BEFORE THE HON’BLE CONSUMER DISPUTE REDRESSAL COMMISSION DISTRICT EAST, SAINI ENCLAVE, DELHI COMPLAINT CASE NO. 2025 INTHEMATTEROF: DALIP GUPTA . COMPLAINANT vs BAJAJALLIANZ GENERAL INSURANCE COMPANY LIMITED .OPPOSITEPARTY COMPLAINT U/S35(1)(a)OFTHECONSUMERPROTECTIONACT,1986 THE, COMPLAINANT ABOVENAMED STATES AS UNDER:- MOSTRESPECTFULLYSHOWETH:- 1, FACTSOFTHECASE ‘That Mrs. Ekta Gupta (deceased) R/o B-50, KH No-! 149/790, Gali No-5, Uchepar, Mandawali Fazalpur East Delhi India- 110092, purchased a home, for that purpose she took a loan vide loan account no. 944330 from India Infoline Housing Finance Limited herein referred as IIFL of Rs.32,90,000. IIFL (absolute assignee) compelled Mrs. Ekta Gupta to take policy of Rs.20,00,000 as a surety for home loan. As per the policy, issuance date 31- 12-2020, from Bajaj Allianz General Insurance Company Limited where the Master Policy Holder's Name is India Infoline Housing Finance Limited bearing Master Policy No. OG-19-1002-8440-00000002 in which IIFL is absolute assignee of the insurance policy and the deceased was a Beneficiary. IIFL payed the gross premium of Rs.1,55,737/-with a clearpurpose to safeguard financial Security in the event of mishap likes critical illness or death. Thus the policy was linked to a home loan from IIFL (India Infoline Finance Limited), The residential property of Mrs, Gupta was insured under this policy, which stipulated that, in the event of claims, the sum of, Rs.20,00,000 would be directly payed to IIFL(absolute assignee) without any intervention of any third party. Thus, the IIFL is the Master- Policy Holder bearing policy no, OG-19-1002-8440-00000002. Only the sum of Rs.1,00,000 insured vide policy no. OG-21-1155-8439-00004597 will be given to Dilip Gupta (nominee) chosen by the deceased On 21st February 2024, while returning from the temple, Mrs. Ekta Gupta fainted. Neighbours informed her husband, who rushed her to the hospital, where she was declared dead by the doctor reason claimed cardiac arrest. Devastated by the sudden demise of his wife, complainant and their children were plunged into deep sorrow. A few days later, he received a letter from LIFL(absolute assignee) demanding payment of the home loan installment, where the loan was secured from the insurance company ic. Bajaj Allianz General Insurance. In his grief, he went to Bajaj Allianz’s office, on which the liability to pay the loan amount was led as per the condition of Insurance Policy A COPY OF THE INSURANCE POLICY FOR THE REFRENCE TO HON’BLE COMMISSION HAS BEEN ANNEXED AS ANNEXURE A-1 A COPY OF THE DEATH CERTIFICATE ISSUED BY THE MUNICIPAL CORPORATION OF DELHI HAS BEEN AND ANNEXURE A-2 DAS2, That the complainant, further submits the Dead Summary Report issued by Max Healthcare, which clearly states Cardiac Arrest as the primary cause of death of Mrs. Ekta Gupta. This document is crucial as it serves as direct medical evidence confirming the sudden nature of her demise. The report contradicts any claims by the insurance company alleging pre-existing conditions to justify repudiation, A COPY OF THE DEAD SUMMARY REPORT ISSUED BY THE MAX HEALTH CARE ON 21.02.2024 HAS BEEN ANNEXED AS. ANNEXURE A-3 RELEVANTLAWANDPROVISION 45, Policy not to be called in question on ground of mis-statement after {wo years. No policy of life insurance shall be called in question on any ground whatsoever after the expiryofthreeyearsfomthedateofthepolicy,ie.,fromthedateofissuanceofthe policy or the date of commencement of risk or the date of revival ofthe policy or the date of the rider to the policy, whichever is later. 2) A policy of life insurance may be called in question at any time within three years from the date of issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later, on the gyound of fraud: Provided that the insurer shall have to communicate in writing to the insured or the legal representatives or nominees or assignees of the insured the grounds and materials on which such decision is based. Explanation I.-For the purposes of this sub-section, the expression “fraud” means any of the following acts committed by the insured or by his agent, with 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 insured does not believe to be true; (b)the active concealment of a fact by the insured having knowledge or belief of the fact ()any other act fitted to deceive; and (d)any such act or omission as the law specially declares to be fraudulent. Explanation Il—Mere silence as to facts likely to affect the =assessment of the risk by the insurer is not fraud, unless the circumstances of the case are suchthatregardbeinghadtothemtisthedutyoftheinsuredorhisagentkeeping silence, 10 speak, or unless his silence is, in itself, equivalent to speak (3)Not with standing any thing contained in sub-section(2),no insurer shall repudiate a life insurance policy on the ground of fraud ifthe insured can prove that the misstatement of or suppression of a ‘material fact was true to the best of his knowledge and belief or that there was node liberate intention to suppress the factor that such misstatement for suppression of @ ‘material fact are within the knowledge of the insurer: Provided that incase of fraud, the onus of disproving lies upon the beneficiaries, in case the policyholder is not alive. Explanation. —A person who solicits and negotiates a contract of insurances hall be deemed for the purpose of the formation of the contract, to be the agent of the insurer. (A policy of life insurance may be called in question at any time within three years from the date of issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later, on the ‘ground that any statement of or suppression of a fact material to the expectancy of the life of the insured was incorrectly made in the proposal or other document on the basis of which the policy was issued or revived or rider issued: Provided that the insurer shall have to communicate in writing to the insured or the legal representatives or nominees or assignees of the insured the grounds and materials on which such decision to repudiate the policy of life insurance is based: Provided further that in case of repudiation of the policy on the ground of misstatement or suppression of a material fact, and not on the ground of fraud, the premiums collected on the policy till the date of repudiation shall be paid to the insured or the legal representatives or nominees or assignees of the insured ‘within a period of ninety days from the date of such repudiation. Explanation.--For the purposes of this sub-section, the misstatement of or suppression of fact shall not be considered material unless it has a direct bearing on the risk undertaken by the insurer, the onus is on the insurer to show that had the insurer been aware of the said fact no life insurance policy would have been issued to the insured (5)Nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to do so, and no policy shall be deemed to be called in questionmerely because the terms of the policy are adjusted on subsequent proof that the age of the life insured was incorrectly stated in the proposal."No policy of life insurance effected before the commencement of this Act shall after the expiry of two years from the date of commencement of this Act and no policy of life insurance effected after the ‘coming into force of this Act shall after the expiry of two years from the date on which it was effected, be called in question by an insurer on the ground that a statement made in the proposal for insurance or in any report of a medical officer, or referee, or friend of the insured, or in any other document leading to the issue of the policy, was inaccurate or false, unless the insurer shows that such statement was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the policy- holder and that the policy-holder knew at the time of making it that the statement was false or that it suppressed facts which it was material to disclose: Provided that nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to do so, and no policy shall be deemed to be called in question merely because the terms of the policy are adjusted on subsequent proof that the age of the life insured was incorrectly stated in the proposal.” [Link] risk to be assumed unless premium is received in advance (1) No insurer shall assume any risk in India in respect of any insurance business on which premium is not oF ily payable outside India unless and until the premium payable is received by him or is guaranteed to be paid by such person in such manner and within such time as maybe prescribed or unless and until deposit of such amount as may be prescribed, is made in advance in the prescribed manner. (2) For the purposes of this section, in the case of risks for which premium can be ascertained in advance, the risk may be assumed not earlier than the date on which the premium has been paid in cash or by cheque to the insurer. Explanation, Where the premium is tendered by postal money order or cheque sent by post, the risk may be assumed on the date on which the money order is booked or the cheque is posted, as the case may be (3) Any refund of premium which may become due to an insured on account of the cancellation of a policy or alteration in its terms and conditions or other wise shall be paid by the insurer directly to the insured by a crossed or order cheque or by postalmoneyorder and a proper receipt shall be obtained by the insurer from the insured, and such refund shall in no case be credited to the account of the agent (4) Where an insurance agent collects a premium on a policy of insurance on behalf of an insurer, he shall deposit with, or dispatch by post to, the insurer, the premiums collected in full without deduction of his commission within twenty- four hours of the collection ‘excluding bank and postal holidays. (5) The Central Government may, by rules, relax the requirements of sub-section (1) in respect of particular categories in insurance policies. (6) The Authority may, from time to time, specify, by the regulations made by it, the ‘manner of receipt of premium by the insurer Section 2(11) in Consumer Protection Act, 2019 (11)"deficiency""means any fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be maintained by or under any law for the time being in force or has been undertaken to be performed by a person in pursuance of a contract or otherwise in relation to any service and includes- i any act of negligence or omission or commission by such person which causes loss or injury to the consumer, and Gi) deliberate withholding of relevant in formation by such person to the consumer, REJECTIONOFCLAIM That as per the impugned repudiated letter dated 08-08-2024, the claim no. [Link]-25-1002-8439-000001 220f Rs. 1,00,000/- was rejected from the insurance company, citing alleged pre- existing conditions, exclusion of sudden cardiac arrest, and failure to meet the criteria for “First Myocardial Infarction.” A COPY OF THE REPUDIATED INSURANCE POLICY HAS BEEN ANNEXED AS ANNEXURE A-4 A Complaint has been made to the IRDAI vide IRDAI Token No: 12-24- 000202 Name: Dalip Gupta PolicyNo: OG-21-1155-8439-00004597 but no satisfactory reply has been given till now.A COPY OF THE COMPLAINT MADE HAS BEEN ANNEXED AS ANNEXURE A-5 5. HOW THE REJECTION OF POLICY VIOLATES THE ESTABLISHED LAW A. That the impugned letter of repudiation is totally baseless without any evidence, no proper justification has been given to the claimant for the repudiation of the claim. As per the abovementioned rules the repudiation letter dated 08-08-2024 clearly violates section 45 of the Insurance Act, 1938 the reasons cited by the insurance company for repudiating the claim are baseless and deliberate attempt to defraud the complainant by manipulating terms and conditions to avoid liability, as no concrete evidence has been provided to substantiate the rejection of the claim. B. That the complainant, further submits the Dead Summary Report issued by Max Healthcare, which clearly states Cardiac Arrest as the primary cause of death of Mrs. Ekta Gupta. This document is crucial as it serves as direct medical evidence confirming the sudden nature of her demise. The report contradicts any claims by the insurance company alleging pre- existing conditions to justify repudiation. C. That the insurance company also violated Section 64VB of the Insurance Act, 1938 as this section mandates insurers 10 assess risks comprehensively before issuing policies. The insurer's post-issuance reliance on underwriting failures is a clear procedural lapse. D. That violation of Section 2(11) of the Consumer Protection Act, 2019 as insurer’s failure to clarify exclusions and its arbitrary rejection violate the consumer's rights to fair treatment. This denial constitutes deficiency in services and unfair trade practice.Seer eeeeeeeere er eerrreee eer E. That Breach of the Doctrine of Utmost Good Faith (Uberrima Fides) Insurance contracts are governed by the principle of utmost good faith, requiring insurers to act transparently and fairly at all stages, including underwriting and claim settlement, F, That despite the policy's clear provisions, Bajaj Allianz. arbitrarily repudiated the claim, causing undue financial hardship to the complainant, who now faces the loss of housing and further distress due to the non-settlement of the claim, | 6. GROUNDS The repudiation of the insurance claim is arbitrary, unsustainable in law,and therefore void. Accordingly, Legal Aspects laid down by the Hon'ble Supreme Court is being mentioned to the Hon'ble Commission as to clear A. Because the repudiation of the insurance claim by the insurer lacks any substantive evidence and fails to provide a valid justification, the action violates Section 45 of the Insurance Act, 1938. The insurer's reliance on vague terms and conditions amounts to a deliberate attempt to defraud the claimant, further breaching the principle of utmost good faith (Uberrima Fides) central to insurance contracts. B. Because, Insurers cannot deny claims based on alleged misrepresentation unless fraud is conclusively proven that fraud or suppression must be specifically proven to reject claims under Section 45 C. Because, if the insurer failed to exercise due diligence in investigating the alleged pre-existing conditions at the proposal stage, there by violating its duty under the doctrine of utmost good faith. Insurer cannot rely on non- disclosure when it has not conducted proper due diligence during the underwriting process. This lapse on the part of the insurer renders their rejection of the claim unjust and legally unsustainable. D. Because, the lifestyle diseases and claim rejection if pre-existing conditions like lower limb ischemia or thrombolysis existed, they cannotbe grounds for denial unless directly contributing to death., such life style diseases cannot invalidate claims unless causally linked to death. E. Because, a claim cannot be denied unless there is a direct and proximate causal link between the condition and the cause of death. In this case, the alleged pre-existing conditions (lower limb ischemia, thrombolysis) had no established role in causing Mrs. Gupta's sudden cardiac arrest, making the denial baseless. F, Because, the Ambiguity in Policy Terms in defining “First Myocardial Infarction” under the policy creates confusion about its applicability to sudden cardiac arrest violates the principle of Contra Proferentem. Hence ambiguities in insurance contracts must be resolved in favor of the insured. G. Because, insurance company Bajaj Allianz has failed to provide medical evidence linking the alleged conditions to complainant's wife death. Hence insurers cannot deny claims for death unless they substantiate that pre-existing conditions directly caused the insured event. H. Because, the lifestyle diseases like hypertension or diabetes cannot invalidate claims unless they directly cause the insured event. This principle applies equally here. I. Because, the rejection does not establish a direct causal link between the alleged pre-existing conditions and cardiac arrest. The NCDRC ruled that pre-existing conditions cannot invalidate claims unless they directly cause the illness or death and in the present case no direct linkage have shown to deny the abovementioned claim, J. Because, the primary purpose of tying the insurance policy to the loan was to ensure repayment in the event of the insured’s critica illness or death, Rejection of such claims directly contradicts the principle of public benefit embedded in such policies. K. Because the complainant, [Link] Gupta, has a handicapped child whois entirely dependent on him for financial and medical support, The wrongful repudiation of the insurance claim has caused severe financial distress to the complainant, making it difficult to mect the essential medical and daily care needs of his handicapped child. A COPY OF THE HANDIHAPPED DOCUMENT OF THE CHILD HAS BEEN ANNEXED ANS ANNEXURE NO. A-6 7. PRAYER FOR THE RELIEF A. That it is humbly requested to Bajaj Allianz General Insurance Company Limited shall approve and process the claims under Policy No. OG-21- [Link]-19-1002-8440- 00000002 in accordance with [Link] it is humbly requested to Bajaj Allianz General Insurance Company Limited shall approve and process the claims under Policy No. OG-21-1155-8439-00004597 and Master Policy No. OG-19- 1002-8440-00000002 in accordance with law. B. Insurer to release the insurance claim amount of %20,00,000 under the Master Policy directly to IIFL as the absolute assignee, ensuring compliance with Section 38 of the Insurance Act, 1938, to facilitate the repayment of the outstanding loan amount. C. Award compensation for the deficiency in services, unfair trade practices, and mental agony caused to the complainant of Rs. 2,00,000/- due to the arbitrary rejection of the claim, as per the provisions of the Consumer Protection Act, 2019. D. Award costs of litigation to the Complainant amounting to %1,11,000/- for the expenses incurred in issuing legal notice and pursuing this complaint. E, Impose suitable penalties on the Opposite Parties for indulging in unfair trade practices and breach of statutory obligations under the Consumer Protection Act, 2019, the IRDAI Guidelines, and RBI Circulars on Digital Payment Integrity.F. Pass such other ai proper, and ne\ conscience. jew Delhi vated:12.06.2025 I, Dalip Gupta, Complainant, verify the contents of paras documents and legal advice t material facts. nd further orders as this Hon'ble For ccessary in the interest of justice. rum may deem fit, and good equity: vf Applicant Through Advocate Counsel for Applicant 81, Nitikhand-2 Indirapuram Ghaziabad, Uttar Pradesh201014 Phone No. 9027118309 Email. harshgupta6278@[Link] VERIFICATION S/o Sh. Santosh Kumar Gupta, do hereby | to 7 are believed to be true on the basis of endered and that I have not suppressed anyBEFORE THE HON’BLE CONSUMER DISPUTE REDRESSAL COMMISSION DISTRICT EAST, SAINI ENCLAVE, DELHT COMPLAINT CASE NO. 2025 IN THE MATTER OF: DALIP GUPTA COMPLAINANT | vs BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LIMITED ..OPPOSITEPARTY AFFIDAVIT I Dalip Gupta, aged about 49 years, S/o Sh. Santosh Kumar Gupta . R/o B-50, KH No-1149/790, Gali No-5, Mandawali Fazalpur, East Delhi 110092, do hereby solemnly declare and affirm: 1. That I am the Complainant in the above captioned case, | am well conversant with the facts of the case, and competent to swear the present affidavit. 2. That the present complaint ws 35(1)(a) of the consumer protection act,1986has been drafted by my Counsel under my instructions, the contents of the same have been read over and explained to me in the facts stated therein are true and correct to my bé the present complaint u/s 35(1)(a) of the consumer 86 may be read as part and parcel of this affidavit which DEPONENTVERIFICATION: ase (1.2 JUN 20% Verified at Delhi on this 12th of June, 2025 that the contents of my above affidavit are true and correct to my knowledge and belief and nothing material has been concealed there from. ale DEFONENT CERTIFIED ™ OOM ip yh ee -c : Gow ieatt has ©