. It is also advised that the insurers must not repudiate such claims unless and until the reasons of delay are specifically ascertained, recorded and the insurers should satisfy themselves that the delayed claims would have  otherwise been rejected even if reported in time.

The insurers are advised to incorporate additional wordings in the policy documents, suitably enunciating insurers’ stand to condone delay on  merit for delayed claims where the delay is proved to be for reasons beyond the control of the insured.

                                                          J. Harinarayan

                                                            Chairman”:

A bare reading of circular shows that if the claim is otherwise payable then it should not be repudiated or rejected simply on the ground of delay and delay is only to be considered when claim is otherwise not made out and is liable to be rejected even if the matter has been reported in time. In case titled as National Insurance Company Limited Vs. Kulwant Singh 2014(IV) CPJ page 62 (NC) the Hon’ble National Commission  observed that the insurance company should not have repudiated the claim merely on account of delay in giving the information to insurance company particularly when there was absolute no delay in lodging the FIR with the police. In the case in hand also, the theft took place on 16.9.2014 and intimation to the police was also given on the same day i.e. 16.9.2014 and as such, there was no delay at all for giving the intimation to the police. Moreover, in similar case titled as Reliance General Insurance Company Limited- Petitioner Vs. Sri Avvn Ganesh-Respondent 2012(1) CPJ page 176  in case under Consumer Protection Act, 1986 the intimation of death was given to the insurer with delay and claim was repudiated on the ground that death of insured was intimated after 4 months as against stipulated period of one month. The complainant filed complaint on the allegation of deficiency in service by insurance company, but the same was dismissed, but appeal filed by the complainant was allowed by Hon’ble State Commission. On revision, the Hon’ble National Commission, New Delhi observed that all the conditions for acceptance of insurance claim except point of reporting loss within one month of its occurrence had been substantially  fulfilled and delayed intimation of death of insured due to injuries he suffered on account of accident could not be held to be destructive to insurance claim because the facts and circumstances of death were clearly established on the basis of medical on records as well as  deposition of doctor who attended the insured and it was observed that like in case of theft of moveable insured property, delay in intimation was not prejudicial to the insurer because in such cases, Insurance company was not prevented, because of delay, from carrying out any investigation into the facts and circumstances as to whether the accident and consequent loss fell within the substantive condition of insurance policy and no infirmity  was found in the order and revision petition was dismissed. In the case in hand, the husband of complainant died on 10.8.2022 in a young age and due to the death of her young husband, the circumstances in the house of complainant were not normal. As such we are not agreed with the stand taken by the opposite parties.

8        The other point taken by the opposite parties is that policy has not completed three years from the date of risk which is 15.4.2021 to date of death of the life assured on 10.8.2022. As such we have examined the claim keeping in view of provisions of Section 45 of the Insurance Act, 1938 and further Insurance Laws (Amendment) Act, 2015. On this point, Ld. Counsel for the complainant has stated that neither the terms nor conditions were ever supplied nor explained to the complainant and her husband at the time of issuance of the said insurance Policy and it has also been pleaded in the complaint by the complainant also, but on the other hands, the case of the opposite parties is that terms and conditions have been supplied at the time of policy. But to prove their contention, the opposite parties have not placed on record any document i.e. letter, postal receipt and mode on the basis of which terms and conditions have been supplied to the insured. As such,  we are not agreed with the contention of the opposite parties.

9        The other point taken by the opposite parties is that the complainant has given the wrong answers regarding his health in the proposal form and has suppressed the material facts which have had a bearing on the granting of risk who clearly done with intent to mislead the corporation.  The stand taken by the of the opposite parties in the written version is that the claim of the complainant with respect to the policy No. 148180209 of the deceased Major Singh was repudiated by the opposite party vide repudiation letter dated 2.6.2023 on the basis of treatment record of EMC Super Specialty Hospital, Amritsar where the said Major Singh remained hospitalized with a past history of Type 2 Diabetes Mellitus for the last 6-7 years and old Pulmonary Koches (Tubeculosis) for the last 3-4 years and died on 10.8.2022. While proposing for the policy No. 148180209, he had not disclosed about his ill health. These facts were not disclosed by the deceased Major Singh with the sole intention of defrauding the Corporation i.e. opposite party as the intimation regarding his illness was in his exclusive knowledge which he concealed intentionally at the time of proposal. It is also stand of the opposite parties in their written version that the opposite party has also taken expert medical opinion of Dr. Anil Khanna M.D. Divisional Medical Refree (DMR), LIC of India Amritsar who opined that deceased life assured was suffering from Type 2 Diabetes Mellitus for the last 6-7 years and old Pulmonary Koches (T.B) for the last 3-4 years before his death. The opposite parties have rejected the claim of the complainant on the basis of medical opinion of Dr. Anil Khanna. But we are not agreed with the stand taken by the opposite parties because the opposite parties have not placed on record affidavit of Dr. Anil Khanna to support the medical opinion given by him.  Furthermore, the opposite parties have repudiated the claim of the complainant on the ground that the complainant has concealed this fact from the opposite parties at the time of obtaining the policy regarding the diabetes. But we are not agreed with the opposite parties because the diabetes is not a material disease, therefore, non-disclosure thereof is not a concealment. We draw support from Life Insurance Corporation of India Vs. Sushma Sharma from II (2008) CPJ 213 wherein Hon'ble State Commission has held as under:-

“So far as hypertension and diabetes is concerned, no doubt, it is a disease but it is not a material disease. In these days of fast life, majority of the people suffer 14 from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. If these diseases had been material Nand Lal insured would not have survived for 10 years after he started suffering from these medical problems. Like hypertension ,diabetes has also infected a majority of the Indian population but the people who suffer from diabetes and continue managing it under the medical advice, they survive for number of years and none of these diseases is fatal and as discussed above, if these diseases had been material deceased Nand Lal insured would not have survived for 10 years.”.

We further draw support from Life Insurance Corporation of India Vs. Sudha Jain II (2007) CPJ 452 wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has held that maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease.   

10      The opposite parties relied upon the history of EMC Super Speciality Hospital Green Avenue Amritsar which pertains to DLA and in the column of History of Past illness, it is written that patient is K/C/O T2 (DM 6-7 years) on O.H.A, family History Old P.Koch (3-4 years) treated.  In this regard, the opposite party has not placed on record any report of test which was conducted by the hospital to reach the conclusion that patient is suffering from above mentioned disease and also failed to prove that on whose instance the past history of patient was recorded. In this regard, a reference can be made to the judgment of the Hon'ble National Commission in Revision Petition No. 200 of 2007 "Mr. Satinder Singh versus National Insurance Co. Ltd." decided on 24.1.2011 wherein it has been observed that "recording of history of patient in the above stated manner does not become a substantiate piece of evidence and convincing evidence be brought on record that complainant was aware of preexisting disease." Further, it has been observed by the Hon'ble National Commission in the III 2014 CPJ 340 (NC) "New India Assurance Company Limited through its duly Constituted Attorney, Manager versus Rakesh Kumar" that people can live months/years without knowing the disease and it is diagnosed accidentally after routine checkup and on that ground repudiation is not justified. Further it has been observed by the Hon'ble National Commission in its judgment IV (2008) CPJ 89 (NC) "Life Insurance Corporation of India & Ors. Versus Kunari Devi" that history recorded in the hospital bed head ticket is not to be taken as evidence as Doctor recording history not examined and suppression of disease not proved. In the present case, except the medical record of the present ailment, Ops have not placed on the record any independent evidence that the insured had the knowledge or that he had been taking the treatment of the disease, in question, before purchasing this policy and in the absence of any specific evidence on the record how the disease, if any, to First Appeal No 220 of 2020 which the insured does not have the knowledge can be termed as pre-existing disease. Therefore, we are of the opinion that repudiation of the claim is not justified. Hence we are not agreed with the opposite party that patient was suffering from any pre existing disease.

11      We have also gone through some judicial pronouncements relevant to the present case. In case M/s ICICI Prudential Life Insurance company Ltd. Vs Veena Sharma & Others 2014(4) CLT 507(NC), the Hon’ble National Commission held that it was for the insurance company to prove that complainant was suffering from pre-existing disease and has knowingly failed to disclose the same. The Hon’ble National Commission has also relied upon a case decided by the Hon’ble Supreme Court titled Balwinder Kaur Vs Life Insurance Corporation of India, Civil Appeal No. 7969 of 2010 decided on 13.9.2010, wherein it was held that the onus to prove that deceased had obtained policy by suppressing the material facts relating to his illness, was on the corporation at the time of taking policy and he deliberately suppressed the facts.

12      In case National Insurance Company Limited and Another Vs Balwinder Singh 2012(1) CLT 34, the Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh held that the appellants have not produced any evidence to prove that before the purchase of policy the insured/ respondent had taken any treatment from any doctor or any hospital and the insured/ respondent had the knowledge that he was suffering from the heart disease. This pronouncement was based upon the decision of the Hon’ble Apex Court in case titled LIC Vs GM Channabasamna, 1991(1) SCC 357  and of the Hon’ble National Commission in case titled LIC Vs Joginder Kaur and others, 2005(2) CLT 229. 

13      In case Kotak Mohindra Old Mutual Life Insurance Ltd. Vs Chander Isarsingh Dhansinghani & anr 2013(3) CLT 186, the Hon’ble State Commission Ahemdabad held that Doctor certificate without any affidavit of the doctor in support cannot be basis for repudiation of claim. It was held that the onus was upon the appellant to prove that the insured suppressed material facts. In this pronouncement citations Smt. Sunita Agarwal Vs LIC of India, III (2005) CPJ 446 = 2005 CTJ 874 relying on Supreme Court Judgment in case of Mithoolal Nayak, AIR 1962 SC 814, the Hon’ble MP State Commission were discussed.

14      In case Tarlok Chand Khanna Vs United India Insurance Co. Ltd. 2012(2) CLT 617(NC) wherein the Hon’ble National Commission held that onus to prove was on the respondent/ insurance company regarding pre-existing disease. In that case insurance company repudiated the claim on the ground that replacement of knees cannot occur within days or months and infact takes years for the keens to degenerate to a condition where total replacement is medically advised. In this case, Tarlok Chand Khanna obtained a mediclaim insurance policy from the respondent/ Insurance company valid from 1.1.2002 to 31.12.2002 for a sum of Rs. 1,50,000/- for himself and his wife Smt. Kurana Khanna. Smt. Karuna Khanna developed pain in her knees and on 15.9.2002 she underwent surgery for knees replacement of her both knees at a total cost of Rs. 1,78,945/-. She died due to sudden Cardiac arrest in the hospital on 29.9.2002. The complaint to claim the expenses was dismissed by the District Forum on the ground that there is no affidavit of any doctor of Nayyar Hospital nor there is any death certificate issued by Cardiologist showing cause of death of the wife of the complainant as cardiac arrest on 29.9.2002. The Hon’ble State Commission also dismissed the appeal. Sh. Updip Singh, ld. counsel for revisionist contended before the Hon’ble National Commission that the onus to prove that she had a pre-existing disease was on the respondent who failed to file any expert medical or credible evidence in support of its case. The counsel for petitioner relied upon a case titled National Insurance Co. Ltd. Vs Raj Narain, 1(2008)CPJ 501(NC), wherein Hon’ble National Commission had observed as follows:-

“Most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer because the Insurance Company relies on their Clause 4.1 of the policy in a mala fide manner to repudiate all the claims. No claim is payable under the mediclaim policy as every human being is born to die and diseases are perhaps pre-existing in the system totally unknown to him which he is genuinely unaware of them. Hindsight everyone relies much later that he should have known from some symptom. If this is so every person should do medical studies and further not take any insurance policy.” In view of the above facts, the Fora below erred in saying that claim was rightly repudiated.  

          In a nutshell it was held that onus was on the insurance company to prove that insured was suffering from pre-existing disease at the time of purchase of policy.

15      In case United India Insurance Company Vs Safiya 2013(3) CLT 195, identical view was taken by Hon’ble Kerala State consumer Disputes Redressal Commission, Thruvananthapuram

16      Furthermore, It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of DharmendraGoel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.UshaYadav& Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.        The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

The policy Ex. C-2 shows the sum assured Rs. 4,00,000/-. However, out of said amount, the opposite parties have made payment of Rs. 41,178 to the complainant and the complainant is entitled to the remaining insurance amount i.e. Rs. 3,58,822/-. (Rs. 400000-41,178=358822) By withholding the genuine claim of the complainant, the opposite parties have committed deficiency in service and unfair trade practice on the part of the opposite parties.

17      In light of the above discussion, the complaint succeeds and the same is hereby allowed with costs in favour of the complainant. The opposite Parties are directed to make the payment of Rs. 3,58,822/- to the complainant. The complainant has been harassed by the opposite parties unnecessarily for a long time. The complainant is also entitled to Rs. 15,000/- as compensation on account of harassment and mental agony and Rs 10,000/- as litigation expenses. Opposite Parties are directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation.  Copy of order be supplied to the parties free of costs as per rules. File be consigned to record room.

Announced in Open Commission

13.11.2024