Madhya Pradesh

StateCommission

A/17/1960

LIC - Complainant(s)

Versus

BHUPENDRA SINGH - Opp.Party(s)

SH.SOMENDRA SAXENA

11 Jul 2023

ORDER

M. P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BHOPAL

                   PLOT NO.76, ARERA HILLS, BHOPAL                         

                                                                         

                                      FIRST APPEAL NO. 1960 OF 2017

(Arising out of order dated 28.08.2017 passed in C.C.No.453/2015 by the District Commission, Indore)

 

1. REGIONAL MANAGER,

    LIFE INSURANCE CORPORATION OF INDIA,

    CENTRAL REGIONAL OFFICE-JEEWAN SHIKHA,

    60-B, HOSHANGABAD ROAD, BHOPAL (M.P.)

 

2. SENIOR DIVISIONAL MANAGER,

    LIFE INSURANCE CORPORATION OF INDIA,

    DIVISIONAL OFFICE, JEEWAN PRAKASH,

    19, MAHATMA GANDHI MARG, INDORE (M.P.)                                         …          APPELLANT.

 

Versus

                 

BHUPENDRA SINGH,

S/O SHRI DILIP SINGH BHATIA,

R/O 61, VEER SAWARKAR NAGAR,

INDORE (M.P.).                                                                                                 …         RESPONDENT.                                   

 

BEFORE :

            HON’BLE SHRI JUSTICE SHANTANU S. KEMKAR   :  PRESIDENT

           HON’BLE DR. (MRS) MONIKA MALIK                         :  MEMBER

         

COUNSEL FOR PARTIES :

                Shri Deepesh Shukla, learned counsel for the appellants.

           Shri P. N. Shukla, learned counsel for the respondent.    

 

                                                         O R D E R

                                       (Passed on 11.07.2023)

                   The following order of the Commission was delivered by Dr.(Mrs) Monika Malik, Member:

 

                         This appeal by the opposite parties/appellants-Life Insurance Corporation of India (hereinafter referred to as ‘LIC’) is directed against the order dated 28.08.2017 passed by the District Consumer Disputes Redressal Commission, Indore (For short ‘District Commission’) in C.C.No.453/2015 whereby the complaint filed by the complainant /respondent (hereinafter referred to as ‘respondent’) has been allowed.

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2.                Briefly put, admitted facts of the case are that the respondent’s wife Late Smt. Harvinder Kaur (hereinafter referred to as ‘deceased-insured’) had obtained two life insurance policies no. 346636304 w.e.f. 23.03.2011 to 23.03.2021 for sum assured of Rs.7,00,000/- & no. 347484265 w.e.f. 16.07.2012 to 16.07.2027 for sum assured of Rs.2,00,000/- respectively from the LIC.  The respondent was nominee under both the aforesaid policies. The deceased-insured fell ill on 23.12.2013 and was admitted in Greater Kailash Hospital, Indore from where she was referred to Choithram Hospital, Indore. There she died on 23.01.2014 due to ‘septicemia’.  It is alleged by the respondent that when he approached the LIC regarding payment of death claim of the deceased-insured, LIC denied the same vide letter dated 10.09.2014 on the ground that the deceased-insured was ‘diagnosed as K/C/O Rheumatic Heart Disease (RHD) & Balloon Mitral Valvotomy (BMV), 20 years back’ but the same was not disclosed to the LIC.  It is alleged that the deceased-insured did not die due to heart ailment and therefore, the LIC has wrongly denied her death claim.  Therefore, alleging deficiency in service on part of LIC, the respondent approached the District Commission, seeking relief.

3.                The LIC in its reply before the District Commission submitted that since the claim of the deceased-insured was early death claim, an

 

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investigation was carried out. Upon investigation, it was found that the deceased-insured had obtained treatment for heart ailment before obtaining

the insurance policies in question.  She had also underwent surgery for a heart ailment.  Had the deceased-insured intimated the LIC regarding aforesaid facts, her proposal form would not have been accepted. The LIC has thus rightly repudiated the claim and there has been no deficiency in service on LIC’s part. 

4.                The District Commission partly allowed the complaint and directed the LIC to pay Rs.9,05,000/- to the respondent within two months, failing which the amount is directed to be paid with interest @ 9% p.a. from the date of order, till realization.  In addition respondent is also awarded Rs.3,000/- as litigation cost.

5.                Heard. Perused the record.

6.                Learned counsel for the appellant-LIC argued that the documents available in the record of the District Commission including the discharge summary of the Greater Kailash Hospital, Indore and a certificate issued by Dr. Vidhut Kumar Jain, Consultant Cardiologist clearly show that deceased-insured was a known case of Rheumatic Heart Disease (RHD) & Balloon Mitral Valvotomy (BMV) since 20 years. However, while filling up the proposal form in order to obtain the aforesaid policies, the deceased-insured had suppressed this material information. The District Commission

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has erred in holding that the query in the proposal form was with regard to consultation, observation and treatment or surgery in the past 5 years and there was no specific query with regard to treatment received by the deceased-insured in the past 20 years, whereas the fact is that query in Column 11(b) of the proposal form pertains to admission of the deceased-insured in any hospital for general check-up, treatment or operation with no specific mention of any time frame for that.  The District Commission has therefore erred in allowing the complaint which deserves to be dismissed.

7.                Learned counsel for the complainant/respondent supported the impugned order and argued that the District Commission has rightly allowed the complaint. He also reiterated that the deceased-insured had died due to septicemia and the same is nowhere linked with the heart ailment.  He therefore argued that the appeal deserves to be dismissed.

8.                The discharge summary of Greater Kailash Hospital, Indore annexed as P/1 in the record of the District Commission mentions that:

                    “Patient Mrs. Harvinder Kaur Bhatiya, 57 years old female is admitted in GKH on 23.12.2013. She is a k/c/o RHD/status post BMV (20 years back)”

 

                    The certificate dated 30.04.2014 issued by Dr. Vidhut Kumar Jain, Consultant Cardiologist annexed as P/3 in the record of the District Commission mentions that:      

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                                        “Mrs. Harvinder Kaur Bhatiya, was suffering from Rheumatic Heart Disease-20 years and had underwent Balloon Mitral Valvotomy (BMV) in 1997 at Hyderabad in past.”

 

In ‘Case Summary: Death’ of Choithram Hospital, Indore, it is mentioned that:

“Pt. k/c/o RHD BMV done 20 years back”.

 

‘Initial Evaluation of Patient’ (History Sheet) of Choithram Hospital and Research Centre annexed at R-11 mentions the deceased-insured as:

“57 yrs old female, k/c/o RHD/Status post BMV (20 years back)”

 

9.                From the above mentioned documents, it is evidently clear that the deceased-insured was a known case of Rheumatic Heart Disease (RHD) & Balloon Mitral Valvotomy (BMV) which was done 20 years back.  Now, we observe that in the proposal form with respect to policy no. 346636304, in response to the relevant queries asked in the column 6, the deceased-insured has though mentioned that she was operated for small intestine, one and half years ago but there is no specific mention about Rheumatic Heart Disease (RHD) & Balloon Mitral Valvotomy (BMV).  Notably, this query does not signify any time duration.

 

 

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10.              In the another proposal form with respect to the second policy, the deceased-insured had wrongly replied in negative to the relevant query asked in Column 11 (d) when she had earlier suffered a heart ailment.

11.              Therefore, the District Commission has committed error in holding that the deceased-insured was required to provide information for past five years only.  On this account, we conclude that the LIC has not been deficient in service in denying the death claim of the deceased-insured. 

12.              The District Commission has erroneously allowed the complaint and therefore the impugned order deserves to be and is hereby set-aside.

13.              As a result, the appeal is allowed. No order as to costs.

 

         (JUSTICE SHANTANU S. KEMKAR)       (DR. MONIKA MALIK)                      

                           PRESIDENT                                       MEMBER