Chandigarh

DF-I

CC/394/2023

BHANU MEHTA WIFE OF LATE ASHISH MEHTA - Complainant(s)

Versus

PNB METLIFE INDIA INSURANCE COMPANY LIMITED - Opp.Party(s)

SANJEEV SHARMA AND VISHAL SINGAL

16 Dec 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/394/2023
Date of Institution	:	17.8.2023
Date of Decision	:	16/12/2024

 

Bhanu Mehta wife of late Sh Ashish Mehta, resident of House No: 2577, sector 40-C, Chandigarh-160036

..Complainant

Versus

 

1. PNB MetLife India Insurance Company Limited 101, Techniplex 1. Techniplex Complex, Veer Savarkar Flyover, Off S V Road, Goregaon, West Mumbai 400062 Through its Managing Director and CEO Ashish Kumar Srivastava.

2. PNB MetLife India Insurance Company Limited through its Chairman, Claims Committee, PNB Metlife Insurance Company Ltd. Ist floor, Techniplex Complex, Off Veer Savarkar Flyover, Goregaon, West, Mumbai- 400062 through Ashish Vadhera Regional Operation Manager.

3. PNB MetLife India Insurance Company Limited through its Cluster Head, Shalini Kapoor having its office at SCO no: 68 &69, 2nd floor, Bridge Market, Sector 17, Chandigarh.

.opposite parties

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR SURESH KUMAR SARDANA	MEMBER MEMBER

                       

ARGUED BY	:	Sh. Sanjeev Sharma, Advocate for the complainant.
	:	Sh. Rajesh Sabharwal, Advocate for OPs.
	:

Per surjeet kaur, Member

     Briefly stated  the deceased husband of the complainant Mr. Ashish Mehta (hereinafter referred to be as DLA) had availed life insurance policy from OP i.e. PNB Metlife Super Saver Plan with a sum assured to the tune of Rs.1,01,89,948/- in case of death payable to the family members of the insured by paying annual premium amount of Rs.10,00,000/- and the complainant is the sole nominee in the said policy. The proposal form was filled by the agent of the OPs and the insured DLA was made to sign on dotted lines on the prescribed performa and no terms and conditions were supplied alongwith the policy certificate. Even no medical of the DLA was got done by the OPs. In  December 2012 for the first time the husband of the complainant was diagnosed with CA tongue and  the DLA underwent surgery on 21.12.2021 followed by chemotherapy and radiotherapy.  In the meanwhile the second premium of Rs.9,78,469/- was also paid by the DLA to the OPs insurance company which was encashed on 30.9.2022. Unfortunately on 15.1.2023 the DLA succumbed to the disease and died.  The complainant on 22.2.2023 submitted claim form alongwith requisite documents and accordingly the OPs appointed investigator and the complainant provided all the documents as and when required by the OPs. However, to the utter shock of the complainant the OPs insurance company vide email dated 29.3.2023 Annexure C-9  rejected the claim of the complainant on the flimsy ground that   the facts were deliberately and fraudulently represented by  the DLA. Thereafter the complainant  made various requests to the Ops but nothing was done.  Ultimately, the OPs at their own credited an amount of Rs.19,78,469/- in the account of the complainant being the premium paid by the DLA instead of the claimed amount. 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 Parties in their reply while admitting the factual matrix of the case stated that there is no cause of action in favour of the Complainant and against OPs. The policy under question "PNB MetLife Super Saver Plan" bearing number 23986247 was issued by the OP Insurance Company on the basis of the information provided by the deceased in the proposal application form no. 520114420. Since the information provided by DLA in the proposal / application form was established to be incorrect by the OP insurance company hence, the Company was well within its right to repudiate the claim of the Complainant. Since the Company has acted within the four corners of the statutory provisions, therefore, the present complaint is liable to be dismissed. Moreover, the policy in question was issued on 30.09.2021 with date of commencement of risk 30.09.2021 and the DLA died on 15.01.2023 just within 16 months from the date of commencing the policy. The early death of insured clearly proves that the policy in question was taken by the DLA with malafide intention to play fraud with opposite party-company. DLA passed away within a short span of signing of the Proposal Form and issuance of the Policy, which itself is a strong ground to raise reasonable doubt over the correctness of the material representations made in the Proposal Form. Thus the DLA had suppressed material facts with regard to his health at the time of taking the policy. Denying any deficiency on their part, all other allegations made in the complaint has been  denied being wrong.
3. Rejoinder was filed and averments made in the consumer complaint were reiterated.
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 sole grouse of the complainant  through the present case is that  her genuine claim  has been arbitrarily and illegally repudiated by OPs on flimsy ground without any base and evidence.
7. The stand taken by the Ops is that the  claim has been rightly repudiated as the deceased insured husband of the complainant (hereinafter referred to be as DLA)   has concealed material facts with regard to his health in the proposal form. Since the   information provided in the proposal form established to be incorrect hence, the claim of the complainant was repudiated.  It has also been stated that the total amount of the premium has already been refunded to the complainant. Hence, there is no deficiency in service on their part.
8. After going through the documents on record it is admitted fact as well as evident that the policy in question was purchased by the DLA on 30.9.2021  and the maturity date of the same was 30.9.2033. The first installment of the annual premium was Rs.10,00,000/- which was duly paid by the DLA  in the month of September as policy terms and conditions and the sum insured was Rs.1,01,89,948/-  and the  first premium of Rs.10 lakh was mentioned on the policy document itself and the premium paying period is of 12 years and frequency of  paying the premium is yearly basis. The complainant is the sole nominee   in the policy in question  and the most important document to be taken care of is patient’s history and physical record given by the treating hospital Fortis and the proposal form. Undoubtedly,  there is mention by the doctor regarding history of the  DLA which was conveyed by the complainant, the wife of the DLA  to the doctor concerned,   that there is non healing ulcer on left lateral tongue since March 2021  and pain referring to ear. It is specifically mentioned that the DLA was suffering from pain in the ear and difficult in swallowing. Initially the patient i.e. the DLA  went to the dentist for consultation and took treatment accordingly thereafter took homeopathic treatment also.  It is also evident from history of patient and physical record that the DLA was advised biopsy on 4.12.2021  and diagnosed with squamous  cell    carcinoma  tongue  i.e. subsequent to the commencement of the policy in question and even the Ops received second installment of the premium on 30.9.2022.
9. As per complainant his deceased husband was earning Rs.57,04,790/- annually  so being a wise person he in order to secure his life decided to purchase the policy in question with a high premium of Rs.10.00 lakh. The claim was submitted by the complainant after death of DLA being nominee  in the policy in question for the sum insured on death of the DLA. Annexure C-8 reveals the receipt of claim of the complainant by the OPs. However, the Ops repudiated the claim of the complainant  on 28.3.2023 vide Annexure C-10  on the ground of non disclosure of the material facts  as per terms and conditions  of the insurance policy and refunded the paid premium amounts. Pertinently Annexure OP-1-2/3   the proposal form  shows that the medical details are typed one and not filled by hand  and even not signed by  the insured.
10. In view of the above we are of the considered opinion that the repudiation of the claim by the OPs is baseless and contrary to the documents. As per record Annexure C-11, C-12, and C-13 at page 104,105, and 106 of the paper book of complaint it is evident that various requests were made by the complainant to Ops for supplying her proposal form and documents as well as report of any health check up and recent tests conducted by the OPs but there was no response  by the Ops and later on refused to provide the same being personal information of the DLA ignoring the fact that the complainant is nonelse but the wife of the DLA and also sole nominee in the policy in question and not any stranger. Hence, the said act of the OPs for non-providing documents to the nominee itself is unfair trade practice on their part.
11. As per record the OPs  rejected the claim of the complainant on the basis of report of private investigator who was on the job of the OPs only. However,  as per Annexure OP-1-2/5 the death summary  at page 113 of the written version of the Ops  it is revealed that  the DLA was diagnosed with squamous cell carcinoma left tongue  in December 2021 i.e. subsequent to the purchase of the policy in question. Hence, in our opinion, there is no occasion to the DLA to visit the dentist and ENT to get himself treated when he was aware that he is suffering from tongue cancer. Thus, there is  carelessness on the part of the  OPs by selling a high premium policy to the DLA without  conducting proper medical tests.  The investigator himself has mentioned that  he visited various hospitals, laboratories, clinics and even pharmacies of nearby location of the complainant/insured but he could not get any information regarding the sickness of the deceased.
12. We are of the considered opinion that any reasonable and prudent man, if is aware of any disease cannot remain without seeking medication from any hospital /doctor for his recovery and as the deceased husband of the complainant was never aware of any disease prior to December 2021, so he was not found under any medication or treatment from  any hospital/doctor. Even as per record of the file of the instant case the DLA took second opinion only after he was diagnosed with the disease in December 2021. Thus, in view of the forgoing discussion, we are of the opinion that  the OPs have arbitrarily and illegally repudiated the genuine claim of the complainant under the garb of mis-representation, which is not the case of the complainant. Moreover, the refund of the premium by the OPs itself shows that the OPs in order to hide their own misconduct of repudiating the genuine claim of the complainant refunded the premium amount though the complainant was entitled for the claimed amount.
13. The Hon’ble National Commission in various judgments have also allowed claim of complainants, even in cases wherein the mentioning of any past ailment/illness is there in medical records but it is not supported by any affidavit of concerned doctor who recorded past history and nor the doctor was produced in evidence. In the present matter the Ops have failed to produce on record any material evidence to show that the deceased husband of complainant i.e. late Sh Ashish Mehta was suffering from said ailment prior to issuance of policy.
14.   Reliance has been put on the judgment titled as National Insurance Company Ltd.  Vs. Swaraj Jain 2008(2) C.P.J. 59, decide by the Hon’ble  Rajasthan SCDRC, Jaipur, Life Insurance Corporation of India vs. Charanjit Kaur 2011(4) C.P.J. 373 decided by the Honb’ble National Commission, New Delhi and further in case titled as SBI Life Insurance Co. Ltd. Vs. Harvinder Kaur and another 2014(3) C.P.J. 552 decided by the Hon’ble National Commission, New Delhi. The principle of law  laid down in the aforesaid cases is squarely applicable to the instant case as the Ops have failed to produce on record any evidence or affidavit of any doctor that the complainant was suffering from pre-existing disease prior to issuance of the policy.  
15.  Hence, the act of OPs for repudiating the genuine claim of the complainant and forcing her to knock the door of this Commission amounts to deficiency in service and unfair trade practice on the part of the OPs.  Further as per the policy, the complainant is entitled for  the sum insured  of Rs.1,01,89,948/-. As the OPs have already refunded the amount of Rs.19,78,469/-  to the complainant being total premium amount received by them, therefore, we order the OPs to pay the remaining amount to the complainant to the tune of Rs.82,11,479/- (Rs.1,01,89,948/-minusRs.19,78,49/-).
16. In view of the above discussion, the present consumer complaint succeeds and the same is accordingly allowed. OPs are directed as under:-

1. to pay ₹82,11,479/- to the complainant alongwith interest @ 9% per annum (simple) from the date of institution of the present consumer complaint till onwards
2. to pay ₹50,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

17. This order be complied with by the OPs jointly and severally within a period of 45 days from the date of receipt of certified copy thereof, failing which the amount(s) mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation, over and above payment of ligation expenses.
18.  Pending miscellaneous application(s), if any, also stands disposed off.
19.  Certified copies of this order be sent to the parties free of charge. The file be consigned.

			[Pawanjit Singh]
			President
			[Surjeet Kaur] Member
16/12/2024			[Suresh Kumar Sardana]
mp			Member