1.      This first appeal has been filed by the appellants, Aviva Life Insurance & Anr. against the order dated 24.03.2015 of the State Consumer Disputes Redressal Commission, Himachal Pradesh, (in short ‘the State Commission’) passed in consumer complaint No.11/2014.

2.      Brief facts of the case are that on 26.10.2012, Late Shri Shyam Lal (DLA-Deceased Life Assured) filed a proposal form to purchase a Life Insurance policy from the appellant company.  On 31.10.2012, Aviva Life Shield Advantage Police No.BLA0068674 was issued by the appellant company in favour of DLA for a sum assured of Rs.34,50,000/ with an annual premium of Rs.24,754/-.  On 28.11.2012, unfortunately, DLA passed away (within 28 days of getting the policy).  On 10.01.2013, the appellants received a Death Claim Intimation Form along with Death Certificate of the DLA from the respondent No.1 who is the nominee of the DLA.  On 11.01.2013, the appellant sent a condolence letter to the respondent and requested the respondent to provide the necessary documents for processing the claim under the said policy.  On 22.01.2013, since the claim was an early claim, to check the bonafides of the claim, appellant got the matter investigated and received a certificate issued by Dr. Virandra Mohan who was treating the DLA for his illness since 31.08.2009.  On 31.01.2013, appellant communicated the rejection of respondent’s claim to the respondents.  On 04.03.2013, respondents represented their claim to the Claims Review Committee and sent the aforesaid claim through Review Committee through Registered Post.  On 09.03.2013, Claims Review Committee of the appellants received the said representation.  On 29.04.2014, before the claims Review Committee could reply, a Consumer complaint bearing No.11/2014, was filed by respondent/complainant before the State Commission.  On 24.03.2015, the State Commission, decided the consumer complaint in favour of the respondent/complainant and ordered the appellants to pay a sum of Rs.34,50,000/- on account of sum assured for the subject policy along with interest @9% p.a. from the date of complaint till the date of payment and further directed to pay Rs.50,000/- as compensation for mental harassment etc. and Rs.10,000/- as litigation expenses. 

3.      Hence the present appeal.

4.      Heard the leaned counsel for both the parties and perused the record.

5.      Learned counsel for the appellants stated that the insured died within one month from the date of commencement of the policy and hence the appellant Insurance Company got the matter investigated.  The Investigator submitted his report on 24.01.2013.  It was found by the Investigator that the insured was suffering from the disease ‘recurrent mania’ for the last 17 years, but the same fact was not disclosed by the insured in the proposal form, whereas, he was under regular treatment of Dr. Virandra Mohan, who has issued certificate dated 22.01.2013 stating that the insured was suffering from ‘recurrent mania’ and visited him at his OPD since 2009 till 2012 and was under his treatment.  The certificate also states that the insured was suffering from this disease for the last 17 years.  The insured has not given this information in the proposal form and has wrongly answered most of the columns relating to health status of the insured.  The visit of the DLA as mentioned on the doctor’s certificate: 31.08.2009- 30.11.2009, 30.05.2011- 21.07.2011 & 04.05.2012 – 03.08.2012 clearly reflects that the DLA’s mental illness lasted for more than 3 months on three occasions and thus by suppressing such mental illness in the proposal form will automatically render the policy null and void.

6.      The learned counsel for the appellants argued that non-filing of the affidavit of the treating doctor cannot lead to any adverse finding against the opposite party.  Moreover, if the decision of State Commission is based on insufficiency of evidence then the matter may be remanded back to the State Commission.

7.      Learned counsel for the appellants referred to the following judgments in support of his arguments:-

(1)     Life Insurance Corporation of India Vs. Krishan Chander Sharma, 2 (2007) CPJ 51 (NC).  It has been held that:-

“4.  …..As part of submission it was urged that deceased had died due to heart failure which had no nexus with the ailments she was allegedly suffering from. To be only noted that as policy in question had not run for two years, Section 45 of Insurance Act would not be attracted. Said decisions are, thus, not of any assistance to the respondent. On the other hand, it was pointed out by Mr. S.P. Mittal, for petitioner that nonfiling of affidavit and/or non-examination of treating doctor of the deceased is not fatal. In para No. 8 of the complaint as also by way of ground No. 2(iii) of the response filed to revision petition it is admitted by the respondent that deceased was treated for allergic bronchitis etc. in a hospital. He invited our attention to the claim inquiry report (Copy at pages 22 to 26) and certificate issued by N.C. Jindal Hospital, Hissar (copy at pages 27 to 30). Against Column Nos. 16 and 33 in claim inquiry report it is mentioned that deceased remained admitted in the said hospital from 23.5.1992 to 9.6.1992, 28.7.1993 to 12.8.1993 and l.l2.1993 to 26.12.1993 as she was seriously ill because of asthma and allergic bronchitis. It is further mentioned that treatment files were in personal custody of Dr. Ravinder Gupta. It is not in dispute that respondent is also a doctor by profession. After said certificate was issued by the above hospital with reference to admission of the deceased from 23.5.1992 to 9.6.1992. In view of said pleadings and evidence, we are in agreement with Mr. Mittal, Advocate that non-filing of affidavit and/or non-examination of treating doctor is not ruinous.”

(2)     RP No.46 of 2017, Gurmail Kaur (deceased) through LRs Vs. HDFC Standard Life Insurance Company Limited & Anr., decided on 01.03.2017 (NC) It has been held that:-

“4.     The only question which arises for consideration in this petition is as to whether late Sh. Ajaib Singh was suffering from Cancer at the time he took policy or not.  In order to prove the alleged ailment, the insurer relied upon the report of an investigator and the medical record collected by him.  The affidavit of the investigator was filed before the District Forum but neither any official from the hospital was summoned nor his affidavit or affidavit of any doctor or official of the hospital which purportedly issued the medical record, was filed.

9.      On the other hand, learned counsel for the respondents/complainants stated that the insured was not suffering from any disease and he died of natural death as reported in the report of Investigator itself. Even if it is presumed that the insured was suffering from ‘‘recurrent mania’, the death was natural and it means that this disease had no relation with the cause of death.  As the State Commission has critically examined all the allegations of the opposite parties/appellants and has come to the conclusion that no suppression of material fact was made by the insured at the time of filling of the proposal form.  The learned counsel further pointed out that there is a delay of 14 days in filing the appeal and no sufficient cause has been shown for such a delay, hence, the appeal deserves to be dismissed on this ground alone.    

10.    It was further argued by the learned counsel for the respondents that the death was natural and had no relationship with the alleged disease.  Therefore, the claim cannot be denied on this basis. Learned counsel for the respondents referred to the following judgment in support of his arguments:-

RP No.1317 of 2004, Life Insurance Corporation of India Vs. Nishar Khan, decided on 8^th March, 2006 (NC).  It has been observed that:-

“4.  Then the next question that arises for consideration is whether the life assured was actually aware of her pregnancy at the relevant time of filing the proposal form.  It is a known fact that most of the women sometimes do not know about existence of pregnancy in the early days till they go for a check up to a doctor or for a pathology test.  In any case, pregnancy is nothing to do with her death.  Hence, repudiation is unjustified.  There is no evidence to the effect that the respondent was aware of pregnancy.  It is not the petitioner’s case that the respondent took medical consultancy in this regard.”

11.    I have given a thoughtful consideration to the arguments advanced by both the parties and have carefully examined the record. Though the appellants have filed an application for condonation of delay of 13 days, but the office has reported delay of 14 days.  Be it as it may, as the delay is only of two weeks, it is condoned in the interest of justice on the grounds mentioned in the application for condonation of delay.  The Insurance Company/appellant is supporting the repudiation of the claim of the complainant mainly on the basis of alleged wrong answers to questions mentioned at 6.2 B(vii) and 6.2B (xiv).  The question and the answer given by the DLA are as follows:

“6.2  Health & Activity Section

If you answer YES to questions A,B,C (ii), D(ii), E,F,G(ii) & G (iii) please provide us with further background information in the table provided below.  The information given will allow us to come to a decision without having to delay your proposal for further queries.

B.  Have you ever had any medical or surgical treatment, including investigations, tests, scans or X-Ray for any of the following illness or medical conditions:-

12.    The State Commission has basically allowed the complaint on consideration of two main points. First, that the disease of ‘recurrent mania’ did not last for more than three months at one time and it did not warrant consecutive ten days off work which are the two main conditions to deny the claim as per the policy. The State Commission has held that no proof has been filed by the opposite parties to show that the disease remained active for more than three months at any time and that the DLA had remained off work for consecutive 10 days.  On this basis, the State Commission has justified ‘no’ answer to the question 6.2 [B(vii)].  The second point relates to the view of the State Commission that ‘no’ answer to question 6.2 [B (xiv] is also justified because under this column one has to mention only those diseases, which are not covered under specific queries relating to specifically mentioned diseases and because, the mental illness was covered in Item No.6.2 B(vii), therefore, the DLA was not required to write anything on that issue under this question.  However, learned counsel for the appellants has contended that the disease of ‘recurrent mania’ was prevalent for 17 years and therefore, it is incorrect to say that the disease did not last for more than three months.

13.    From the report of the Investigator, it is clear that it was natural death and that the insured was being treated by Dr. Virandra Mohan.  The treating Dr. Virandra Mohan has given the certificate, which mentions the following:-

“It is to certify that Shyam Lal S/o Sh. Tikka Ram R/o Vill. Nanowal Tapria, P.O. Khera Distt Solan (H.P.) visited me in my O.P.D. first time on dated 31.08.2009, he has been suffering from recurrent mania since last Seventeen years.

He was admitted in my nursing home from 24/05/11 to 30/05/11.  He was in actue excitement stage when he was admitted in my nursing home.  He visited me in my O.P.D. on the following dates 30/11/09, 08/06/10, 30/05/11, 27/06/11, 21/07/11, 16/12/11,04/05/12.  Last time he visited me was on 03/08/12.  He visited me early also and it has been recorded, but the record has been lost.”

14.    The Insurance Company vide its letter dated 30.01.2013 repudiated the claim by mentioning the following:-

“As per the information procured by us during the course of claim evaluation, the deceased life assured was suffering from Recurrent Mania since last seventeen years and was under treatment for the same since Aug 31, 2009.  This fact in respect to the pre-existing Psycological ailments were not disclosed in the proposal form.”

15.    The insurance company in the repudiation letter has not given any information received from Dr. Virandra Mohan, whose certificate has been obtained by the Investigator.  The complainant has only mentioned in his complaint that the insured was not suffering from any such disease.  Had the Insurance Company given full details of investigation, the complainant might have given its version in the complaint about the disease of ‘recurrent mania’ and the treatment in this regard.  Neither the Doctor has been examined nor any medical treatment record has been filed.

16.  Though the learned counsel for the appellants has prayed that the matter may be remanded back to the State Commission for fresh decision on the basis of further evidence to be produced by the parties in the light of this Commission’s decision in Gurmail Kaur (deceased) through LRs Vs. HDFC Standard Life Insurance Company Limited & Anr., (supra), however, the appellants have not indicated any further and additional evidence that they can produce to strengthen their case of repudiation.  Thus, I feel that the exercise of remanding the matter to the State Commission would only delay the adjudication in the matter.

17.    From the certificate of Dr. Virandra Mohan it is evident that only the dates of visit to his OPD have been mentioned in his certificate. It does not mention that the patient was admitted in his hospital or what is the duration of any one episode. Disease mentioned is ‘recurrent mania’ and the name itself suggests that it would be recurring.  No certificate or any other proof has been filed by the opposite party to indicate the period of continuance of the disease in any one episode.  Moreover, neither the doctor has been examined nor any medical record of the treatment has been filed.  The doctor in his certificate has also written the medical record is not available.  From the doctor’s pad on which the certificate has been given, it seems that he is a private doctor and not a doctor of any Government hospital.  The complainant has denied that the insured was suffering from any such disease.  In these conditions, first of all the certificate of the doctor cannot be treated as evidence for the disease of the insured and particularly to show that the disease lasted for more than three months in any one episode.  Thus, the State Commission has rightly held that the insured did not suppress any information for the question 6.2 [B (vii].  Column 6.2 B (xiv) is related to any other disease.  The reasoning of the State Commission that this column only covers the other diseases not specifically mentioned in other columns, seems reasonable and justified.  Hence, I find no force in the contention of the opposite party/petitioner that even in column 6.2 B (xiv), the insured had not mentioned anything about his disease. 

18.    As per the report of the investigator the death of the insured was a natural death, which also proves that the insured did not die of ‘recurrent mania’ and thus his suffering from this disease is also not corroborated from his death.

19.    Based on the above discussion, I find no force in the First Appeal No.380 of 2015 and the same is dismissed. No order as to costs.