Haryana

Ambala

CC/301/2016

Jamero Devi - Complainant(s)

Versus

PNB Metlife India Insurance Co Ltd. - Opp.Party(s)

Deepak Saini

05 Mar 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA

 

                                                          Complaint case no.        : 301 of 2016.

                                                          Date of Institution         : 01.08.2016.

                                                          Date of decision   : 05.03.2018.

 

Jamero Devi aged about 50 years wd/o Sh.Ram Singh r/o village Sainmajra, Tehsil Naraingarh District Ambala.

 

 

……. Complainant.

                                      Versus

 

 

1.PNB Metlife insurance company ltd. registered office Brigade Seshamahal No.5, Vani Vilas Road, Vasavangudi, Banglore, Karnatka through its Chairman.

2.PNB Metlife India Insurance Company Ltd, Platinum Tower, 4^th Floor Sohna Road, Sector 47 Gurgaon  through Sh.Appoorv Bagga, Deputy Manager Customer Service Team.

3.PNB Metlife India Insurance Company Limited Branch Office, Second floor, SCO-36 Sector 11, Panchkula through its Branch Manager.

4.Ms.Meenu Sabharwal Corporate Agent, PNB Metlife India Insurance Company Ltd. c/o Punjab National Bank, Branch, Nariangarh District Ambala.

5.Punjab National Bank, through its Branch Manager, Naraingarh Branch District Ambala.

 

                                                                             ….…. Opposite parties.

 

BEFORE:   SH. D.N. ARORA, PRESIDENT

                   SH. PUSHPENDER KUMAR, MEMBER         

                   MS. ANAMIKA GUPTA, MEMBER                 

 

Present:       Sh.Deepak Saini, counsel for complainant.

                   Sh.Shubh Kumar Sharma, counsel for OP Nos. 1 to 3.                              Sh.Bimal Kant, counsel for the OP No.4.                                                         OP No.5 exparte.

 

ORDER

                   The complainant has filed the present complaint with the averments that her husband Ram Singh - since deceased had opened a joint saving bank account No.27330000402831098 with OP No.5 which introduce Op No.4 and asked about insurance policy of Op No.1. After being convinced, the complainant and her husband purchased policy Met Family Income Protection Plus INV. It was told by the Op No.4 that for policy the purchaser had to pay Rs.3746/- per month as premium for 15 years and they would be entitled for the maturity amount of Rs.15 lacs after 15 years besides death claim of Rs.15 lacs to be given to the nominee.  The premium was deducted automatically from the joint saving account. In the end of September, 2014 Ram Singh-since deceased received the policy No.21383615. On 09.04.2015 Ram Singh-since deceased felt pain in chest besides breathing problem and for which he was taken to GMCH Sector 32 Chandigarh where he remained admitted and died on 13.04.2015 as natural death. The complainant intimated the same to the Op Nos. 4 & 5 but they without bothering the same kept on deducting the monthly premium upto August, 2015. The complainant visited Op No.3 who assured that the claim amount would be paid after completing the formalities which were demanded by Op No.1 vide letter dated 19.08.2015. The complainant submitted the requisite documents with OPs but she was taken by surprise when OPs vide letters dated 28.03.2016 and 30.05.2016 on the ground of non-disclosure of the material facts and also refused to return the documents wrongly and illegally. The OPs kept on receiving the premium for 12 months after the death of her husband since 27.08.2014 to 05.08.2015 without any fault.  The act and conduct of the OPs clearly amounts to deficiency in service on their part. In evidence, the complainant has tendered affidavit Annexure CX and documents Annexure C1 to Annexure C10.

2.                          On notice Op Nos.1 to 3 in their joint reply have submitted that there is no deficiency in service on their part. The deceased life assured (hereinafter to be referred as DLI) had obtained insurance policy against sum assured of Rs.12 lacs. The policy in question was issued after understanding the terms and conditions of the plan by the proposer wherein they had declared that all the relevant information have been disclosed.  The policy was issued on believing the information provided by the DLI in the proposal form with risk commencement date of 04.09.2014.  The complainant has been appointed as nominee in the policy. The OPs had received death claim of the DLI on 13.08.2015 wherein it has been intimated that the person insured had died on 13.04.2015 due to natural death. Being an early claim thorough investigations were carried out which revealed that the DLI had not provided true and correct information at the time of filing of proposal form with respect to his medical history. The DLI had obtained the policy in question by playing fraud upon the OPs because he was well aware about the deadly disease before purchasing the policy in question. The claim has rightly been repudiated on account of non-disclosure of the material facts as the DLI was suffering from DM Type 2 since 5 years and was an alcoholic and smoker since 25 years. The policy terms and conditions are drawn as per guidelines laid down by the IRDAI and before issuance to general public each policy format is approved by the IRDAI.  The grounds for repudiation was duly communicated by the Ops to the complainant vide letter dated 12.10.2015. The complainant being beneficiary/ nominee under the said policy was bound by the contents stated by the DLI in the proposal form and cannot challenge the same, therefore, she is not entitled to claim any benefits under the said policy. Other contentions have been controverted and prayer for dismissal of the complaint has been made.

                             OP NO.4 in its separate reply has taken many preliminary objections such as maintainability, cause of action and suppression of material facts from this Forum. The Op nO.4 being agent had told about the policy to the husband of the complainant  but it is denied that he was told about getting a maturity amount of Rs.15 lacs after 15 years. The policy was obtained by the complainant and her husband after understanding all the terms and conditions but the policy in question was purchased after concealing the material facts because he was suffering from various diseases and was a chronic patient. He himself had violated the terms and conditions of the policy, therefore, the complainant is not entitled for any claim. There is no deficiency in service on its part. Other contentions have been controverted and prayer for dismissal of the complaint has been made. Op No.5 did not appear before this Forum, therefore, it was proceeded against exparte vide order dated 30.09.2016.  In evidence, the appearing Ops have tendered affidavits Annexure RX and documents Annexure R1 to Annexure R34.

3.                The complainant has filed the replication to the replies filed by the Ops wherein she has reiterated the contents taken in the complaint after denying the averments made in the replies by the OPs.  

4.                We have heard learned counsel for the parties and gone through the case file very carefully.

5.                Undisputedly, the husband of the complainant had obtained an insurance policy Met Family Income Protector Plus - NV for 15 years commencing from 04.09.2014 on monthly payment basis from the Ops and paid the installment upto 05.08.2015 as per statement of account placed on file as Annexure C8/R42. The grouse of the complainant is that her husband died during the period of insurance policy but the OPs have repudiated the claim despite the fact that it was the duty of the insurance company to indemnify the same.  

6.                          On the other hand the OPs have come with the plea that the husband of complainant was having pre-existing disease and the present policy was obtained by the complainant after concealing the material facts qua his health from the insurance company and in support of this plea learned counsels for the Ops have draw the attention of this Forum towards Annexure R21 i.e. Death report of DLI Ram Singh issued by GMCH Sector, 32 Chandigarh and the certificate issued by the last attending doctor of the DLI Annexure C3. It has been further argued that the claim has rightly been repudiated as the complainant has violated the terms and conditions of the policy by concealing the material facts qua his health status from the insurance company. In support of his contentions he placed reliance of case law titled as United India Insurance Company Limited Vs. MKJ Corporation III (1996) CPJ 8 (SC), Satwant Kaur Sandhu Versus New India Assurance Company decided by Hon’ble Supreme Court of India on 10.07.2009 in Civil Appeal No.2776 of 2002 and Jai Kishan Vs. LIC (NC) Revision Petition No.1883 of 2015 decided on 12.08.2015.

7.                          Undisputedly the husband of the complainant had obtained Policy Annexure C1 from the OPs and he died on 13.04.2015 Annexure R11 during the subsistence of the policy Annexure R4. The complainant in her complaint has specifically mentioned that for the very first time her husband diagnosed with heart disease but subsequently he died on 13.04.2015 at GMCH, Sector, 32 Chandigarh on 13.04.2015. The OPs remained mum whether the husband of the complainant was medically examined or not before issuing the policy in question, therefore, the Ops are ceased to take such plea that the complainant was having pre-existing disease of DMII besides smoker and alcoholic for the last 25 years. It is strange that the Ops have repudiated the claim of the complainant without producing any previous medical history of the complainant, though the Ops have tried to take the benefit of certificate issued by last attending doctor of the DLI wherein it has been mentioned that he was suffering from DMII besides smoker and alcoholic for the last 25 years

 but it is not enough to deny the claim of the complainant because in this very document it has also been mentioned that the DLI had died natural death.  There is nothing on the case file to show that the DLI was aware of the disease and even also, the OPs did not produce any evidence to prove that which medication and for how long the complainant was taking for diabetes. The counsel vehemently argued that the DLI was having deadly disease besides diabetes but without any documentary proof this argument arguments has no substance. We have perused the report of investigator Annexure R18 wherein he has opined that DLI was admitted in the hospital on 09.04.2015 to 13.04.2015 in Government Medical College and died due to Cardio Respiratory arrest. Even then the investigator has not filed his affidavit on the file. From the perusal of report of investigator wherein he has mentioned that he enquired from Numberdar as well as neighbours and chemist shop but none of them have disclosed that the DLI was chain smoker and alcoholic. The surveyor has also mentioned in his report that the hospital did not provide medical document to insurance company. Had it been so it was the burdened duty of the insurance company to summon the treatment record but it has failed to do so. It is worthwhile to mention here that it is known that, many times the healthy persons are unaware of such silent aliments of diabetes and hypertension, which come to their knowledge first time during health checkup camps or in any emergent situation. Thus, OPs can not apply a hard and fast rule to presume that, the complainant was suffering for long duration i.e. before taking the policy. Therefore, we are not convinced with this argument. No doubt the medical literature states that, the Diabetes is risk factor for Coronary Artery Disease, but the OPs failed to prove that this disease was pre-existing in this case. Support can be had from the judgment rendered by Hon’ble National Commission in L.I.C. of India versus Joginder Kaur and Another, 2005(1) C.P.C. 52 (N.C.), wherein it has been held that:-

 

“…….Simple allegations were made by the petitioner that the deceased was alcoholic; was suffering from diabetes mellitus, and jaundice etc would not be sufficient. The unproved case history recorded by some person on the date of admission of Sh. Bachan Singh, the deceased, would not be cogent and convincing evidence to repudiate the claim unless it was coupled with medical report for the treatment prior to submission of the proposal form.”

 

It was just a hypothetical presumption of OPs to repudiate the claim of complainant. Such argument is bereft of any merit and has no medical basis.  The Ops have failed to prove on the case file that there was any nexus between the death and disease which the Ops have claimed as pre-existing disease. On this point reliance can be taken from case law titled as United India Insurance Co. Limited Vs. Krishan Prakash Dubey, 2011 (4)  CPJ 142  wherein Hon’ble National Commission has held that  As per exclusion clause a person would not be titled to indemnification if he contracts the disease as stated during the first 30 days from the commencement of the date of the policy-But the note which has the effect of a provisio, clearly states that the exclusion clause will not apply if in the opinion of a penal of medical practitioner constituted by the company for the purpose, the insured person could not have known of the existence of the disease or the symptoms or complaints thereof at the time of making the proposal for insurance- The burden to prove that the respondent complainant had any prior  knowledge about his medical problem was squarely on the petitioner Insurance Company who have not been able to discharge the same satisfactorily Revision petition liable to be dismissed.

8.                          Keeping in view the above discussion as well as facts and circumstances of the case we are of the considered view that the complainant has been able to prove his case against the Ops by leading cogent and reliable evidence because her husband had died during the subsistence of the policy and she has been nominee in the said policy. The Ops have wrongly and illegally declined the genuine claim of the complainant; therefore, the repudiation dated 28.11.2016 Annexure C5 made by the Ops is hereby quashed. Accordingly, we allow the present complaint with cost which is assessed at Rs.10,000/-. The complainant has pleaded that her husband had purchased the policy having value to the tune of Rs.15 lacs but the policy Annexure R4 reveals that the sum assured in the said policy was Rs.12 lacs, therefore, the complainant is entitled for Rs.12 lacs being sum assured alognwith interest @ 9% per annum to the complainant from the date of filing of the complaint till its realization. Present complaint is allowed accordingly. Copy of this order be sent to the parties concerned, free of costs.  File be consigned to the record room after due compliance. 

ANNOUNCED ON: 05.03.2018

                                               

(PUSHPENDER KUMAR)     (ANAMIKA GUPTA)      (D.N.ARORA)                      MEMBER                  MEMBER               PRESIDENT