Punjab

Faridkot

CC/16/75

Dalbir Kaur - Complainant(s)

Versus

Branch Manager LIC - Opp.Party(s)

Charanjit Sidana

10 Oct 2016

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :     75

Date of Institution: 14.03.2016

Date of Decision :  10.10.2016

 

Dalbir Kaur wife of late Sewak Singh, r/o  VPO Machaki Mall Singh, District Faridkot.                                           

                                                                                      ...Complainant

Versus

1. Branch Manager, Life Insurance Corporation of India, Branch Office, Faridkot.

2. The Manager (CRM), Life Insurance Corporation of India, Divisional Office, Jallandhar.

                                                                          .............OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Sh P Singla, Member.

 

Present: Sh Charanjit Sidana, Ld Counsel for Complainant,

              Sh Lakhwinder Singh, Ld Counsel for OPs.

(Ajit Aggarwal, President)

                         Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against  OPs seeking directions to OPs to make payment of insurance claim  with interest and for further directing OPs to pay Rs 20,000/- as compensation for deficiency in service and harassment alongwith litigation expenses.

2                           Briefly stated, the case of the complainant is that husband of complainant purchased two Policies from OPs to insure his life during his life time and thereafter, husband of complainant was physically examined by the doctor appointed by LIC and then on 3.12.2013, OPs issued two policies bearing no. 302510415 and 302510416 in his name. On 4.12.2013, husband of complainant felt some pain in stomach and he consulted doctor, who suggested him to admit in hospital. On advice of doctor, husband of complainant was admitted in Sukhmani Hospital, Faridkot, but his condition became serious and Doctor Harjinder Singh referred him to Max Hospital, Bathinda. After treatment for two days in Max hospital, her husband died on 8.12.2013. Complainant being nominee of his husband, approached Branch Office, Bathinda to get insurance claim of his husband, but Bathinda Branch Office refused to do so by saying that his policies were transferred to Branch Office, Faridkot. Then, complainant went to Branch Office of LIC at Faridkot, but they replied that they cannot give claim because polices were issued from Bathinda Branch. Thereafter, complainant sent a legal notice to OPs. In reply to said legal notice, OPs told complainant to go to Branch Office, Faridkot with all the documents and then, complainant went to Branch Office, Faridkot alongwith all requisite documents and letter of OPs dt 9.01.2015, but Branch Manager, flatly refused to give any claim by saying that she is not eligible to get any claim. Thereafter, complainant filed complaint before this Forum and on direction of OPs, complainant submitted all the documents during pendency of complaint, but at the time of arguments, OPs asked complainant that her claim cannot be settled until she files appeal before Zonal Office and then, complainant withdrew the complaint and filed appeal before Zonal Office, who repudiated the claim of complainant without any reason. All this amounts to deficiency in service and has caused harassment and mental tension to complainant. Complainant has prayed for directing the OPs to pay Rs 20,000/- as compensation alongwith litigation expenses besides the main relief. Hence, the complaint.

3                                    The counsel for complainant was heard with regard to admission of the complaint and vide order dated 21.03.2016, complaint was admitted and notice was ordered to be issued to the opposite party.

4                                 On receipt of the notice, the OPs filed written statement wherein admitted that Policies in dispute were purchased by deceased Life Insured on 2.12.2013, but denied all the other allegations levelled by complainant being wrong and incorrect and asserted that both the policies were issued to complainant  under Non Medical Special (Scheme) without calling any medical and special reports. Claim of complainant has been rightly, lawfully and legally  repudiated as per rules, regulations and terms and conditions of the Insurance Policy and statements made and signed by life assured in the proposal form regarding these policies. Claim is repudiated with full application of mind after considering all the facts of this case. As per Discharge Summary of Max Hospital, “the Patient is a chronic alcoholic presented from outside hospital with abdominal distension and diagnosed as a case of acute pancreatitis with Prerenal ARF with multiorgen failure, which he was suffering during his life time before signing the proposal forms dated 2.12.2013 and said Sewak Singh now deceased got himself  insured with the LIC of India vide these two policies. There is concealment of material facts while purchasing the policies in question as complainant withheld the greater information from OPs as well as from Forum. About 15 days, prior to death, deceased was suffering from Abdomen pain. It is further averred that claim of complainant has been rightly repudiated after due application of mind and considering all the facts of case. There is no deficiency in service on the part of answering OPs. Legal notice issued by complainant was duly replied by the Divisional Office, Jallandhar as well as by Branch Office, Faridkot. It is denied that Branch Manager flatly refused to give any claim by saying that complainant is not eligible to get any claim.  It is asserted that husband of complainant obtained these two policies by hiding the material information regarding illness of his health from OPs and played fraud with them. At the time of making proposal for getting insured, deceased Sewak Singh intentionally and knowingly defrauded with OPs and withheld the material information regarding his disease of Abdominal Distension and acute Pancreatitis with Prerenal ARF with Multiorgan failure, which he was suffering throughout his life before signing the proposal form dated 2.12.2013 and he got insured vide these policies by withholding the information from proposal form on 2.12.2013 as both these policies were issued issued under Non-Medical Special (Scheme) without calling any medical and special reports. To all the important questions regarding health like if he was ever admitted to any hospital during last five years; if he remained absent from place of working on the ground of ill health; if he was suffering from any ailment of liver, stomach, heart, lungs, kidneys, brain or nervous system; if he was suffering from High/low BP, cancer, epilepsy, hernia etc; if he ever used alcoholic drinks, narcotics, any other drug or tobacco etc. deceased Sewak Singh has replied as ‘No’, which is against the rules of policy and thereby he has concealed the material facts regarding his health from OPs. All the answers given by deceased in his proposal form are false. As per form no.3784, doctor of Max Hospital has stated that symptoms of abdominal distension c pain abdomen were observed by the deceased and as per form no.3816, the same hospital stated that patient had history of acute Pancreatitis, which preceded with the ailment at the time of patient’s admission in the hospital. Deceased Sewak Singh got admitted in Sukhmani Hospital, Faridkot on 4.12.2013 and reported his history of illness himself and discharged on same day. The Max Hospital, Bathinda firstly observed said Sewak Singh on 5.12.2013 as per form no 3784 and he was got admitted there on 6.12.2013 and died on 8.12.2013 and as per Discharge Summary it is narrated that Patient is a Chronic Alcoholic Presented From Outside Hospital with Abdominal Distension and Diagnosed as a case of Acute Pancreatitis with Prerenal ARF. Before repudiating the claim of complainant, Sh Gurmail Singh Gill Sr Branch Manager of LIC of India Branch Faridkot conducted enquiry by visiting the village of deceased Sewak Singh and got recorded the statements of respectables. He placed on record statements of Sh Lakhwinder Singh Panch Gram Panchayat, Jaswinder Singh, Namberdar, Baljinder Kaur, Sarpanch Gram Panchayat and Satnam Singh, Panch Gram Panchayat of village Machaki Mall Singh and submitted his Enquiry Report wherein mentioned that said Sewak Singh was suffering from Abdomen pain about 15 days prior to his death. This fact also proves that said Sewak Singh was suffering from disease mentioned by doctors in their reports. In present complaint, the death claim under both the policies have been rightly repudiated lawfully, bonafidely with full application of mind and after thorough investigation as deceased was not keeping good health and he concealed the material fact regarding his health from OPs. There is no negligence of deficiency in service on the part of OPs. All the other allegations and allegation with regard to relief sought too were refuted with a prayer that complaint deserves to be dismissed with costs.

5                                 Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in evidence her affidavit Ex.C-1 and documents Ex C-2 to C-37 and then, closed their evidence.

6                          In order to rebut the evidence of the complainant, Counsel for OPs tendered in evidence documents Ex OP-1 to 30 and then, closed the evidence.  

7                         We have heard the ld counsel for complainant as well as OPs and have carefully gone through evidence and documents placed on record by respective parties.

8                         Ld Counsel for complainant vehementally argued that husband of complainant purchased two Policies from OPs to insure his life during his life time and thereafter, husband of complainant was physically examined by the doctor appointed by LIC and then on 3.12.2013, OPs issued two policies bearing no. 302510415 and 302510416 in his name. On 4.12.2013, husband of complainant felt some pain in stomach and he consulted doctor, who suggested him to admit in hospital. On advice of doctor, husband of complainant was admitted in Sukhmani Hospital, Faridkot, but his condition became serious and Doctor Harjinder Singh referred him to Max Hospital, Bathinda. After treatment for two days in Max hospital, her husband died on 8.12.2013. Complainant being nominee of his husband, approached Branch Office, Bathinda to get insurance claim of his husband, but Bathinda Branch Office refused to do so by saying that his policies were transferred to Branch Office, Faridkot. Then, complainant Branch Office of LIC at Faridkot, but they replied that they cannot give claim because polices were issued from Bathinda Branch. Thereafter, complainant sent a legal notice to OPs. In reply to said legal notice, OPs told complainant to go to Branch Office, Faridkot with all the documents and then, complainant went to Branch Office, Faridkot alongwith all requisite documents and letter of OPs dt 9.01.2015, but Branch Manager, flatly refused to give any claim by saying that she is not eligible to get any claim. Thereafter, complainant filed complaint before this Forum and on direction of OPs, complainant submitted all the documents during pendency of complaint, but at the time of arguments, OPs asked complainant that her claim cannot be settled until she files appeared before Zonal Office and then, complainant withdrew the complaint and filed appeal before Zonal Office, who repudiated the claim of complainant without any reason. All this amounts to deficiency in service and has caused harassment to complainant. She has prayed for accepting the present complaint.

9                       To controvert the allegations of complainant, ld counsel for OPs asserted that Policies in dispute were purchased by deceased Life Insured on 2.12.2013, but denied all the other allegations levelled by complainant being wrong and incorrect and asserted that both the policies were issued to complainant  under Non Medical Special (Scheme) without calling any medical and special reports. Claim of complainant has been rightly, lawfully and legally  repudiated as per rules, regulations and terms and conditions of the Insurance Policy and statements made and signed by life assured in the proposal form regarding these policies. Claim is repudiated with full application of mind after considering all the facts of this case. As per Discharge Summary of Max Hospital, “the Patient is a chronic alcoholic presented from outside hospital with abdominal dimension and diagnosed as a case of acute pancreatitis with Prerenal ARF with multiorgen failure, which he was suffering during his life time before signing the proposal forms dated 2.12.2013 and said Sewak Singh now deceased got himself insured with the LIC of India vide these two policies. There is concealment of material facts while purchasing the policies in question as complainant withheld the greater information from OPs as well as from Forum. About 15 days, prior to death, deceased was suffering from Abdomen pain. It is asserted that husband of complainant obtained these two policies by hiding the material information regarding illness of his health from OPs and played fraud with them. At the time of making proposal for getting insured, deceased Sewak Singh intentionally and knowingly defrauded with OPs and withheld the material information regarding his disease of Abdominal Distension and acute Pancreatitis with Prerenal ARF with Multiorgan failure, which he was suffering throughout his life before signing the proposal form dated 2.12.2013 and he got insured vide these policies by withholding the information from proposal form on 2.12.2013 as both these policies were issued issued under Non-Medical Special (Scheme) without calling any medical and special reports. To all the important questions regarding health like if he was ever admitted to any hospital during last five years; if he remained absent from place of working on the ground of ill health; if he was suffering from any ailment of liver, stomach, heart, lungs, kidneys, brain or nervous system; if he was suffering from High/low BP, cancer, epilepsy, hernia etc; if he ever used alcoholic drinks, narcotics, any other drug or tobacco etc. deceased Sewak Singh has replied as ‘No’, which is against the rules of policy and thereby he has concealed the material facts regarding his health from OPs. All the answers given by deceased in his proposal form are false. As per form no.3784, doctor of Max Hospital has stated that symptoms of abdominal distension c pain abdomen were observed by the deceased and as per form no.3816, the same hospital stated that patient had history of acute Pancreatitis, which preceded with the ailment at the time of patient’s admission in the hospital. Deceased Sewak Singh got admitted in Sukhmani Hospital, Faridkot on 4.12.2013 and reported his history of illness himself and discharged on same day. The Max Hospital, Bathinda firstly observed said Sewak Singh on 5.12.2013 as per form no 3784 and he was got admitted there on 6.12.2013 and died on 8.12.2013 and as per Discharge Summary it is narrated that Patient is a Chronic Alcoholic Presented From Outside Hospital with Abdominal Distension and Diagnosed as a case of Acute Pancreatitis with Prerenal ARF. Before repudiating the claim of complainant, Sh Gurmail Singh Gill Sr Branch Manager of LIC of India Branch Faridkot conducted enquiry by visiting the village of deceased Sewak Singh and got recorded the statements of respectables. He placed on record statements of Sh Lakhwinder Singh Panch Gram Panchayat, Jaswinder Singh, Namberdar, Baljinder Kaur, Sarpanch Gram Panchayat and Satnam singh, Panch Gram Panchayat of village Machaki Mall Singh and submitted his Enquiry Report wherein mentioned that said Sewak Singh was suffering from Abdomen pain about 15 days prior to his death. This fact also proves that said Sewak Singh was suffering from disease mentioned by doctors in their reports. It is further averred that claim of complainant has been rightly repudiated after due application of mind and considering all the facts of case on thorough examination of all record. There is no deficiency in service on the part of answering OPs. Prayer for dismissal of complaint is made.

10                         The case of the complainant is that on 3.12.2013 her husband Sewak Singh purchased two insurance policies from OPs securing his life and paid premium for the same. Copies of the insurance policies are Ex C-2 and 3. On 4.12.2013, he felt some pain in his stomach and he consulted doctor, who admitted him in hospital and doctor started to treat him. On 6.12.2013, the condition of the husband of complainant became serious and he was referred to Max Hospital, Bathinda and on 8.12.2013, he died at Max Hospital, during his treatment. Copy of the death certificate is Ex C-5 and medical certificate issued by the attending doctor are Ex C-6 and 7. Being nominee in those insurance policies, the complainant lodged claim with OPs, but repudiated her genuine claim vide letter dated 9.07.2015, which is deficiency in service on their part. On the other hand, OPs admitted that husband of complainant purchased the insurance policies in question from them securing his life but they submitted that he purchased these insurance policies fraudulently by concealing his health condition from OPs. The said policies were issued to Sewak Singh under Non Medical Special Scheme on 3.12.2013 on the basis of proposal form dated 2.12.2013. In the proposal form regarding his prior ailment and medical history, the insured gave wrong information to the OPs regarding questions like whether he was ever consulted any medical practitioner in the last five years, if he is admitted in any hospital, if he ever remained absent from his working place on ground of ill health or if he was ever suffering from ailments pertaining to liver, stomach, heart, lungs, kidney, brain or nervous system and if he ever suffered from diabetes, tuberculosis, High/Low BP, Cancer, epilepsy, hernia hydrosol, leprosy or any other disease. In reply to all these questions, the insured gave negative reply in response to questions and stating himself of good health. On the basis of proposal form, OPs issued Insurance Policies to him in Non Medical Special Scheme without calling any medical report. The insured died on 8.12.2013, within 5 days from the issuance of insurance policy. As per medical record submitted by complainant alongwith claim form, the insured was of ill health and was suffering from the disease of acute pancreatitis with Prerenal ARF with multiorgen failure, of which he was suffering prior to the signing the proposal form dated 2.12.2013.  He purchased the policy by withholding the material information regarding his health and disease. As per medical certificates of attending doctor of Max Hospital, Bathinda, where he was admitted on 5.12.2013, they stated that he was suffering from illness from one week prior to the admission i.e prior to 2.12.2013 when he filled the proposal form and also he was a chronic alcoholic. The copies of medical certificates are Ex OP-19 and 20 and Ex C-6 and 7 as produced by complainant themselves. Copy of discharge summary issued by Max Hospital, Bathinda is Ex OP-21, copy of medical certificate issued by Sukhmani Hospital is Ex OP-22. As it was an early claim, the OPs conducted investigation of the claim through their Branch Manager Gurmail Singh Gill, who inquired into the matter and visited the village of insured. He recorded evidence of respectable persons of the village who stated that said Sewak Singh was suffering from abdomen pain about 15 days prior to his death. This also proves that Sewak Singh was suffering from disease mentioned by the doctor very much prior to purchase of insurance policy. Copy of the Claim Investigation Report is Ex OP-13 and copies of statements of respectable persons of the village are Ex Op-15 to 18.

11                         From all these documents, it is clearly proved that complainant was suffering from disease of acute pancreatitis with Prerenal ARF with multiorgen failure much prior to the purchase of the insurance policy and he purchased these insurance policies by suppressing his disease from OPs only to defraud them. Therefore, in view of these circumstances, as per terms and conditions and regulations of the Insurance Policy, the Ops have correctly and legally repudiated the claim of complainant. There is no deficiency in service on the part of Ops.

12                        From the above discussion, we do not find any merit in the present complaint and we are of considered opinion that complainant and her husband fraudulently purchased the insurance policies in question from OPs by concealing and suppressing the medical condition of the insured from them only to get wrongful monitory benefit and to defraud the Ops. Hence, present complaint in hand is hereby dismissed being devoid of any merits. Copy of order be given to parties free of cost under rules. File be consigned to record room.

Announced in Open Forum

Dated : 10.10.2016

                                                Member                   President

                                                          (P Singla)              (Ajit Aggarwal)