1. Brief fact of the case of the complainant is that her husband was policy holder of LIC of India bearing policy no. 571801086 for sum assured value of Rs. 7,70,000/- with a premium of Rs. 22,269/- and submitted the proposal form for insurance on 08.11.2007, subsequently, the O.Ps have issued the insurance policy in  favour of the policy holder.  Further the submission of the complainant is that her husband was expired on 10.01.2008. After his death, she claimed the insurance assured value from the O.Ps, but the O.Ps taking the pleas with one and other, have declined to pay the assured value, in that regard several approaches of the complainant yielded no result, thus, alleging deficiency in service and unfair trade practice on the part of the O.Ps, she filed this case claiming the sum assured of Rs. 7,70,000/-, Rs. 2,00,000/- towards compensation and Rs. 10,000/- towards cost of litigation from the O.Ps.
    
2.           On the other hand, the Opp. Parties appeared in this case, filed their joint written versions admitting the issue of alleged insurance policy in favour of the deceased policy holder on 20.12.2007 and denying other allegations of the Complainant, contended that the insurance claim against the death coverage of the insured policy holder (deceased) was repudiated on account of deceased having with held material information regarding his health status at the time of effective the assurance with the O.Ps. and was communicated vide letter ref. BDO/Claim/Rep./JPR dated 05.03.2014 and the death claim against the said insurance policy was repudiated on the ground that the DLA was suffering from Infective Hepatitis 30 days prior to his consultation with Doctor Sri T.P.K.Swamy of Jeypore on 27.12.2007 and also contended that the DLA did not inform the Corporation regarding his illness of malaria, gastro enteritis, ulcer foot at the time of submitting the proposal dated 08.11.2007.  Further emphasizing the provisions under Section 45 of Insurance Act, 1938, they have contended also that since the DLA has given the incorrect information, the death claim was repudiated and with other contentions, the O.Ps have prayed to dismiss the case against them.
    
3.            Both parties have filed certain documents in support of the submission along with verdicts of Higher Forums. Heard from the parties through their respective A/Rs at length and perused the record and material documents available therein.
    
4.            In the instant case, complainant has filed certain documents like (1) copy of insurance policy issued by Bajaj Allianz Life Insurance Co. Ltd. vide policy no.0073706224 issued in the name of V. govind Rao, (2) copy of claim payment on policy no.0073706224 dated: 23.12.2014,(3)  copy of payment of death claim issued by the Bajaj Allianz Life Insurance Co. Ltd. for better clarification we marked these documents as exhibits C-1,C-2 and C-3 on behalf of the complainant. The O.Ps have also filed certain documents on their behalf such as (a) attested copy of medical attendant’s certificate issued by the LIC Agent Sri. R. Satyanarayana, (b) attested copy of proposal form and  (c) copy of agent’s confidential report / moral hazard report and all these documents were marked exhibits on O.P.-a, O.P.-b and O.P.-con behalf of the opp. Parties for better clarification.
    
5.            In the instant case, there is no dispute regarding the submission of proposal on 08.11.2007 by the policy holder (deceased) and issuance of the alleged insurance policy in favour of the policy holder on 20.12.2007 and it is also admitted fact that after death of the policy holder on 10.01.2008 the death intimation was received by the O.Ps on 31.10.2008, but the repudiation of death claim was intimated to the complainant on 05.03.2014 vide O.Ps their letter Ref. BDO/Claims/Rep./JPR dated 05.03.2014.  The submissions of complainant is that taking one plea or the other the O.Ps have declined to pay the sum assured value against the death claim of policy holder (her deceased husband), on the other hand, the contentions of O.Ps is that the policy holder had given incorrect information regarding his health status at the time of submission of the insurance proposal form, whereas the policy holder was suffering from several deceases like malaria, gastro enteritis and ulcer foot and  the death claim was repudiated on the ground of existence of Infective Hepatitis with the policy holder.  So, now the question arose before us to decide that :
   a.     Whether the policy holder (deceased) was having the deceases like infective hepatitis at the time of submission of proposal form or at the time of issuance of insurance policy?
   b.     Whether the medical report of concerned Doctor establishes the existence of diseases of the policy holder on such dates as mentioned above ?
   c.      Whether the complainant is entitled the reliefs, if so, to what extent?
6.           For better clarification, we have decided the first & second point simultaneously. First we have carefully gone though the documents filed by the Opp. Parties i.e. O.P.-b (proposal from),and  ascertained that prior to submit the proposal from with the O.Ps, the said form / documents was signed and witnessed by one LIC Agent Sri, R.Satyanarayan bearing agent code no. 4227588 of bell Road, Jeypore and also the insurance proposer (deceased) was medical examined by their empanelled Doctor Sri. T.P.K.Swamy of jeypore bearing his code no. 99/588 and the said Doctor has put his singnature in the clause “for  medical cases only”  after medical examination of the proposer was taken up. Further had the policy holder (deceased) any symptoms relating to his health status to the alleged disease, on that occasion, the empanelled Doctor could have advised for further medical checkup, but without doing so, the concerned Doctor has certified as “ I certify that the Life  Assured has signed / put his / her thumb impression in my presence after admitting that all the answer to Question Nos.10 onwards of this from have been correctly record.” From which it is clearly concluded that at the time of submission of the proposal from, the policy holder (deceased) had been gone through proper medical checkup by the  concerned Doctor of the opp. Parties then they could have medically re-examined the policy holder (deceased) prior to acceptance of the proposal from and could have produced the cogent evidence to that effect.

          Further we have gone the document filed by the O.Ps i.e. O.P-c (Agent’s Confidential Report / moral Hazard Report) of the concerned agent namely Sri. R. Satyanarayana, in which the policy holder (deceased) has good health conditions and no other diseases exist in his body part and the said fact was also verified and  satisfied by the concerned  Branch Manager of Opp. Parties and after their porper verification, the alleged insurance policy was issued in favour of the  policy holder (deceased). From which it is safely concluded that the proposal form and  issued the insurance policy in favour of the policy holder (deceased). In this regard, the complainant draws our attention towards the verdicts of  Hon’ble National Commission, pankj Pandey, wherein it is held that “ After issuance of policies if policy holder has suffered any medical illness, then it cannot be said, that he had suppressed material facts.”

            Further, we have gone through the document of O.P. vide  Ext. No. O.P.-a (Medical Attendant’s Certificate), wherein the concerned Doctor Sri. T.P.K. Swamy, have clearly stated  that he was the usual medical attendant of the policy holder since 30 years and mentioned therein that the primary cause of death of the policy holder is due to Infective Hepatitis which is first observed prior to 30 days of the death of policy holder on occurred on 10/01/2018 and during last three years he has examined / treated the policy holder (deceased) regarding malaria, gastro enteritis and ulcer foot. Now the question arose that if the concerned Doctor, who was treating the policy holder since last 30 years and was treating him for malaria, gastro enteritis and ulcer foot since last three years, then why could he not able to come to know regarding the existence of Infective Hepatitis in the body of the policy holder during these three year. Being a medical proficient, the concerned Doctor could have ascertained about the existence of the disease like Infective Hepatitis, but nowhere in his report, he has mentioned that he is aware of the existence of such disease during the last three years. Rather his report in clause “c” of col. No.4 revealed that the policy holder was suffering from this disease 14 days before his death. If it is considered that the policy holder (deceased) was having such disease 14 days prior to the death, then it can be calculated that the first date of existence of the infective hepatitis starts from 27.12.2007 and also by that date the alleged insurance policy was already issued. Further the  concerned  Doctor could have immediately inform the corporation i.e. O.Ps regarding the existence of the alleged disease and also could have suggested for further medical check up, but without doing so, he kept quite till the day on which the O.Ps have obtained the medical certificate from him i.e. on 30.12.2018. Further as per the Ext. O.P.-a, it is observed that the concerned Doctor  Sri. T.P.K. Swamy, nowhere, has stated that the policy holder (deceased) had Infective Hepatitis as on the date of submission of proposal form or on the date of issuance of the insurance policy. As such without any cogent evidence, the plea of opp. Parties regarding pre-existing disease is not sustainable in the eye of law, as in the case between Usha Happa Vrs LIC of India and another, Hon’ble National Commission has held that “allegation of suppression of material fact has to be proved by congent evidence.” Further in another case between  Kamala Devi Vrs. LIC of India and another, Hon’ble Commission  has held the same view as “Plea of suppression of pre-existing ailment must be proved by cogent evidence.” Hence it can be safely concluded that the opp. Parties have miserably failed to establish their plea regarding suppression of material facts by the policy holder, so also the medical report of concerned Doctor produced by the O.Ps, dies not revealed that the policy holder (deceased) had the disease like Infective Hepatitis prior to submit the proposal form or on the date of issuance of the alleged insurance policy, as such both the answers went against the Opp. Parties.

                Further medical jurisprudence emphasizes that “while examining a person for obtaining life insurance, there is often a set proforma issued by the life insurance companies which requests for height’ weight, blood pressure, pulse rate, and urine analysis. The applicant for life insurance cannot sue a medical practitioner if he incorrectly gives wrong information to the insurance company which leads to the rejection of the policy. However, the medical practitioner has a duty of contract to the insurance company who is paying the fee to be conscientious and accurate. Therefore, these examinations should not be performed in a casual manner.”

7.          Further it is observed that in that in para no. 4 of their counter, the opp. parties have clearly admitted that they have got information about the death intimation of that policy holder on 31.10.2018 through the nominee-V.Laxmi (complainant), whereas they have already obtained a medicalcertificate to that effect on 30.12.2008, just one day prior to their to their receipt of the death intimation of the policy holder, which is a matter of surprise.
8.          Further as per the counter version of the O.Ps., it is clearly observed that the death intimation of the policy holder was came to their knowledge on 05.03.2008 after the nominee of the life assured intimated them, whereas the death claim of the life assured was repudiated on 05.03.2014 vide their letter ref. BDO/Claims/Rep./JPR dated 05.03.2014 after lapse of more than five years. The Opp. Parties have not brought out the fact and circumstances which make them silent for more than 5 year for keeping the medical certificate obtained from the concerned Doctor with them and after making the complainant wait for more than five years they have repudiated the death claim, which is not justified in the eye of law. Whereas as the O.ps. have obtained the medical certificate of the empanelled Doctor on 30.12.2008, and in our view, repudiation of death claim after keeping silent for more than five years i.e. on 05.03.2014 is grave deficiency in service on the part of the O.Ps.
9.          We have gone though the documents filed by the complainant i.e. Ext. C-1, C-2 and C-3, which reveals that another life insurance company has already settled the death claim of the life assured (present policy holder-deceased) in favour of the complainant. Further prima facie all the life insurance companies are guided by one organization i.e. Insurance regulatory Development Authority (I.R.D.A.) and the rules and insurance companies running over the Country. While Bajaj Allianz Life Insurance Co. Ltd has already settled the death claim of the life assured (policy holder in the present case), it is not digestive one that why the present Opp. Parties i.e. Life Insurance Corporation of India has taken unnecessary and baseless pleas without any appropriate evidence that the policy holder (deceased) had suppressed the material fact regarding his ailments without settling the death claim of the policy holder in favour of the nominee-complainant.
10.            As per the discussions made in the foregoing pars, in our view, the question no. C is also goes in favour of the Complainant, as the Opp. Parties have not properly and carefully gone through the medical certificate/documents obtained from the concerned Doctor and have tried to play hide and  seek game with the emotions of the complainant, which they should not do at all. Further making the complainant wait for about 6 years since date of the receipt of death intimation, the O.ps have proved grave misconduct and negligence on their part by playing with the emotions, sentiments and future aspects of the nominee-complainant, for which the complainant must have suffered mental agony and physical harassment and was compelled to file the case incurring some expenses, as such she is entitled some compensation and costs. Considering her suffering and mental  agony, we feel an amount of Rs.50,000/- towards compensation and Rs.5,000/- towards costs of litigation will meet the end of justice. Hence this order.

ORDER

            The complaint petition is allowed on part.  The O.P. is herewith directed to pay the full sum assured in both the policies in favour of the Complainant after deducting the amount credited in her SBI account, and to pay Rs. 10,000/- towards compensation and Rs. 2,000/- towards costs of litigation to the complainant within 30 days from the date of the communication of this order, failing which, the compensation amount shall carry interest @ 10% p.a. from the date of this order till payment. 

           Pronounced in the open Forum on this the 30^th day November, 2017.

           Issue free copies to the parties concerned.