Tamil Nadu

StateCommission

FA/59/2013

LIC, THE MANAGER - Complainant(s)

Versus

KALYANI - Opp.Party(s)

S.R.S. ANANDAM

13 Sep 2022

ORDER

IN THE TAMIL NADU STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI.

 

                                 Present: Hon’ble Thiru. Justice R.SUBBIAH ... PRESIDENT

                                             Thiru.R VENKATESAPERUMAL       … MEMBER

 

F.A. No.59 of 2013

 

(Against the Order, dated 11.12.2012, in C.C. No.60 of 2011, on the file of  the DCDRF, Erode)

                                                    

                                                                                                                    Orders pronounced on: 13.09.2022

 

1. Life Insurance Corporation of India,

Erode North Branch Office,

rep. by its Manager,

660 Park Road, Erode-3.

 

2. Life Insurance Corporation of India,

rep. by its Divisional Manager,

Divisional Office,

Post Box No.3810,

India Life Building,

Trichy Road, Coimbatore-641 018.       .. Appellants/OPs-2 & 3

 

vs.

 

1. Kalyani,

W/o.Late R.Ganesan,

68, Teachers Colony,

Paramethi-637 207.           .. 1^st Respondent/Complainant.

 

 

             For Appellants         :  M/s.R.S.Anandan

             For 1^st Respondent  :  M/s. K. R. Ramesh Kumar

 

This First Appeal came up for final hearing on 01.08.2022 and, after hearing the arguments of the appellants' side and perusing the materials on record and having stood over for consideration till this day, this Commission passes the following:-

 

O R D E R

R.Subbiah, J. – President.

 

             Life Insurance Corporation (LIC) of India have preferred this appeal as against the order, dated 11.12.2012, passed by the DCDRF, Erode, in C.C. No.60 of 2011, whereby, the complaint filed by the respondent herein/complainant was allowed by the District Forum, directing the OPs/LIC to pay to her the insured amount of Rs.1 lakh and a further sum of Rs.25,000/- as compensation for mental agony & deficiency in service, besides a sum of Rs.2,000/- towards costs of the proceedings.

 

             2. For the sake of convenience, the parties shall be referred to in the course of this Order, as per their respective rankings before the District Forum.

 

             The facts, as projected in the complaint, may be concisely stated as follows:-

             The complainant's husband by name T.Ganesan had taken a 'money plus' policy bearing No.764924507, from the OPs/LIC covering the risk of life from the date of commencement of the policy that was on 17.03.2007, on which date, a sum of Rs.10,000/- was paid towards the first premium and again, another sum of Rs.10,000/- was paid on 10.03.2008 as the next instalment premium.   Before issuance of the said policy, the insured was examined by a panel doctor of the LIC and, only after his approval, the policy was issued.  One another policy under 'jeevan sanchey plan' was also taken by the complainant's husband from the LIC.  While so, on 16.11.2008, the policy holder died, whereupon, being his wife and nominee, the complainant laid a claim with the 2nd OP in respect of both the aforesaid policies.  While the said OP had settled a sum of Rs.1,54,217/- towards the policy under jeevan sanchey plan,  they postponed the settlement of claim in respect of the money plus policy.   After a number of letters and reminders by the complainant, the 2nd OP informed that, since the policy holder has made incorrect statements and withheld correct information regarding his health, the claim has been repudiated.   According to the 2nd OP, the policy holder had suppressed in the proposal form the fact that he was suffering from diabetes mellitus and hypertension.   OP No.1, an LIC Agent is a close relative of the policy holder and he knows well about his health status. The policy holder took many policies and all those polices were filled up only by the 1st OP.  In some of the proposal forms, OP No.1 disclosed about the policy holder's ailments but in the remaining forms, he did not disclose the same and this was not made known to the policy holder at that time.  Further, OP No.1 used to get the signatures of the policy holder in the proposal form without filling up the columns therein. While all other claims were settled by the LIC, the present claim alone under the money plus plan has been repudiated, which is absolutely unjustifiable.  When the insurance company insisted the policy holder to appear before its panel Doctor, it is the duty of the said Doctor to clinically examine the  policy holder in all aspects and record the diseases found, if any.   For the negligence on the part of the LIC in that regard, the claim cannot be repudiated. Hence, the complaint, seeking the District Forum to direct the OPs/LIC to pay to her a sum of Rs.3 lakh that includes the policy amount due to the complainant as well as the compensation claimed, besides costs of the complaint.

 

             3. The OPs/LIC resisted the complaint by stating that it is true that the Doctor of the LIC had examined the deceased/policy holder, however, the latter failed to furnish proper information to the said Doctor regarding his health condition and the complications suffered by him previously.   At the time of examination, he might have taken medicines properly and hence, unless the insured discloses the health history, the Doctor cannot exactly certify his health condition.  The LIC repudiated the claim for the reason that material fact about health status was suppressed by the husband of the complainant.  It is not correct to say that the Agent of the LIC whimsically filled up the application.  Being an agent of the company, he can only fill up the information that was furnished by the policy holder and if really any wrong information was entered, that should be corrected by the proposer before signing the forms.  It is totally false to say that the Agent used to get signature from the policy holder in the proposal form without even filling up the same.  Since the deceased has placed false and misleading information, the claim was repudiated by giving valid reasons.  Thus, there is no cause of action for the complaint and the same, being a classic case of gross abuse of process of law, is liable to be dismissed with exemplary costs.

 

             4. In order to substantiate the claim and counter-claim, both sides filed their respective proof affidavits and, while the complainant marked 7 documents as Exs.A1 to A7, on the side of the Insurance Company, 3 documents were marked as Exs.B1 to B3.  In the impugned order, the District Forum, by pointing out that examination of the insured by the panel doctor is not denied by the LIC,  recorded a finding that there is no evidence to prove that the OPs repudiated the claim of the complainant for a justifiable reason that the deceased was suffering from diabetes mellitus and hypertension and such fact was  suppressed at the time of taking the policy.  By consequently holding that the LIC has committed service deficiency, the District Forum ultimately allowed the complaint by issuing a direction, as aforementioned.  Hence, the present Appeal by the LIC/OP Nos.2 and 3.

 

             5. Heard the submissions of the learned counsel for the appellant and perused the materials available on record.

             On a careful examination of the materials available on record, we find that the complainant has not disputed the fact that her husband was suffering from Diabetes Mellitus and Hypertension.  But, her case is, when the panel doctor of the Insurance Company clinically examined the insured before issuance of the policy, he should have properly recorded as to whether the individual concerned was suffering from any ailment like diabetes and hypertension.  For any lapse on the part of its panel doctor to properly record such details of illness, the LIC cannot blame the insured so as to repudiate the claim. Therefore, non-disclosure of the ailments at the time of taking the policy would not affect the validity of the policy and hence, the claim has to be honoured.   But, it is common knowledge that it is not possible for a panel Doctor to accurately record the health status of the insured particularly regarding diabetes and hypertension, which may go undetected in one single sitting if the individual concerned has been regularly taking medicines there-for. According to the LIC, their scrutiny over the claim in question revealed that the deceased was a diabetic patient with hypertension, that he was taking treatment for the said ailments for more than 15 years prior to commencement of the policy viz., 17.03.2007, from Dr.Satyamoorthi of Erode and that the deceased was subjected to ECG test on 16.07.2001 at Trichy, Colour Doppler Scans and the result showed that he had hypertrophy and diastolic dysfunction grade-1.   Needless to mention, had such relevant details been duly informed to the LIC at the inception, the complainant's husband would not have been issued with the policy.  It is settled legal principle that, in matter of insurance policies like the present instance, suppression and misrepresentation of material facts would render the policy invalid in the eye of law.  Such an instance enables the Insurance Company to repudiate the claim arising from the policy for the reason that the principle of uberrima fides/utmost good faith is flouted due to suppression of material facts.  If the insured has a knowledge of facts which others cannot know, he should not resort to suppresso veri/suppression of truth.  In the case on hand, since the insured had suppressed the material facts about his medical history which is the criterion for considering the issuance of the policy itself, by simply referring to the examination by the panel doctor, the complainant cannot expect any positive consideration of the claim.  It is also stated that the LIC have repaid the premiums received and has only disallowed the risk portion.  As such, we find no valid reason to sustain the impugned order passed by the District Forum and hence, the same is liable to be set aside.

             6. In the result, the appeal is allowed by setting aside the impugned order, dated 11.12.2012, passed by the DCDRF, Erode, in C.C. No.60 of 2011. No costs.

 

R  VENKATESAPERUMAL                            R.SUBBIAH, J.

MEMBER                                                           PRESIDENT.