Chandigarh

DF-I

CC/455/2020

Munish Julka - Complainant(s)

Versus

M/s TATA AIA Life Insurance Co. Ltd. - Opp.Party(s)

Devinder Kumar

01 Sep 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                  

Consumer Complaint No.	:	CC/455/2020
Date of Institution	:	14/10/2020
Date of Decision	:	01/09/2023

Munish Julka son of Sh. Prannath Julka, aged about 42 years, resident of House No.21-A, Sector 42-A, Chandigarh.

… Complainant

V E R S U S

1. M/s TATA AIA Life Insurance Company Limited, Regd. & Corp. Office : 14^th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai 400013 through its the Managing Director.
2. M/s TATA AIA Life Insurance Company Limited, SCO No. Sector 22/C, Chandigarh through its the Branch Manager.
3. M/s Policy Bazar.com, Registered Office : Plot No.119, Sector 44, Gurgaon, Haryana 122001 through its Managing Director.

… Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                                               

ARGUED BY	:	Sh. Devinder Kumar, Advocate for complainant
	:	Sh. Nitin Thatai, Advocate for OPs 1 & 2 alongwith Ms. Monika Thatai, Advocate
	:	Sh. Vikas Mehra, Advocate proxy for Sh. Munish Kumar Garg, Advocate for OP-3

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Munish Julka, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that in the month of March 2020, during COVID-19 pandemic, wife of the complainant, namely Smt. Jyotsna, intended to buy a life insurance policy for her.  As it was not possible for the complainant and his wife to visit local branch/office of the Insurance Company for the purchase of the insurance policy, they opted for digital platform and approached the online portal Policybazaar.com (OP-3). The online portal of OP-3 had provided various types of insurance plans of different insurance companies and finally the agent of OP-3 allured the complainant to purchase the life insurance policy of OPs 1 & 2.  Under the direction of OP-3, complainant’s wife had paid monthly premium of ₹1,078/- on 22.3.2020 which is also shown in the statement of account (Annexure C-1). Prior to the issuance of a policy, agent of OP-3 had put two queries to the complainant’s wife i.e. general present health and any BP/sugar related issues for the last years and on this proposal form was filled and her PAN and aadhar card were verified.  On completion of all the formalities, “Tata AIA Life Insurance Sampooran Raksha” policy (Annexure C-2) (hereinafter referred to as “subject policy”) was issued in the name of Mrs. Jyotsna (hereinafter referred to as “Life Assured”) on 27.3.2020.  On the morning of 20.4.2020, at around 11:30 a.m. the Life Assured faced some neurology related problem and immediately complainant took her to PGI, Chandigarh for treatment and after treatment she was discharged at around 2:00 p.m. Copy of the treatment card is Annexure C-3. On the same evening at around 10:50 p.m. the Life Assured faced chest pain and breathing problem and she was again brought to the PGI where the doctors advised for ECG.  On 21.4.2020, after performing ECG, the doctors declared that she has died due to sudden cardiac arrest. Copies of ECG report and death certificate are Annexure C-4 & C-5. Immediately information qua death of Life Assured was given to the OPs. Vide emails (Annexure C-6 & C-7) OPs 1 & 2 asked for some documents, which were also provided by the complainant pertaining to the medical record.  The complainant remained in touch with the OPs requesting them to settle the claim of the Life Assured, but, with no result.  Ultimately, OPs 1 & 2 with malafide intentions repudiated the genuine claim of the complainant vide letter dated 31.8.2020 (Annexure C-16) on the ground that the Life Assured had concealed information in the proposal form.  Thereafter, the complainant sent a legal notice dated 14.9.2020 (Annexure C-17) to the OPs stating that the genuine claim has wrongly been repudiated.  The said notice was replied by the OPs on 25.9.2020 (Annexure C-18).  In this manner, the aforesaid acts of the OPs amount to deficiency in service and unfair trade practice.  OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their separate written versions.
3. In their written version, OPs 1 & 2, inter alia, took preliminary objections of maintainability and concealment of facts.  It is admitted that the Life Assured had purchased the subject policy from the answering OPs by submitting the proposal form/application (Annexure OP-2) and she had concealed material information about earlier treatment taken for her heart related and neuro related diseases as well as hyper tension and also that she was a known case of Cortical Venous Thrombosis and Cerebral Venous Thrombosis even in the year 2014 (Cerebral Venous Thrombosis is a form of stroke in which a clot in one of the blood vessels in the brain impedes the free flow of blood).  As the Life Assured was bound to give material information to the insurer before purchasing the policy and in the case in hand as the Life Assured had concealed material information qua her earlier diseases and treatment taken by her from the PGI even in the year 2014, she has violated the terms and conditions of the policy and the claim of the complainant was accordingly rightly repudiated. On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
4. In its separate written version, OP-3 took preliminary objections of maintainability and cause of action.  On merits admitted that the Life Assured had purchased the subject policy through it by paying monthly premium of ₹1,078/-, but, denied that the complainant has any cause of action against the answering OP.  It is further alleged that the subject policy was issued by OPs 1 & 2 and the consumer complaint is not maintainable against the answering OP. The cause of action set up by the complainant is denied. The consumer complaint is sought to be contested.
5. In replication to the written version of OP-3, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the deceased Life Assured i.e. wife of the complainant had purchased the subject policy (Annexure C-2) from OPs 1 & 2 through the digital mode having been provided through OP-3 on 27.3.2020 by paying monthly premium of ₹1,078/- and also that she had taken treatment at PGI on the morning of 20.4.2020 and was discharged at around 2:00 p.m., but, again on the same evening she was brought to the PGI around 10:50 p.m. when she was having chest pain and breathing problem and on 21.4.2020 after ECG, she was declared dead due to sudden cardiac arrest and also that the life assured died within 25 days of the purchasing of policy, and the claim of complainant was repudiated by OPs 1 & 2 vide repudiation letter (Annexure C-16) on the ground of concealment of material facts qua the pre-existing disease, the case is reduced to a narrow compass as it is to be determined if the OPs are unjustified in repudiating the claim of the complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of the OPs.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy and the medical record having been relied upon by both the parties and the same is required to be scanned carefully. 
   3. As per the case of complainant, Life Assured was not suffering from any disease prior to obtaining the subject policy, which fact has specifically been denied by the OPs as they have come with specific defence that, in fact, deceased Life Assured and complainant had concealed material facts qua the diseases related to neuro as well as heart at the time of purchasing the subject policy and have not disclosed even in the proposal form which has been admittedly submitted by Life Assured to OPs 1 & 2.
   4. Perusal of proposal form (Annexure OP-2) clearly indicates that while submitting the same, deceased Life Assured had specifically concealed material information sought by OPs 1 & 2 under Part B : Health & Personal Details and the relevant columns of the same are reproduced as under :-

“4.	Have you ever been advised to and/or have undergone any tests, investigations or surgery or had signs or symptoms of any condition, ailment or injury and/or were advised treatment for or have been hospitalized for check-up or treatment other than minor flu, cold or influenza?	No
5.	Have you ever been diagnosed with or investigated for any of the following :
	a. Cardio :High or Low Blood Pressure/Raised Cholesterol/Chest Pain/ Palpitation/Rheumatic Fever/Heart Murmur/Shortness of Breath/ Heart Attack/Stroke/Any other heart condition	No

 

Thus, one thing is clear on record that the Life Assured had specifically intimated OP-1 that she had never undergone any tests, investigations or surgery etc. for any of the aforesaid ailments/diseases.

5. On the other hand, the medical record even relied upon by the complainant itself shows that the Life Assured was suffering from various diseases even before purchasing the subject policy, which fact is also clear from the copy of out-patient card (Annexure C-3), having been issued by PGI, Chandigarh on 20.4.2020 indicating multiple episodes of seizure to the patient (Life Assured) on 31.8.2014.  Not only this, even OPs 1 & 2 have called/proved the record (Ex.CX) from PGI relating to the Life Assured Smt. Jyotsna, which clearly proves that even on 15.9.2014 she was having history of Cortical Venous Thrombosis.  At the same time, even other record (Annexure OP-4), having been proved by OPs 1 & 2, further indicates that the Life Assured was having neurology problem in the year 2014 regarding which she was seeking treatment from the PGI, Chandigarh. Thus, one thing is further clear on record that the complainant and his wife i.e. deceased Life Assured had concealed material information from the OPs while submitting the proposal form and before purchasing the subject policy by not disclosing about the serious diseases which the Life Assured was suffering even in the year 2014 and she was continuously taking treatment for the same.
6. It has been contended on behalf of the OPs that as concealment of material information by the insured is clear violation of the terms and conditions of the policy, the claim of the complainant was rightly repudiated by the OPs.  On the other hand, it has been contended on behalf of the complainant that since OPs 1 & 2 have failed to prove on record that the aforesaid diseases had any relation with heart attack due to which the Life Assured had died, the same has no concern with the present case and OPs 1 & 2 have wrongly repudiated the claim of the complainant.
7. There is no force in the contention of the complainant as Annexure 4, Section 45 of the terms and conditions of the subject policy (Annexure OP-3 at page 68 of the paperbook) clearly prescribes that on the ground of fraud, a policy of life insurance may be called in question within three years from the date of issuance of the policy or commencement of the risk etc. and the said clause is reproduced below for ready reference :-

                                “ANNEXURE 4

c.     Section 45 – Policy shall not be called in question on the ground of mis-statement after three years.

Provisions regarding Policy not being called into question in terms of Section 45 of the Insurance Act, 1938, as amended by Insurance Laws (Amendment) Act, 2015 are as follows:

01.   No Policy of Life Insurance shall be called in question on any ground whatsoever after expiry of 3 yrs from

a. the date of issuance of Policy or

b. the date of commencement of risk or

c. the date of revival of Policy or

d. the date of rider to the Policy

whichever is later.

02.    On the ground of fraud, a Policy of Life Insurance may be called in question within 3 years from

a. the date of issuance of Policy or

b. the date of commencement of risk or

c. the date of revival of Policy or

d. the date of rider to the Policy

whichever is later.

For this, the insurer should communicate in writing to the Life Assured or legal representative or nominee or assignees of insured, as applicable, mentioning the ground and materials on which such decision is based.

03.    Fraud means any of the following acts committed by Life Assured or by his agent, with the intent to deceive the insurer or to induce the insurer to issue a life Insurance Policy:

a. The suggestion, as a fact of that which is not true and which the Life Assured does not believe to be true;

b. The active concealment of a fact by the Life Assured having knowledge or belief of the fact;

c. Any other act fitted to deceive; and

d. Any such act or omission as the law specifically declares to be fraudulent.”

8. In the case in hand, as it has come on record that the complainant as well his wife i.e. Life Assured had concealed material information pertaining to her health, the instant case is clearly covered under the afore-extracted definition of fraud of the terms and conditions of the subject policy, especially when the Life Assured has an active concealment of the fact, having knowledge or belief of the fact in order to deceive the insurer and the claim of the complainant was rightly repudiated by the insurer.  In support of their case, OPs have relied upon the judgment of the Hon’ble Apex Court in the case of Life Insurance Corporation of India Vs. Manish Gupta, 2019 (2) RCR (Civil) 906, in which it was held as under :-

“Consumer Protection Act, 1986 Section 23 Mediclaim - Repudiation - Documentary material indicates there was clear failure on part of claimant to disclose that he had suffered from rheumatic heart disease since childhood - Ground for repudiation was in terms of exclusions contained in policy - Failure of insured to disclose past history of cardiovascular disease was valid ground for repudiation - Consumer fora have made fundamental error in allowing claim for reimbursement of medical expenses.”

9. In view of the foregoing, it is safe to hold that the complainant has failed to prove any deficiency in service or unfair trade practice on the part of OPs and the present consumer complaint deserves dismissal.

4. In the light of the aforesaid discussion, the present consumer complaint, being devoid of any merit, is hereby dismissed leaving the parties to bear their own costs.
5. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
6. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 01/09/2023 hg			Sd/- [Pawanjit Singh] President
			Sd/- [Surjeet Kaur] Member
			Sd/- [Suresh Kumar Sardana] Member