Chandigarh

DF-I

CC/165/2020

Upinder Kaur - Complainant(s)

Versus

New India Assurance Co. Ltd. - Opp.Party(s)

Paras Money Goyal

27 Dec 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/165/2020
Date of Institution	:	26.5.2020
Date of Decision	:	27/12//2023

 

Upinder Kaur W/o Sh. Adarshvir Singh d/o late Sh. Harinder bir singh r/o H. No.39, phase 3-A, SAS Nagar (Mohali), Punjab.

 

… Complainant

V E R S U S

1.   The Divisional Manager New India Assurance Company Ltd. SCO No.58, Sector 26-C, Chandigarh.

 .  … Opposite Party

 

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR	MEMBER

                       

ARGUED BY	:	Ms. Niharika Goel, Advocate proxy for Sh. Paras Money Goyal, Advocate for complainant.
		Sh. Sukaam Gupta, Advocate for OP.

Per SURJEET KAUR, Member

     Briefly stated the policy holder Harinder bir Singh (now deceased) the father of the complainant was having medi claim insurance policy (Business and Holidays)  of OP  valid w.e.f. 9.9.2018 to 6.10.2018. The insured Harinder Bir Singh and his wife had a trip to USA from 9.9.2018 to 4.10.2018. During  the stay in USA of the insured Harinder Bir Singh he suffered a cardiac arrest and died on 30.9.2018. It is stated that in the process of for repatriation of the mortal remains of the deceased/insured  from California to New Delhi, postmortem and for air tickets and visa and other charges a total amount of 6562USD were incurred. After mortal remains came back to India the cremation was undertaken at Chandigarh. Thereafter the complainant lodged a claim with the OP and completed all the documentary formalities but nothing was done by the OP insurance company and the complainant is running from post to pillar get her claim despite exchange of various mail. The OP insurance company ultimately vide email dated 6.2.2020 closed the claim of the complainant. Alleging the aforesaid act of Opposite Parties deficiency in service and unfair trade practice on their part, this complaint has been filed.

2. The Opposite Party in its reply while admitting the factual matrix of the case stated that the claim of the complainant was repudiated   due to non –disclosure of material facts by the insured late Sh. Harinder Bir Singh at the time of taking the policy.  It is  averred that the insured Hardinder Bir Singh was having a past history of diabetes and said fact intentionally never disclosed in the proposal form.  the insured was also treated for hyperglycemia and having history of diabetes and as such the claim was denied and the said fact was intimated to the son of the  insured and he was advised to submit the medical reports from Washington Hospital mentioning that the insured does not have history of diabetes which he could not submit. Thus the claim of the complainant was rejected on account of pre-existing disease condition. Thus there is no deficiency on the part of the answering OP.  All other allegations made in the complaint has been denied being wrong.
3. No rejoinder filed by the complainant.
4. Contesting parties led evidence by way of affidavits and documents.
5. We have heard the learned counsel for the contesting parties and gone through the record of the case.
6. The complainant who is daughter of the deceased insured Sh. Harinder Bir Singh through the present complaint being nominee  has prayed for reimbursement of USD 6562 spent on the treatment and  repatriation  of the insured being duly covered under the disputed policy.
7. The grouse of the complainant through the present complaint  is that her genuine claim was repudiated by the OP on account of non disclosure of pre-existing disease i.e. of diabetic history of the insured.
8. The stand taken by the Ops is that the insured has not disclosed about his diabetic history, hence, due to suppression of material facts the claim was repudiated.
9. After going through the documents on record as per Annexure C-9 the death certificate  issued by the hospital/authorities at USA the cause of death is mentioned as probable cardiac insufficiency meaning thereby the insured died of cardiac arrest.
10. Perusal of Annexure C-2 the policy schedule at page 16 of the paper book reveals that in the event of death of the insured person the nominee shall be entitled for all the benefits covered under the policy. The relevant portion of the same is reproduced as under:-

“In the event of death of the insured person(s) due to an insured peril all benefits payable, in respect thereof under this insurance shall become payable to the Nominee declared in the proposal (incorporated herein as the schedule) and the Nominee declared in the proposal(incorporated herein as the schedule) and the receipt shall be construed as full and final discharge to the company in respect of all liability under this policy.”

 

     It is apparent from the  policy schedule  that the complainant is  the nominee of the insured.

11. So far as the question of suppression of material fact in respect of diabetic condition of the insured is concerned the same is falsified by the documents Annexure C-2 issued by the OP where there is mention of the name of physician in India as Dr. Gupta at Sector 19D, Chandigarh and original reports and medical certificates were attached by the insured were duly accepted saying “yes” by OP. Hence, it shows contradictory stand taken by the OP as on the one hand it says that the complainant  was suffering from diabetic condition on the other hand as per Annexure C-2 all reports and medical certificates of the complainant were duly checked by the OP before issuing the policy in question. Admittedly, the complainant died during the currency of the policy in question.  
12. Annexure C-5  is the detail summary  of the health status of the insured issued by the Washington Hospital Health Care System where the complainant before death was admitted specifically at page 23 of Annexure C-5 there is mention as under:

“past social history negative for: alcohol use and tobacco use. Past medical history is negative for diabetes mellitus type-I, diabetes mellitus type II and high BP”

 

     Again at page 29 there is mention of treatment of dka, endocrine crisis, unstable vs.. Hence, there is no evidence and document on record from which it can be concluded as alleged by the OP insurance company. Hence, the act of the OP insurance company  repudiating the genuine claim of the complainant is deficiency in service and unfair trade practice.

13. Even otherwise the Hon’ble National commission in Neelam Chopra vs Life Insurance Corporation Of  India  decided  on 8 October, 2018   held as under:-

“11.      “From the above, it is clear that the insurance claim cannot be denied on the ground of these life style diseases that are so common. However, it does not give any right to the person insured to suppress information in respect of such diseases.  The person insured may suffer consequences in terms of the reduced claims.”

xx x x x x x x

14. Moreover, the non-disclosure of information in respect of this life style disease of diabetes, will not totally disentitle the complainant for indemnification of the claim in the light of the judgement of Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., (supra)."

 

14. In view of the above discussion, the present consumer complaint succeeds and the same is accordingly allowed. OP is directed as under:-

1. to pay USD 6562  to the complainant in Indian currency prevailing at the time of filing of the claim with interest @9% P.A. from the date of repudiation of claim till onwards.
2. to pay Rs.20,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay Rs.10,000/- to the complainant as costs of litigation.

15.      This order be complied with by the OP within 45 days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
16. Pending miscellaneous application(s), if any, also stands disposed off.
17.      Certified copies of this order be sent to the parties free of charge. The file be consigned.

			sd/- [Pawanjit Singh]
			President
			Sd/-
			[Surjeet Kaur] Member