Haryana

StateCommission

A/26/2015

BHATERI DEVI - Complainant(s)

Versus

ICICI PRU.LIFE INSURANCE CO. - Opp.Party(s)

AJAY CHHIKARA

16 Dec 2015

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

                                                         First Appeal No.26 of 2015

Date of Institution: 12.01.2015

                                                               Date of Decision: 16.12.2015

 

Smt. Bhateri Devi widow of Late Sh.Dhupa, age 45 years, resident of village Chandana,Tehsil and District Kaithal.

…..Appellant

Versus

 

1.ICICI Prudential Life Insurance Company Limited Branch office at Ambala Road, Kaithal.

2.ICICI Prudential Life Insurance Company Limited, Vinod Silk Mills compound, Chakravarthy Ashok Nagar,Ashok road, Kandwali (E) Mumbai-400101.

                                      …..Respondents

 

CORAM:             Mr. R.K.Bishnoi, Judicial Member.

                             Mrs. Urvashi Agnihotri, Member.                                                                                                                                        

Present:              Shri Gopal Sharma, Advocate for appellant.

Mr.Hitender Kansal, Advocate for the respondents.

                                                   O R D E R

R.K.BISHNOI, JUDICIAL MEMBER:

 

As per  complainant her husband obtained two policies bearing Nos.14702929 and 14708423 from Opposite parties (O.Ps.).  On 07.07.2011 he expired due to heart attack.  O.Ps.-respondents issued cheque qua policy No.14702929 but repudiated her claim pertaining to policy No.14708423 on the ground of suppression of material facts, whereas no material was concealed.  He never consumed alcohol or any other intoxicant.  He was never admitted to the hospital due to decomposed alcoholic liver disease, sepsis with hapitities.  The allegations about alcoholic were altogether wrong.  The O.Ps. be directed to pay the claim qua insurance policy No.14708423 also.

2.      O.ps. filed reply controverting her averments and alleged that during investigation it was found that the complainant remained admitted in the hospital and received treatment from Dr.Arvind Sahni, as detailed in para No.6 of reply which is as under:-

“S.No	Name of document	Description
1	Consultation Note from Fortis Hospital, Mohali By Dr. Arvind Sahni Dated: September 03, 2011	To whom it may concern DOA June 13,2011 Patient Dhoop Singh, 55 years old male was admitted with complaints of jaundice-1 month and history of chronic alcohol since 15 years. He was diagnosed as decomposed alcoholic liver disease, sepsis and hapatities Patient left against medical advise on 15.06.2011 Annexure R-2
2.	Multi Specialty in patient history and physical record Date of Admission: 13 June 2011 Source of History Patient	. Diagnosis: Alcoholic Liver Disease with Ascitis R/oSBP . Provisional diagnosis: . ALD with alcoholic hepatitis with ascites to R/o SBP Annexure R-3
3.	LAMA SUMMARY By Dr. Arvind Sahni	Pt. Dhoop Singh, 55 years old  male ____________ so pt. was sent lama on 15.06.2011. Annexure R-4”

 

          As per terms and conditions of insurance policy in case of concealment of material facts or ailments nominee of life assured (DLA) was not entitled for any compensation. Objections about maintainability of complaint, concealment of true facts, etc. were also raised and requested to dismiss the complaint.

3.      After hearing both the parties, learned Consumer Disputes Redressal Forum, Kaithal dismissed the complaint vide impugned order dated  25.11.2014.

4.      Feeling aggrieved therefrom, complainant has preferred this appeal.

5.      Arguments heard. File perused.

6.      Learned counsel for the O.Ps. vehemently argued that at the time of the issuance of proposal form Ex.R-1 DLA did not disclose that he was suffering from any ailment or received any  treatment, whereas according to certificates Ex.R-2 and R-4 he was a chronic Alcholic for 15 years and was diagnosed as decomposed alcoholic liver disease, sepsis and hapitities.  Certificate Ex.R-2 was issued on 03.09.2011 whereas proposal form was issued on 24.11.2010. It shows that he concealed the disease and that is why her claim was repudiated vide letter Ex.R-5.  Claim about policy No.14702929 was allowed because that was payment policy and there was no such condition.  Terms and conditions of this policy are altogether different from that policy.

7.      This argument is of no avail.  The O.Ps. have failed to relate certificates Ex.R-2 and R-4 with the complainant. As per this certificate patient was 55 years old whereas according to proposal form Ex.R-1 the date of birth of insured was 15.04.1968 years which comes to 43 years in the year 2011.   There is difference of 12 years.

8.      More so, name of the father of Dhoop Singh or his place of residence is not mentioned in Ex.R-2 or Ex.R-4. When complainant has specifically alleged that he was never admitted in any hospital for any treatment then it was the bounden duty of the O.Ps. to co-relate the certificates with the deceased. Discharge summary is no ground to presume that patient was suffering from problem since the period mentioned therein unless proved by the doctor who prepared the same and prove that the history was told by the patient as opined by Hon’ble National Commission in revision petition No.2021 of 2009 titled as LIC of India & Anr. Vs. Smt. Chawali Devi decided on 03.12.2015. Para No.6 of above said judgment is important and is as under:-

“As far suppression of material facts regarding existing disease and treatment is concerned,  learned counsel for the petitioner has drawn my attention towards history of deceased noted by doctor in which it was mentioned that deceased was having breathlessness, caugh c expectoration etc. No doubt, this fact has been mentioned as patient’s history, but petitioner has failed to place any document on record regarding treatment of aforesaid breathlessness, caugh c expectoration etc. and has not filed any affidavit of concerned doctor who recorded history to prove that this history was given by deceased himself.  In such circumstances, only on the basis of recorded history of deceased, it cannot be held that deceased was suffering from breathlessness, cough expectoration etc. since last 10 years and had taken any treatment.”

9.      Further vide letter dated 05.09.2011 Ex.R-7 claim was allowed qua other policy.  Two policy documents under Ex.R-6  are placed on the record of District Forum.  In clause 5 of first policy document and clause 6 of second policy document it is mentioned that if there is any concealment of facts or false or forged declaration is made then the claim can be repudiated. Even if policy No.14702929 was payment policy, insured was not supposed to conceal any fact when the claim in that policy has been released it means that nothing was concealed by the life assured and this objection has been raised later-on.  Otherwise as per these terms that claim in that case must have been declined.  O.Ps. cannot get out of these policies. So these arguments are of no avail.

10.    Learned District Forum has failed to take into consideration all these aspects. When O.Ps. have failed to prove that DLA was suffering from above said ailment the claim cannot be repudiated.  Hence impugned order dated 25.11.2014 is set aside. The complainant is entitled for the insured amount pertaining to policy No.14708423 alongwith interest @ 9% per annum from the date of repudiation till realization.  The complainant is entitled to Rs.5500/- as compensation for mental agony and harassment. She is also entitled to Rs.1100/- as litigation expenses.

 

 

December 16th, 2015 Urvashi Agnihotri                                R.K.Bishnoi,                                                               Member                                              Judicial Member                                                         Addl. Bench                                        Addl.Bench                

S.K.