DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

SHAHEED BHAGAT SINGH NAGAR

Consumer Complaint No. RBT/CC/17/197 Date of Institution: : 14.03.2017

Date of Decision : 15.12.2021

Rajinder Kaur 56 years w/o late Major Singh, r/o village Otalan, District Ludhiana.

….. Complainant

Versus

1. HDFC Standard Life Insurance Company Ltd, 279, Ward No. 20, Near Gurudwara Kalgidhar Sahib, G.T Road, Ludhiana, Khana

141401 Khanna through its authorized signatory.

2. HDFC Standard Life Insurance Company Ltd., Lodha Excelus, 13^th Floor, Apollo Mills Compound, N.M Joshi Marg, Mahalaxmi Mumbai 400011 through its authorized signatory.

3. HDFC Standard Life Insurance Company Ltd., Mayur Vihar Phase 1, Star City Mall, 1^st Floor Mayur Place, District Center Pin Code 11009, Delhi through its authorized signatory.

…..Opposite parties

(Complaint under the provision of Consumer Protection Act)

QUORUM:

SH.KULJIT SINGH, PRESIDENT

SH.YADWINDER PAL SINGH BAATH, MEMBER

SMT. RENU GANDHI, MEMBER

ARGUED BY:

For complainant : Sh. M.S. Sethi, Advocate For OPs : Sh. Nitin Kapila, Advocate

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PER : KULJIT SINGH, PRESIDENT

1. The present complaint received by transfer from District Consumer Disputes Redressal Commission, Ludhiana, in compliance order dated 26.11.2021 passed by Hon'ble State Commission, Punjab Chandigarh.

2. The complaint filed by the complainant on the averments that her husband Major Singh (since deceased) obtained services of OPs for obtaining HDFC Life Classic Assure Plus Insurance Policy bearing no.18097010 on 14.12.2015 for tenure period of 15 years against sum assured of Rs.2,81,655/- and minimum death benefit of Rs.4,31,890/-. Major Singh (since deceased) paid first installment of Rs.43,189/-on 31.12.2015. Major Singh husband of the complainant was also examined by penal of doctors along with conducting of necessary tests including of bloods before issuance of the said policy and proposal form was filled by agent of OPs, thereafter policy document issued to Major Singh on 01.01.2016 consisting policy schedule bearing policy no.18097010. During the tenure of the policy, Major Singh husband of the complainant (since deceased) got admitted in the hospital for the period 17.08.2016 to 22.08.2016 and was diagnosis for Type 2 Diabetes Mellitus, Diabetic foot right foot, diabetic retionopathy and opium addict and Major Singh died in the evening at home on same day i.e. 22.08.2016. The claim was lodged by complainant being nominee with OPs but same was repudiated vide its letter dated 02.02.2017 on the ground that

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life assured was suffering from diabetes mellitus, hypertension, chronic renal disease and hepatic encephalopathy prior to the policy issuance. The complainant alleged that her husband was not suffering from diabetes mellitus, hypertension and chronic renal disease prior to issuance of the policy. The complainant alleged that her husband has not given any wrong answer and never taken any kind of treatment against queries in part II in the proposal application well before the commencement of the policy. The complainant was married with Major Singh in year 1984 but she never found her husband with any above such referred diseases before commencement of the policy no.18097010 or previous policy no.17949460 before commencement of the policy was found in order hence claim has been denied illegally and arbitrary. The complainant alleged deficiency in service and unfair trade practice on the part of OPs. Due to act and conduct of OPs, she has filed the instant complaint being nominee of her husband and prayed that the OPs be directed to pay Rs.1,00,000/- as compensation for mental harassment and Rs.22,000/- as costs of litigation.

3. Upon notice, OPs appeared, filed written reply and contested the complaint of the complainant by raising preliminary objections that complaint is not maintainable. The complainant suppressed the material facts from this Commission. On merits, it was averred that complainant had obtained HDFC Life Classic Assure Plus Insurance Policy on 14.12.2015 for

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a tenure of 15 years against the sum assured of Rs.2,81,655/- and against the said policy, only one premium of Rs.43,189/- was paid by him to OPs. The complainant lodged her claim with OPs and in terms of the said policy, OPs processed the claim and from investigation, it was established that life assured was suffering from Diabetes Mellitus, Hypertension and Chronic Renal Disease and Hepatic and this fact was not disclosed by the assured in the application dated 14.12.2015. Even then OPs refunded the amount of premium of Rs.43,189/- to the complainant, which was duly accepted by complainant without any protest and upto her complete satisfaction. The claim of the complainant has already been settled by OPs and no further amount is payable by OPs to complainant. After receipt of amount of Rs.43,189/- from OPs, the complainant has no right to re-agitate the matter by filing the complaint. The insurance policy is a contract in itself and parties are bound by the terms and conditions of the policy and policy issued on the basis of utmost good faith. It was denied that Major Singh was examined by penal doctors along with conducting of necessary tests. The claim of the complainant has already been settled by OPs and no further amount is payable by the OPs to the complainant. There is neither any deficiency in service nor any unfair trade practice on the part of OPs. Rest of the averments were denied by OPs and they prayed for dismissal of the complaint.

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4. The complainant has tendered in evidence her affidavit Ex.CA-1 along with copies of documents Ex.C-1 to Ex.C-8 and close the evidence. On the other hand, OPs tendered in evidence affidavit of Gaurav Sikka Deputy Manager as Ex.R-A along with copies of documents Ex.R-1 to Ex.R-10 and close the evidence.

5. We have heard learned counsel for the parties and have also gone through the record of the case very minutely as well as written arguments filed by OPs.

6. The counsel for the complainant alleged that the she lodged the death claim with OPs being nominee of her husband. She alleged that her husband got admitted in the hospital for the period 17.08.2016 to 22.08.2016 against complaints of altered sensorium and fever and diagnosis for Type 2 diabetes mellitus. Her husband died on 22.08.2016 and after his death she lodged claim with OPs but OPs repudiated her claim vide letter dated 02.02.2017 on the ground that assured was suffering from diabetes mellitus, hypertension, chronic renal disease and hepatic encephalopathy prior to policy issuance. The complainant alleged deficiency and unfair trade practice on the part of OPs.

7. To controvert the allegations of the complainant leveled in the complaint, OPs pleaded that it is admitted that the complainant had obtained HDFC Life Classic Assure Plan Insurance Policy on 14.12.2015 for tenure

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of 15 years against sum assured of Rs.2,81,655/- and against the said policy, only one premium of Rs.43,189/- was paid by him to OPs. Major Singh was liable to pay the premium of Rs.43,189/- continuously for ten years. The assured was suffering from Diabetes Mellitus, Hypertension, Chronic Renal Disease Mellitus and said fact was not disclosed by complainant in application dated 14.12.2015. But OPs refunded the premium of Rs.43,189/- to complainant which was duly accepted by complainant without any protest and upto her entire satisfaction. Therefore, the claim of the complainant has already been settled by OPs and no further amount is payable by OPs. OPs prayed for dismissal of the complaint.

8. It is an established fact that the complainant obtained insurance policy no.18097010 from OPs on 01.01.2016, this fact is proved from copy of policy Ex.C-1 on the record. The husband of the complainant Major Singh died on 22.08.2016, vide death certificate Ex.C-8 on the record. The policy in question commenced from 14.12.2015 and issued on 31.12.2015 with premium of Rs.43,189/- and maturity date is 14.12.2030 this fact is clear from perusal of policy document Ex.C-3 placed on the record. The complainant Rajinder Kaur nominee of her husband Major Singh (since deceased) vide nomination schedule Ex.C-3 placed on the record. The diagnosis given to the life assured as Type 2 Diabetes Mellitus, Diabetic foot right foot, diabetic retinopathy and opium addict, this fact is proved from

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copy of data summary Ex.C-6 on the record. The complainant obtained policy for sum assured of Rs.2,81,655/- and only one premium of Rs.43,189/- was paid by him to OPs. From perusal of data summary Ex.C-6, this fact is clear that the life assured suffering from Type 2 Diabetes Mellitus, Diabetic Retinopathy and Opium addict. All terms and conditions were supplied to the life assured and this fact is within the knowledge of the life assured. The policy in question issued to the life assured on 31.10.2015 consisting policy schedule. The life assured get the treatment from the Fortis Hospital Ludhiana before issuance of the policy in question, this fact is clear from perusal of progress notes dated 30.09.2015 Ex.R-6 placed on the record. Ex.R-6 is vital document on the record for adjudication of the case in hand. This document shows that life assured taken the treatment before issuance of the policy but he suppressed this material fact from OPs. From perusal of document Ex.R-6 it is proved that Major Singh (since deceased) has already got the treatment from Fortis Hospital Ludhiana. At the time of filling up the proposal form, life assured had not disclose this fact to OPs. In this document discharge summary, the date of admission is mentioned as 30.09.2015 and date of discharge is 07.10.2015 and the life assured obtained the policy from OPs on 30.10.2015 it seemed that the life assured have got the treatment from the Fortis Hospital Ludhiana before issuance of the policy in question. It appears that

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the life assured have pre-existing disease. In discharge summary, the diagnosis given to life assured as : Diabetes Mellitus, Diabetic Nephropathy, Hypertension, Sepsis, Right Lower lobe pneumonia and Alcoholic liver disease. From perusal of progress notes at page no.103 of this file, it reveals that the life assured was opium addicted, it seemed that life assured had a past habit of opium addiction, that is why he got the treatment from Fortis Hospital Ludhiana before issuance of the policy and this fact is within the knowledge of the complainant and life assured but this fact was not disclosed by life assured at the time of filling up the proposal form. In Dama Summary of SPS Hospital, it has been specifically mentioned that

"we procured that pre-policy discharge summary from the Fortis Hospital, Ludhiana in which found that life assured was admitted here on 30.09.2015 under UHID Number FHL26.33367 and was treated here for the DM, HTN , Liver Disease and on 07.10.2015 he was discharge from the Hospital. But the policy in question issued to the Major Singh (since deceased) on 30.10.2015, therefore it is proved that the life assured get the treatment before issuance of the policy in question. The life assured suffering from pre-existing disease, which not included in the terms and conditions of the policy. From perusal of copy of death claim policy Ex.R- 10, it is clear that when OPs asked some questions from the life assured about his past medical history, he gave answers "No" . He suppressed the

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material facts from OPs at the time of issuance of the policy in question. It proved that he is suffering from pre-existing disease and OPs rightly repudiated the claim of the complainant.

9. The learned counsel for the OPs relied upon citation of Hon'ble Supreme Court in case titled as Satwant Kaur Sandhu vs. New India Assurance Company ltd reported in 2009(3)SCC (Civil) 366 that deceased took a medi-claim policy. At the time of taking the policy, he was suffering from Diabetic Nephropathy/Chronic Renal Failure, deceased did not disclose the fact of ailment while taking the policy, which was within his knowledge. Claim repudiated. There is no deficiency in service. Insurance Company justified in repudiating the claim. Further case titled as

P.C Chacko and another vs. Chairman Life Insurance Corporation of India reported in 2008(3) CPC 248 by Hon'ble Apex Court that insurance company can repudiate the policy on the ground that certain fact have been suppressed which were material to disclose or that it was fraudulently been made by the policy holder or that policy holder knew at the time of making it that the statement was false. The case titled as Diwan Surender Lal vs. Oriental Insurance by Hon'ble National Commission New Delhi reported in 2009(1) CPJ 117 that medi claim repudiated by insurance company on the ground of non-disclosure of material facts. Past illness accepted by complainant in hospital's admission record. Not disclosed in

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proposal form but which was material for the issuance of medi-claim policy. The case titled as Kulwant Singh vs. United India Insurance Company Ltd and another by Hon'ble National Commission, New Delhi reported in 2008(4) CPJ 196 that non-disclosure of pre-existing disease. Claim repudiated by insurer. Complaint allowed by District Forum. Order reversed in appeal. Revision against -plea of complainant that history in discharge summary wrongly recorded not prove. Plea of non-disclosure of pre-existing disease at the time of purchase of policy, not specifically dealt by Commission. Order upheld. Revision dismissed.

10. As per Insurance Act 1938, Section 45, A person obtaining policy by misrepresentation of facts. Contract of insurance found to be vitiated . Life insurance Corporation being a State within the meaning of Article 12 of the Constitution of India , its action must be fair, just and equitable but the same would not mean that it shall be asked to make a charity of public money. The policy holder must have known at the time of making the statement that it was false or that it suppressed facts which it was material to disclose. The insurance policy issued on the basis of utmost good faith, which has been shattered by the complainant. The citations relied upon by counsel for OPs applicable in the case in hand. The contract of insurance is based on utmost good faith. There is requirement of uberima fides i.e. good faith on the part of the assured.

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11. In the present case, the policy bearing no.18097010 in question obtained from OPs on 01.01.2016 consisting policy schedule. The complainant alleged in his complaint that her husband Major Singh (since deceased) admitted in the hospital for the period 17.08.2016 to 22.08.2016 but she had not disclosed this fact that her husband (since deceased) get the treatment from Fortis Hospital Ludhiana for the period from 30.09.2015 to 07.10.2015 before issuance of the policy. This fact is clear from document Discharge Summary prepared by Department of Internal Medicine, Fortis Hospital Ludhiana placed on the record. In this hospital the diagnosis i.e. diabetic mellitus, diabetic Nephropathy with acute on chronic renal disease, hypertension, diabetic foot ulcer, sepsis, right lower lobe pneumonia and alcoholic liver disease were found. It seems that the life assured suffering from above mentioned diseases before issuance of the policy. As such, the repudiation of insurance claim by OPs is justified and as per terms and conditions of the policy. Both parties are bound by terms and conditions of the policy and no one wriggle out from the same. The contact of insurance is based on utmost good faith and it is bounden duty of the insured not to disclose the material facts from insurer at the time of taking the policy. Further, as per Ex.C-1, the Ops have already declined the application of insurance policy of complainant and amount of first premium had already been refunded to the complainant as per letter dated 02.02.2017 Ex.C-1.

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Therefore, the existence of the policy in dispute does not arises. The denial and acceptance of proposal form is sole discretion of the Ops. Further, the complainant has obtained the policy by concealed the pre-existing disease of the Major Singh, which is illegal in the eyes of law.

12. In the light of our above discussion, we dismissed the complaint of the complainant, because the complainant and her husband had concealed the material and vital information of pre-existing disease before obtaining policy in dispute. Parties are left to bear their own costs.

13. This complaint could not be decided within stipulated period due to heavy pendency of the cases.

14. Copies of the order be supplied to the parties free of costs.

15. File is ordered to be sent back to District Commission, Ludhiana.

Dated :15.12.2021

(Kuljit Singh) President

(Renu Gandhi) (Yadwinder Pal Singh Baath) Member Member