Before the District Consumer Disputes Redressal Commission, Rohtak.

                                                                   Complaint No. : 429

                                                                   Instituted on     : 05.08.2021

                                                                   Decided on       : 24.05.2023

Bhateri Devi age 51 years, w/o Late Jagmohan R/o 61/29, Anand Nagar, Rohtak.

                                                                                                                                                                                                          ………..Complainant.

                             Vs.

Divisional Officer Life Insurance Corporation of India, Rohtak. SCO 3,4,5 Sector-1, Rohtak.

……….Opposite party.

COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.

BEFORE:  SH.NAGENDER SINGH KADIAN, PRESIDENT.

                   DR. TRIPTI PANNU, MEMBER.

                   DR. VIJENDER SINGH, MEMBER

Present:       Sh. Naseeb Vats, Advocate for the complainant.

                   Sh. Anuj Gulati, Advocate for opposite party.

                                      ORDER

NAGENDER SINGH KADIAN, PRESIDENT:

1.                Brief facts of the case as per complainant are that on 12.03.2018, the husband of complainant purchased insurance policy No. 101496774 in his favour for the sum of Rs.2,00,000/- from the opposite party. The husband of the complainant was died on 28.11.2018 and thereafter the complainant approached the opposite party for getting the claim of above said policy. The opposite party assured the complainant to settle the claim and demanded some documents. Complainant deposited all the requisite documents as demanded by opposite party. They also assured the complainant to settle the claim within one month. After that the complainant visited the office of opposite party many times for disbursing the claim. But the opposite party rejected the claim of the complainant vide letter number Claim/Rep/2019-20 dated 22.01.2020 on the ground that husband of the complainant was under treatment at the time of taking policy. It is further submitted that husband of the complainant was in good state of health at the time of purchase of said policy and the opposite party also got conducted the medical examination of husband of the complainant. The complainant visited the office of opposite party for settlement of claim but they declined the genuine request of the complainant on pretext of Covid-19 and asked the complainant to come after some time. Complainant visited again but opposite party did not pay any heed to the genuine request of the complainant. The act and conduct of the opposite party is illegal and amounts to deficiency in service. Hence this complaint and it is prayed that opposite party may kindly be directed to pay the claim amount of Rs.2,00,000/-. The opposite party also be directed to pay an amount of Rs.1,00,000/- on account of harassment and Rs.11,000/- as litigation charges.

2.                After registration of complaint, notice was issued to the opposite party. Opposite party in its reply has submitted that the said policy has not completed 3 years from the date of FPR i.e. 12.03.2018 to the date of death of life assured. While examining the claim, it was noted from the proposal form dated 12.03.2018 that the deceased life assured had answered the questions falsely as LIC hold indisputable proof. As per discharge summary of Medanta Hospital Gurgaon, DOA-22/10/2018, Life assured was a K/C/O Cryptogenic NASH related CLD with decompensation, jaundice, GL bleed and ascites and was admitted for liver transplant work up. Moreover as per discharge summary of Sahara Institute of Medical Sciences Hisar, DOA-5/10/2018, life assured was presented with complaint of abdomen, nausea, vomiting, decreased appetite with fever of and on breathlessness was diagnosed as cryptogenic cirrhosis with large oesophageal since 3 years and was old case of chronic liver disease with decompensation and was admitted for liver transplant work up in both hospitals. This suppression of material facts, which have had a bearing on the granting of risk, was clearly done with intent to mislead the opposite party corporation. So the claim was repudiated on the ground of suppression of material facts from the opposite party. All the other contents of the complaint were stated to be wrong and denied and opposite party prayed for dismissal of complaint with costs.

4.                Learned counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C3 and has closed his evidence on dated 29.06.2022. Ld. counsel for the opposite party tendered affidavit Ex. RW1/A, documents Ex. R-1 to Ex. R-12 and closed his evidence on 07.09.2022.

5.                We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.

6.                In the present case claim of the complainant has been repudiated by the opposite party vide letter Ex.C1 on the ground that deceased has given false answers to the questions given in the proposal form  dated 12.03.2018.  It is further submitted that as per discharge summary of Medanta Hospital Gurgaon, DOA-22/10/2018, Life assured was a K/C/O Cryptogenic NASH related CLD with decompensation, jaundice, GI bleed and ascites and was admitted for liver transplant work up. Moreover as per discharge summary of Sahara Institute of Medical Sciences Hisar, DOA-5/10/2018, life assured was presented with complaint of abdomen, nausea, vomiting, decreased appetite with fever of and on breathlessness was diagnosed as cryptogenic cirrhosis with large oesophageal varices on EVL. Life Assured was an old case of chronic liver disease with decomensation and was admitted for liver transplant work up in both hospitals.  To prove the same opposite party has placed on record Certificate of hospital treatment Ex.R6, History sheet of Sahra Institute of Medical Science Ex.R7 and discharge summary of Medanta Hospital Ex.R11.

7.                We have minutely perused the documents placed on record by both the parties. As per ‘Certificate of Hospital Treatment’ Ex.R6, issued by the Medical officer of Sahara Institute of Medical Sciences, answer to the question No.3 that  “Under whose treatment was the patient before he was admitted into the Hospital?” and the answer is –‘NA’. The question no.4(a), what, was the nature of complaint at the time of admission  and the answer is “Pain, Fever,, decreased appetite’, 4(b) that “What was the duration of complaint as reported by him? and the answer is 4 days. Meaning thereby, there was no history of previous treatment. Opposite party has also placed on record ‘Inpatient Initial Assessment & history Sheet’ of Sahara Institute of Medical Sciences as Ex.R7, as per which the deceased was admitted in the hospital on 05.102018. But in this document it is nowhere mentioned that for how many days and from which hospital, the deceased was taking treatment previously. As per discharge summary of Medanta Hospital Gurgaon, DOA-22/10/2018, Ex.R11, Life assured was a K/C/O Cryptogenic NASH related CLD with decompensation, jaundice, HRS, GI bleed and ascites and was admitted for liver transplant work. But from this document also, it is not proved that from which hospital and for how many days he was taking treatment earlier. It has also not been mentioned anywhere in the treatment record or the documents placed on record by the respondents that deceased life assured was suffering from any disease since 3 years. The duration of the deceased has been mentioned in the ‘no claim letter’ placed on record by the respondent as Ex.R12. Hence from the documents placed on record by the opposite parties, it is not established that the deceased was having pre-existing disease at the time of purchase of policy. In this regard, law cited by ld. counsel for the complainant of Hon’ble National Commission in first appeal no.356 of 2018 titled as HDFC standard Life Insurance Co. Ltd. Vs. Gurkirtan Singh  decided on 31.10.2022 and of Hon’ble State Commission, Punjab, Chandigarh in first Appeal no.392 of 2018 titled as Bajaj Allianz Life Insurance Co. Ltd. Vs. Dalbir Kaur are fully applicable on the facts and circumstances of the case. As such opposite party is liable to pay the claim amount to the complainant being nominee in the policy. 

8.                In view of the facts and circumstances of the case, we hereby allow the complaint and direct the opposite party to pay the amount of Rs.200000/-(Rupees two lac only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e 05.08.2021 till its realization and also to pay a sum of Rs.10000/-(Rupees ten thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.

9.                Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.

Announced in open court:

24.05.2023.         

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                                                          Nagender Singh Kadian, President

                                                          …………………………………

                                                          Tripti Pannu, Member.

                                                          …………………………………

                                                          Vijender Singh, Member