DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,<br /> BATHINDA (PUNJAB)<br /> <br /> CC. No. 110 of 11-05-2009<br /> Decided on : 07-10-2009 <br /> <br /> Kamlesh Rani, aged about 47 years, widow of Sh. Ramesh Kumar, R/o 689, Amrik Singh Road, Bathinda.<br /> .... Complainant<br /> Versus<br /> <br /> 1.ICICI Pruential Life Insurance Company Limited, ICICI Pru Life Towers 1089, Appasaheb Marathe Marg, Prabhadevi Mumbai 400 025 India through its Managing Director<br /> 2.ICICI Prudential Life Insurance Company Limited, The Mall, Opposite Dr. Mohan Lal Garg, Bathinda through its Manager<br /> ... Opposite parties<br /> <br /> Complaint under Section 12 of the Consumer Protection<br /> Act, 1986.<br /> <br /> QUORUM <br /> <br /> Sh. George, President<br /> Sh. Amarjeet Paul, Member<br /> <br /> For the Complainant : Sh. Ashok Gupta, counsel for the complainant. <br /> For the Opposite parties : Sh. Ashok Bharti, counsel for the opposite parties.<br /> <br /> <br /> O R D E R<br /> <br /> GEORGE, PRESIDENT<br /> <br /> 1. The complainant Kamlesh Kumari has approached this Forum with the allegations against the opposite parties that Ramesh Kumar, her husband during his life time had obtained on 18-10-08 Life Insurance Policy No. 10119708 for an assured amount of Rs. 3,50,000/- and appointed her as nominee. The insurance policy was valid for ten years and it was issued by the opposite parties after verifying the health of her husband after getting him examined from the doctor at their own panel. Ramesh Kumar expired on 18-01-2009 and the complainant lodged claim with opposite party No.2 in time, but the opposite parties vide their letter 31-03-2009 repudiated her claim on the ground that deceased withheld the correct information regarding his health at the time of effecting the insurance as there was history of habit of alcohol consumption since four years. The ground of repudiation is false and frivolous as the policy holder was enjoying good health at the time of taking policy and his death was all of a sudden and he had died a natural death. The complainant alleges that on account of illegal repudiation of her claim and deficiency of service on the part of the opposite parties, she has suffered mental tension, harassment and botheration and is entitled for compensation to the tune of Rs. 50,000/-. Hence, this complaint for issuing directions to the opposite parties to pay her insurance claim amounting to Rs. 3,50,000/- alongwith accrued bonus and interest @ 12% P.A. and any other alternative relief.<br /> 2. The opposite parties have filed their joint written version by taking preliminary objections that the complainant has concealed and suppressed material and relevant facts of the case and the complaint is frivolous and vexatious. On merits, It is submitted that complainant was issued the said policy after a medical examination conducted by an authorised Medical Examiner of the opposite parties. The complainant was an alcoholic and was suffering from Cirrhosis of liver which is directly linked to alcoholism. Further more, Section 45 of Insurance Act permits repudiation of such policy within a period of two years on the ground that material facts have been suppressed which were obligatory on the part of the life to be assured to disclose and in the present case life assured died within the three months from the date of taking policy. Thus, the decision of the opposite parties to repudiate the claim is fully justified and same cannot be termed as deficiency in service rendered by the opposite parties.<br /> 3. In support of his averments contained in the complaint, the complainant has produced in evidence her affidavit Ex. C-1 and the affidavits of S/Sh. Ved Parkash and Ganesh Mishra Ex. C-2 & Ex. C-3 respectively, photocopy of premium receipt Ex. C-4, photocopy of policy Ex. C-5, another affidavit of complainant Ex. C-6 and photocopy of letter Ex. C-7.<br /> 4. To controvert the evidence of the complainant, the opposite parties produced in evidence affidavit of Ms. Preeti Nahar, Senior Manager Legal Ex. R-1, photocopy of policy Ex. R-2, photocopy of death certificate of Ramesh Kumar Ex. R-3, photocopy of claim intimation form Ex. R-4, photocopy of letter dated 30-01-09 Ex. R-5, photocopy of admission record Ex. R-6, photocopy of medical attendants certificate Ex. R-7, photocopy of family doctor certificate Ex. R-8 and photocopy of letter dated 31-03-09 Ex. R-9.<br /> 5. We have heard learned counsel for the parties and have gone through the entire record of the case.<br /> 6. It is an admitted fact that deceased Ramesh Kumar, husband of the complainant during his life time obtained an Insurance policy on 18-10-2008 for an amount of Rs. 3,50,000/- for a period of 10 years and unfortunately, said policy holder expired on 18-01-2009, within a short span of approximately three months. It is also an admitted fact that at the time deceased Ramesh Kumar obtained his life Insurance policy from the opposite parties, a proposal form Ex. R-2 was filled in and in answer to Q. No. 20 of the said proposal form whether he consumes alcohol, the answer is given in negative. After the assured expired, his nominee the present complainant, filed insurance claim. The claim was repudiated by the opposite parties as per their letter dated 31-03-2009 Ex. C-7 wherein the opposite parties have stated that “the life assured had habit of alcohol consumption since four years. This history which was prior to the proposal was not disclosed in the proposal for insurance. Therefore, the answer to Q. No. 20 (E) as mentioned above, have been found to be false. Had the above fact been disclosed, the company would not have issued the policy on existing terms. The Company has been led to issue the policy by suppressing material facts. We are, therefore, constrained to repudiate your claim for the above policy and all monies that have been paid there under belong to us.”<br /> 7. Now the question of determination before this Forum is whether non-disclosure of the fact of consuming liquor/habit of consumption of alcohol since four years prior to the acquiring of the insurance policy is a material fact which justify the repudiation of Insurance claim of the complainant ?<br /> 8. It is an admitted fact that to Q. No. 20(E) of the proposal form in respect of consumption of alcohol, deceased answered in negative. It is also a fact that after the proposal form Ex. R-2 was filled in, the opposite parties in order to satisfy themselves as to whether the information furnished by the complainant in the proposal form Ex. R-2 in respect of answers to various queries with regard to prevailing health of the assured are correct or not, he was subjected to medical examination by an empaneled doctor of the opposite parties. This fact is also admitted by the opposite parties in their reply. However, the opposite parties have not brought on record alonwith proposal form Ex. R-2, the report of their own doctor with regard to health condition of assured at the time he was subjected to medical examination by them. As to why this important document has been withheld by the opposite parties has not been explained at all.<br /> 9. The opposite parties are heavily banking upon in justifying the repudiation of claim of the complainant on the basis of three documents i.e. Ex. R-6 to Ex. R-8. Ex. R-6 is the admission record of the deceased from the date he was admitted in Civil Hospital, Bathinda, on 10-01-2009 and ultimately he expired on 18-01-2009. <br /> 10. General Case Sheet containing 12 pages history and medical treatment of deceased annexed with Ex. R-6 reveals that the deceased was attended to by doctor of Civil Hospital and he was given treatment for jaundice. <br /> 11. Ex. R-7 has been prepared by one Dr. P. Bansal on 27-01-2009. This pertains to medical attendant/hospital certificate (Format A1-Death Claim) on the proforma of ICICI Prudential Life Insurance . According to information given in this format, the deceased on his admission in the Civil Hospital on 10-01-2009 was provisionally diagnosed as Alcoholism with cirrhosis of liver and finally he was diagnosed as Cirrhosis of liver and ultimately he died due to cardiac arrest on 18-01-2009 due to shock. The primary cause of his death was Cirrhosis of liver. He was admitted in the hospital for seeking treatment of jaundice. This format appears to have been filled in by Dr. P Bansal but his designation and authorised stamp of Civil Hospital is not affixed to authenticate the information given in this format i.e. Ex. R-7. <br /> 12. Similarly Ex. R-8 Usual/Family Doctor Certificate (Format AH) procured by the opposite parties in a format of ICICI Prudential Life Insurance on 04-03-2009 stated to be issued by a family doctor of deceased Ramesh Kumar wherein the said family doctor has not even specifically given his full name and full address nor he has authenticated the information given on this format of two pages Ex. R-8, by disclosing his full identity and office seal etc., In this alleged doctor's certificate, he has stated that he has been a usual doctor of the patient for the last 10 years and is a family doctor of deceased Ramesh Kumar. At page '2' in para '2', he has mentioned that deceased had habit of consuming Beer for the last four years and he was taking 400 ml. Beer per day. From the curious perusal of this document i.e. doctor's certificate, the identity of the doctor who has issued Ex. R-8 and furnished information to the effect that assured was having habit of consuming Beer 400 ml. per day for the last four years is not established.<br /> 13. The record reveals that documents Ex. R-6 to Ex. R-8 have been brought on record by Smt. Navneet Kumari, counsel for the opposite parties. In fact no officer/official of the opposite parties has taken trouble to appear in person before this Forum in order to tender all these documents to prove that these documents have infact come from proper custody and from the records of the opposite parties. Even the affidavit of Preeti Nahar Ex. R-1 stated to be Senior Legal Manager and authorised Signatory of ICICI Prudential Life Insurance Co. Ltd., has been brought on record not by herself/himself but it has been tendered by Smt. Navneet Kumari, counsel for the opposite parties. Neither the execution of this document nor its proper verification and signatures of Preeti Nahar has been legally proved. The opposite parties have brought on record through their counsel documents Ex. R-6 to Ex. R-8. However, correctness and execution of these documents is not proved for the reason that the executants of these three documents have not been examined. The Medical Officer who prepared Ex. R-6 and information containing 12 pages attached to it neither examined nor his affidavit has been brought on record. Similarly neither Ex. R-7 nor information contained in it, has been proved as Dr. P Bansal stated to have prepared this document Ex. R-7 neither appeared as witness nor he has filed any affidavit in support of the information he has furnished in Ex. R-7. Likewise the execution of Ex. R-8 alongwith information given therein is not proved as the alleged family doctor of deceased Ramesh Kumar neither disclosed his full identity nor he has given any source of his information in Ex. R-8 nor he has been examined or his affidavit has been filed.<br /> 14. The next question which arises for determination is as to whether the information, suppressed if any by deceased Ramesh Kumar while answering to Question No. 20 of the proposal form Ex. R-2 , as has been discussed herein above, is so material that if he would have given the answer in affirmative that he has ever consumed alcohol and that he is in habit of having Beer for the last four years and is consuming Beer about 400 ml per day, the opposite parties would have gone to the extent of refusing the insurance. The opposite parties have not brought on record any rules, regulations or a general policy adopted by the opposite parties that a person who is in habit of consuming liquor/beer either occasionally or regularly is not to be accepted for Life Insurance Policy. It has been held by the Hon'ble Supreme Court in the case Biman Krishna Bose Vs. United India Insurance Co. Ltd., III (2001)CPJ 10 S.C that :-<br /> “Where an Insurance Company under the provisions of the Act having assumed monopoly in the business of general insurance in the country and thus acquired the trappings of the 'State' being other authorities under Article 12 of the Constitution, it requires to satisfy the requirement of reasonableness and fairness while dealing with the customers. Even in an area of contractual relations, the State and its instrumentalities are enjoined with the obligations to act with fairness and in doing so, can take into consideration only the relevant materials. They must not take any irrelevant and extraneous consideration while arriving to a decision. Arbitrariness should not appear in their actions or decisions.” <br /> 15. The Hon'ble State Commission, Punjab, Chandigarh in the case titled Life Insurance Corporation of India & Another Vs. Sukhpal Kaur 2008(2) CPC 34 has held that :-<br /> “Insurance – Suppression of material fact – Only ground for repudiation of claim was given that insured deceased had not disclosed the fact that he was a habitual drinker - He was taking liquor for the last six years and was suffering from hypertension for the last ten years which fact was concealed while submitting the proposal of insurance – District Forum accepted the claim of Rs. 5 lacs with 6% interest giving rise to present appeal – It has been held in various judgements that taking of liquor is not a material fact which requires to be disclosed at the time of taking policy – If liquor was a disease he could not survive for such a long time – Impugned order does not suffer from any illegality – Appeal dismissed.” <br /> 16. Taking into consideration the clear position of law as herein stated above and the entire material available on record, it appears that the deceased Ramesh Kumar might be suffering from liver Cirrhosis which may have taken place due to many reasons including infection acquired from infected water or other source which led to serious jaundice and ultimately may result fatal due to cardiac arrest. In the present case, if we take into consideration Ex. R-7 for arguments sake, the deceased assured was admitted in the hospital for seeking treatment of jaundice and he was treated in the civil hospital for jaundice. There is no direct or indirect material has been brought on record by the opposite parties to prove documents Ex. R-6 to Ex. R-8 whereas the complainant Kamlesh Rani wife of deceased has filed her affidavits Ex. C-1 & Ex. C-6 and also brought on record affidavits of one Sh. Ved Parkash Ex. C-2 and Sh. Ganesh Mishra Ex. C-3. In all these affidavits, it has been specifically mentioned that deceased Ramesh Kumar was never in the habit of taking alcohol nor he was suffering from any pre-existing disease at the time of obtaining Insurance policy. Moreover, at the time of deceased Ramesh Kumar insured, doctor of the opposite parties thoroughly examined the state of his health and only after full satisfaction of the medical examination of the deceased, the policy was issued. <br /> 17. Ex. R-7 & Ex. R-8 appears to be procured documents to defeat the claim of the complainant. If these documents have been genuine, there is no reason for the opposite parties to examine the executant of these three documents which are foundation of their defence.<br /> 18. Thus, keeping in view the facts, circumstances and evidence brought on record by the parties, we are of the considered view that repudiation of insurance claim lodged by the complainant of her deceased husband upon the Insurance company on the ground of concealment of facts or drinking habit, is not justified and there is deficiency in service on their part because of which complainant has faced mental agony and has to incur avoidable expenses for filing of this complaint. Therefore, the opposite parties are liable to release the amount under the policy secured by her deceased husband and to pay her compensation and costs.<br /> 19. No other point was urged before us at the time of arguments.<br /> 20. Keeping in view the facts, circumstances and evidence brought on record by the parties, we are of the considered view that there is no cogent and convincing evidence produced on record by the opposite parties to the effect that complainant has suffered disease referred to herein above, due to consumption of alcohol and they repudiated the claim of the complainant on flimsy grounds without any base which itself amounts to deficiency in service. Accordingly, we accept the complaint and set aside the repudiation letter dated 31-03-2009 Ex. C-7. The opposite parties are directed to pay to the complainant claim amount of Rs. 3,50,000/- alongwith interest @ 9% P.A. w.e.f. 18-04-2009 till final payment and compensation of Rs. 20,000/- for mental tension, harassment, botheration and inconvenience suffered by her, besides litigation expenses to the tune of Rs. 5,000/- within a period of 45 days from the date of receipt of copy of this order.<br /> 21. The copy of this order be sent to the parties concerned free of costs and the file be indexed and consigned.<br /> Pronounced :<br /> 07-10-2009 <br /> (George)<br /> (Amarjeet Paul) President<br /> Member <br /> <br /> <br />