Assam

Dibrugarh

CC/21/2015

SMTI DIPALI GOGOI - Complainant(s)

Versus

L.C.I OF INDIA - Opp.Party(s)

SHRI DHRITI SUNDAR BARUAH

18 Jul 2024

ORDER

Date of Argument –  28.08.2023 (Complainant)

                                                                                                          14.07.2023 (O.P.)

                                                                        Date of Judgment –   18.07.2024

 

            This complaint was filed by the complainant under section 12 of Consumer Protection Act, 1986 claiming to direct the opposite party to pay sum assured/death benefit, sum assured under main plan valued at ₹ 75,000/- and ₹ 1,87,500/-, to pay compensation of ₹ 50,000/- for harassment and mental agony and to pay a sum of ₹ 5000/- as expenses incurred by the complainant in attending the office of the O.P. No. 3, 4 & 5 and also cost of the case.

Judgement

            The case of the complainant is that the complainant is the legally married wife of late Nintyananda Gogoi residing within the jurisdiction of this Commission.

            Shri Nityananda Gogoi (now deceased) expired on 30.07.2011 at Dibrugarh and he was an employee of Oil India Ltd., Duliajan.

            Late Nintyananda Gogoi during his lifetime purchased two LIC policies bearing Policy No.443293159 (date of commencement 19.11.2008) and No.443926461 (date of commencement 09.02.2010) and the sum assured value/death benefit sum assured of the mentioned plans were ₹ 75,000/- and ₹ 1,87,500/- from the O.P., Life Insurance Corporation of India. The complainant, wife of Nintyananda Gogoi (now deceased) was the nominee in both the policies and after the death of her husband the complainant visited the office of the O.P. 4/5 times and intimated the matter of death of her husband she had claimed the sum assured value/death benefit sum assured under the main plan. After repeated visits to O.P.No.4 and 5, they asked the complainant to contact O.P. No.3. But to her utter surprise O.P. No. vide letter No,JDO/DCL/REPDN, dated 21.07.2012 informed the complainant that her claims were repudiated by showing some false, fraudulent, baseless and imaginary grounds. However, O.P. No.3 advised the complainant to contact O.P. No.2 in this regard.

            The complainant on 27.09.2012 sent a letter to O.P. No.2 with a view to obtain relief in respect of her claim. But O.P. No.2 did not reply in response to her letter dated 27.09.2012 and reminder dated 15.11.2012.

            The complainant having no alternative took the resort of the insurance ombudsmen situated at Guwahati and placed a representation on 16.01.2013 for consideration of her claim which has been repudiated by O.P. No.3. Her complaint was received and after hearing both the parties the insurance ombudsmen decided the petition of the complainant on 26.12.2013 in a bias manner upholding the decision of O.P.No.3 and repudiated the claim under the erroneous interpretation of law by showing some false, frivolous and baseless ground. The husband of the complainant did not conceal any material facts which were required to be noted at the time of opening of policy. The ailments, i.e. fracture of the neck of femur (right side), loose motion and the chest infection for few days suffered by the deceased long before opening of the policy have no connection as referred by the opposite party with the death of the insured. Moreover, the ailments referred by the opposite parties could not be said to be serious ailment  which are required to be noted at the time of taking insurance coverage and as such there was no suppression of material facts whatsoever by the deceased. It is further stated that at the time/after the opening of the policy the deceased insured had not suffered from any ailments. However, on 29.07.2011 he had suffered from diarrhea and consequently on 30.07.2011 he became unconscious and was admitted in the OIL hospital, but the concerned doctor declared him dead and his death was purely unanticipated as prior to his death he did not face any symptoms of any disease for which even no preventive measure could be taken before death and only after post-mortem it had been revealed that the death was due to syncope resulting from coronary insufficiency. Since the deceased had no ailment which might have resulted in his death and as such the question of concealment/suppression of any material facts by the deceased never arise at all.

            The complainant has claimed that the action of opposite parties has established fraudulent, recklessness, irresponsible and negligent services to the complainant, which amounts to gross deficiency of service.

           The complainant has filed this complaint with prayer to direct the opposite party to pay :

1. Compensation of ₹ 50,000/- (Rupees fifty thousand only) for harassment and mental agony.
2. Sum assured/Death benefit sum assured under main plan, value of ₹ 75,000/- (Rupees seventy five thousand only) and 1,87,500/- (Rupees one lakh eighty seven thousand five hundred only) respectively.
3. A sum of ₹ 5,000/- (Rupees five thousand only) being the expenses incurred by the complainant to attend the office of the opposite party No.3, 4 & 5.
4. For all cost of the case.
5. Any other relief/reliefs to which the complainant is entitled in law and equity.

After registering the case notices were issued to all the opposite parties. Opposite parties No.1 to 5 contested the case by filing their W/S jointly. Opposite parties No.6 and 7, after receipt of notice did not appear before the Commission for which ex-parte order was passed against them and the case was proceeded ex-parte against these two opposite parties.

In their W/S the O.Ps. have stated that the case is not maintainable under law as well as on facts. The proposal form of an insurance policy is the valid document of agreement and made contractual relation under the law between the corporation, i.e. opposite parties and the policy holder. It has been submitted that the contract of insurance is per se different from the ordinary forms of contract which come within the purview of Indian Contract Act, 1972. The contract of insurance is based on the principles of “Uberrima fide” , i.e. utmost good faith. Here the contract is based on the information provided by one party to the contract, i.e. the proposer/life assured. Based on the information provided by him/her in the proposal form as well as the information gathered from the medical examination board, he/she divulges information about the state of his/her health, the corporation undertakes to write the risk based solely and solely on the information furnished by the proposer. Based on this information the corporation decides to accept or decline the proposal or at times even alternate plan is suggested considering the overall information. This is done on scientific manner and this practice is adopted by the insurance companies the world over. The O.Ps. submitted that concealing or non-discloser of any information vitally affect the decision of the corporation. Acceptance of any life where any information is not disclosed leads to acceptance of high risk life that would not have been otherwise accepted and it affects discharge of the functions of the corporation as per statute and ultimately affects the other genuine policy holders whose money corporation holds in trust. O.Ps submitted that both the claims submitted in this case under the policy bearing No.443293159 and 443926461 were presented early and pre-matured for which the cases were referred to Jorhat Divisional Office for their decision, because O.P. No.4 is not authorised to take final decision in respect of early/pre-matured claims.

Policy No.             Sum Assured         Date of Commencement                     Duration of the policy till death

of the life Assured

443293159      ₹75,000/-         19-11-2008                              2 years, 8 months, 11 days

443926461      ₹1,87,500/-      09-02-2010                              1 year, 5 months, 21 days

            The competent authority of the opposite parties has repudiated both the claims on 21.07.2012 U/S 45 of the Insurance Act, 1938 due to withholding material information and facts at the time of submission of the proposal by the deceased life assured Nitya Nanda Gogoi.

            The opposite parties have arrived in the decision of repudiation of the claim after going through post mortem report as well as sick leave report of the employer, i.e. Oil India Ltd., Duliajan wherefrom it reveals that the deceased was suffering from chest infection prior to the proposal, i.e. from 26.08.2008 to 08.09.2008. The deceased, life assured had also availed sick leave from 26.05.2006 to 06.09.2006 for fracture of neck femur and from 11.08.2008 to 15.08.2008 for loose motion. These facts were deliberately concealed in question No.11 of the proposal form.

Document No. ‘A’ is the copy of the post mortem report.

Document No. ‘B’ is the copy of sick leave report.

Document No. ‘C’ is the letter of repudiation dated 21.07.2012.

The O.Ps. have quoted section 45 of the Insurance Act, 1938 in their W/S.

It is also submitted on behalf of the O.Ps that as for the medical examination conducted by Medical Officer of the opposite parties- the scope of the medical Medical Officer is restricted to visible impairments of the proposer and his/her disclosure of ailments, if any, unless, the proposer discloses his/her previous illness, it will be impossible to identify any ailments as non pathological tests are being conducted.

Taking the pleas of the principle “Uberima Fide” the opposite parties submitted that concealment or non disclosure of any information vitally affects the decision of the corporation. Acceptance of any life where any information is not disclosed leads to acceptance of high risk life or life that would not have been otherwise accepted and it affects discharge of the functions of the corporation as per statute and ultimately affects the other genuine policy holders whose money corporation holds in trust. Coping the personal history narrated by the complainant in column 11 of the proposal form the O.Ps. have stated that on investigation it was found that all these answers were false as the opposite parties hold proof to show the deceased life assured had been suffering from certain chronic diseases. They claim that repudiation of a claim for suppression of material facts is neither deficiency nor negligent as the same was done after due application of mind. Since such action has been upheld by Apex Courts and Commissions in several times. They also claim that the intention of the proposer was to defraud the corporation by withholding the history of his previous illness in the proposal form for which his complaint petition is liable to be rejected.

The complainant in this case has submitted her evidence in affidavit on 21.02.2022. She has said that she is the legally married wife of Nityananda Gogoi (since deceased). Her husband Nityananda Gogoi expired on 30.07.2011 at Dibrugarh and he was an employee of Drilling Department, Oil India Ltd., Duliajan.                                                                                                                                                                                                                                                             

                   (Ext. No.1 is the copy of death certificate of Nityananda Gogoi).

During his lifetime her husband opened two Nos. of LIC policies- one bearing policy No.443293150 and the other one bearing policy No.443926461 and the sum assured value/death benefit sum assured under the main plans of the same are ₹ 75,000/- and ₹ 1,87,500/- respectively and the said policies were opened with the O.P. No.4 and O.P. No.5 respectively through O.P. No. 6 and O.P. No.7 who are duly appointed agents of LIC of India.

(Ext. No.2 & Ext. No.3 are the Insurance Policies).

Being the nominee of both the policies the complainant visited the office of the O.P. No. 4 and O.P. No.5 intimating the death of her husband and claimed the sum assured value/death benefit sum assured under main plan which has been deposited in the name of her husband in respect of the mentioned policies. She visited the office of the O.P. No.4 and O.P. No.5 several times but the concerned Managers fails to give any satisfactory reply and finally both of them asked her to contact O.P. No.3

The complainant then contacted with O.P. No.3 and intimated him the matter of her claim in respect of the mentioned LIC policies and submitted both the original LIC policies as asked for by O.P. No.3 but O.P. No.3 vide letter No.JDO/DCL/Repdn/618/619 dated 21.07.2012 informed her that all her claims were repudiated by showing some false, frivolous, baseless and …………..ground but however O.P. No.3 advised her to contact O.P. No.2.

(Ext. No.4 is the letter dated 21.07.2012).

As advised she sent a letter to O.P. No.2 on 27.09.2012 with a view to obtaining relief in respect of her claim but all her efforts did not yield any fruitful result as O.P. No.2 never replied to her letter dated 27.09.2012 and reminder letter dated 15.11.2012.

(Ext. No.5 and Ext. No.6 are those letters).

Finding no alternative, under compulsion she took the resort of Insurance Ombudsmen situated at Guwahati and made a representation on 16.01.2013 for consideration of her claim which has been repudiated by O.P. No.3. After hearing both the parties the Insurance Ombudsmen on 26.12.2013 in a bias manner upholding the decision of the O.P. No.3 and repudiated the claim of the complainant under some erroneous interpretation of law.

The complainant has mentioned in her evidence that her husband did not conceal any material facts which are required to be recorded at the time of opening policies. The ailments, fracture in neck of the femur, loose motion and chest infection for few days suffered by the deceased husband long before the opening of the policies as referred by the O.P. have no connection with the death of her husband. Moreover, the ailments referred by the O.P. cannot be said to be serious ailments which are required to be noted at the time of taking insurance coverage and as such there was no suppression whatsoever by her deceased husband. It is further stated that at the time of / after the opening of policy the deceased had not suffered any ailment. However on 29.07.2011 he had suffered from diarrhea and consequently on 30.07.2011 he became unconscious and was immediately admitted in the hospital of Oil India Ltd., Duliajan. But the concerned doctors declared him dead and his death was totally un-anticipated as prior to his death he did not face symptoms of any disease for which even no preventive measures could be taken before death. After the post mortem examination of his dead body it was revealed that death was due to syncope resulting from coronary insufficiency. The complainant has claimed that her husband (now deceased) had no ailment which might have resulted in his death, the body of the deceased had to undergo post mortem to know the cause of death and as such the question of concealment/ suppression of any material fact by the deceased never arise at all. 

(Ext. No. 7, 8 and 9 are the representation dtd. 16.01.2013, order of Insurance Ombudsmen and police investigation report dtd. 9.10.2011).

The deceased was the only bread earner of his family and after his death his family has to suffer financial hardship. The action of the opposite parties, as claimed by the complainant may be treated as most fraudulent, recklessness, irresponsible and negligent in rendering service to the complainant which amounts to gross deficiency of service for which the complainant has filed this complaint praying to direct the opposite party to pay compensation of ₹ 50,000/- for mantel agony, to pay the sum assured/death benefit sum assured under the main plan value at ₹ 75,000/- and ₹ 1,87,500/- respectively and to pay a further sum of ₹ 5000/- being the expenses incurred by the complainant to attend the office of the opposite parties and for the cost of the case.

In this case one Shri Nikhil Chandra Das, Senior Branch Manager, Life Insurance Corporation of India, Dibrugarh Branch, Dibrugarh has submitted evidence in affidavit for all the O.Ps. No.1 to 5. In his evidence in affidavit denying the liability of all the O.Ps. this witness has stated that the case is not maintainable under law as well as on facts. The proposal form of an insurance policy is the valid document of agreement and made contractual relation under the law between the corporation, i.e. opposite parties and the policy holder. It has been submitted that the contract of insurance is per se different from the ordinary forms of contract which come within the purview of Indian Contract Act, 1972. The contract of insurance is based on the principles of “Uberrima fide” , i.e. utmost good faith. Here the contract is based on the information provided by one party to the contract, i.e. the proposer/life assured. Based on the information provided by him/her in the proposal form as well as the information gathered from the medical examination board, he/she divulges information about the state of his/her health, the corporation undertakes to write the risk based solely and solely on the information furnished by the proposer. Based on this information the corporation decides to accept or decline the proposal or at times even alternate plan is suggested considering the overall information. This is done on scientific manner and this practice is adopted by the insurance companies the world over. The O.Ps. submitted that concealing or non-discloser of any information vitally affect the decision of the corporation. Acceptance of any life where any information is not disclosed leads to acceptance of high risk life that would not have been otherwise accepted and it affects discharge of the functions of the corporation as per statute and ultimately affects the other genuine policy holders whose money corporation holds in trust. O.Ps submitted that both the claims submitted in this case under the policy bearing No.443293159 and 443926461 were presented early and pre-matured for which the cases were referred to Jorhat Divisional Office for their decision, because O.P. No.4 is not authorised to take final decision in respect of early/pre-matured claims.

Sl. No.	Policy No.	Sum Assured	Date of Commencement	Duration of the policy till death of the life Assured
1	443293159	₹75,000/-	19-11-2008	2 years, 8 months, 11 days
2	443926461	₹1,87,500/-	09-02-2010	1 year, 5 months, 21 days

                               

            The competent authority of the opposite parties has repudiated both the claims on 21.07.2012 u/s 45 of the Insurance Act, 1938 due to withholding material information and facts at the time of submission of the proposal by the deceased life assured Nitya Nanda Gogoi.

            The opposite parties have arrived in the decision of repudiation of the claim after going through post mortem report as well as sick leave report of the employer, i.e. Oil India Ltd., Duliajan wherefrom it reveals that the deceased was suffering from chest infection prior to the proposal, i.e. from 26.08.2008 to 08.09.2008. The deceased, life assured had also availed sick leave from 26.05.2006 to 06.09.2006 for fracture of neck femur and from 11.08.2008 to 15.08.2008 for loose motion. These facts were deliberately concealed in question No.11 of the proposal form.

Ext. No. ‘A’ is the copy of the post mortem report.

Ext. No. ‘B’ is the letter of repudiation.

 It is also submitted on behalf of the O.Ps that as for the medical examination conducted by Medical Officer of the opposite parties- the scope of the medical Medical Officer is restricted to visible impairments of the proposer and his/her disclosure of ailments, if any, unless, the proposer discloses his/her previous illness, it will be impossible to identify any ailments as non pathological tests are being conducted.

Taking the pleas of the principle “Uberima Fide” the opposite parties submitted that concealment or non disclosure of any information vitally affects the decision of the corporation. Acceptance of any life where any information is not disclosed leads to acceptance of high risk life or life that would not have been otherwise accepted and it affects discharge of the functions of the corporation as per statute and ultimately affects the other genuine policy holders whose money corporation holds in trust. Coping the personal history narrated by the complainant in column 11 of the proposal form the O.Ps. have stated that on investigation it was found that all these answers were false as the opposite parties hold proof to show the deceased life assured had been suffering from certain chronic diseases. They claim that repudiation of a claim for suppression of material facts is neither deficiency nor negligent as the same was done after due application of mind. Since such action has been upheld by Apex Courts and Commissions in several times. They also claim that the intention of the proposer was to defraud the corporation by withholding the history of his previous illness in the proposal form for which his complaint petition is liable to be rejected.

In their evidence the O.Ps. have submitted that they have proved to show that the deceased life assured had been suffering from chronic chest infection and had undergone treatment at the OIL Hospital, Duliajan for which the deceased life assured availed sick leave for 123 days from 26.05.2006 to 06.09.2006 ; 11.08.2008 to 15.08.2008 and 26.08.2008 to 08.09.2008. But he did not disclose these facts in the proposal/statement and instead he gave false answers therein. The deceased life assured expired due to syncopic resulting from chronic coronary insufficiency. The deceased life assured made deliberate miss-statement and withheld material information from the corporation regarding his health at the time of submission of the proposals and hence in terms of policy contract and the declaration contained in the forms of proposals for insurance and personal statements, competent authority had repudiated the claims and accordingly they are not liable for payment under the above policies. Repudiation of a claim for suppression of material fact is neither a deficiency nor negligence as the same was done after due application of mind. The O.Ps. have submitted the following documents as their exhibits.

Ext. No. ‘C’ & ‘D’ are the duly filled up proposal forms.

Ext. No. ‘E’ & ‘F’ are the copies of the policies.

Ext. No. ‘G’ is the medical attendant’s certificate.

Ext. No. ‘H’ is certificate of hospital treatment.

Ext. No.  ‘I’ is the certificate of employer.

Ext. No. ‘J’ is the copy of the letter of O.P. dtd. 30.11.2012.

 

            The complainant’s filled up para 4(a) of the claimant’s statement as nominee to claim the policy money is as follows :

 

Que. When did the deceased first complaint of being not in usual good health ?

Ans. 30.07.2011.

 

This statement is a blatant lie which was proved in course of investigation made by the corporation and necessary relevant documents in support of their stand are filed along with this evidence. They have claimed that the intention of the proposer was to defraud the corporation by withholding the history of his previous illness in the proposal form.

Praying to dismiss the complaint of the complainant with cost these O.Ps. have further submitted some documents for perusal of the Commission, the originals of which are not in their custody.

Document No.i is the sick leave report of the employer.

Document No.ii is claimant’s statement.

Document No.iii is the certificate of identity and burial/cremation.

Document No.iv is the order of the Ombudsmen.

            In this case written argument for the complainant was filed on 28.08.2023. Narrating the brief of the complaint in her argument has argued that the husband of the complainant did not conceal any material facts which are required to be noted at the time of opening the said policies. The ailments, i.e. fracture of the neck of the femur (right side), loose motion and the chest infection for few days suffered by the deceased long before opening the policies as referred by the O.Ps. have no connection with the death of the insured. Moreover, the ailments referred by the O.Ps. could not be said to be serious ailments which are required to be noted at the time of taking insurance coverage and as such there was no suppression whatsoever by the deceased. It is further argued that at the time/after the opening of policies the deceased insured had not suffered any ailment. However, on 29.07.2011 he had suffered from diarrhea and subsequently on 30.07.2011 he became unconscious and had immediately been admitted in OIL hospital, Duliajan, but the concerned doctor declared him dead purely unanticipated, as prior to the death he did not show any symptoms of disease for which no preventive measures could be taken before his death. Post mortem examination report has showed that the death was due to syncope resulting from coronary insufficiency. The complainant has further argued that after the death of the complainant’s husband while the opposite party authority verified inter alia the cause of death as per the clause 4 of the Ext.-G medical attendant’s certificate issued by chief medical officer. It is clearly mentioned that the exact cause of death of the deceased, symptoms of death and the period of suffering from disease which resulted to death, the conducting medical attendant failed to give any reason/reply thereof as the patient was brought dead to the hospital. As such for ascertaining the cause of death the deceased body had to undergo post mortem and post mortem report revealed that death was due to syncope resulting from coronary insufficiency which was no way relates to ailments fracture in neck, loose motion and chest infection for few days long before the opening of the policies is no way relates to cause of death i.e. syncope coronary insufficiency as it clearly appears in the post mortem report. Hence, there is no suppression of material fact because the death took place not by ailments as mentioned above i.e. fracture in neck, loose motion but it has taken place because of coronary insufficiency. Post mortem report is the only valid and acceptable document to know the exact cause of death particularly when any patient is brought too hospital on death. Moreover, the post mortem does not have any mention that the patient was suffered from any serious ailment which resulted to his death as such there is no concealment and suppression of material fact at the time of opening of the policies. Since the deceased had not suffered any ailment prior to his death or face any symptoms of ailment hence even no preventive measures could be taken before death, only after the body was postmortemed it has been revealed that death was due to syncope resulting from coronary insufficiency which has no any affinity of the ailments i.e. fracture in neck, loose motion and chest infection for few days long before opening of the policy as alleged by the opposite party. Since the deceased had no any ailments which might have resulted to his death, hence the deceased body had to undergo postmortem to ascertain the cause of his death. This being the position the allegation by the opposite parties of concealment suppression does not arise at all.

 

            Moreover, in para 8 of the written objection O.P. specifically mentioned that the medical officer of the O.P. duly examined the deceased policy holder and they have not found any ailment at the time of opening the policies in question and most casually now stated that the scope of the medical officer is restricted to visible impairments of the proposer which is against/violation of the medical ethics in fact by making this statement in para 8 of the written objection itself put the responsibility and duties of a medical officer in question and the opposite party totally failed to refer any document/guidelines of medical council of India or any other rules which restricted to medical officer of LIC of India – the scope of the medical officer is restricted to visible impairments of the proposer as mentioned above. This type of statement made by the opposite parties only to repudiate the bonafide claim of the complainant. It is further stated that the necessary party i.e. the O.P. No. 6 & 7  through whom LIC of India opened policies were totally failed to deny the claim of the complainant and LIC of India also did not represent them either in the affidavit or in the written statement which sufficient assumed that only for the suppressing the real fact the LIC of India kept away the O.P. No. 6 & 7. Further the Hon’ble Supreme Court of India in Life Insurance Corporation of India vs Smti. G.M. Channabasmma observed that the burden of proving that the insured has made false representation and suppressed material facts was undoubtedly on the Life Insurance Corporation of India. But the LIC of India miserably failed to bring the doctors who have examined the policy holder at the time of opening the policy and even did not called the attending doctor of the concerned hospital where the deceased was admitted last. Document No. (i) does not bear any specific reason for sick leave. The complainant has referred the report of Ombudsmen as bias. On careful perusal it appears that the Ombudsmen’s report is the replica of the claim repudiation certificate issued by the Divisional Manager of LIC of India. As the most vital document i.e. the post mortem report was totally ignored and not discussed in the Ombudsman report rather the Ombudsman authority arbitrarily and maliciously repudiated the claim in the tune of LIC authority making the ailments suffered by the deceased (as already stated above) as cause of his death. It is settled law that cause of death of any policy holder must be directly attributed to any ailment suffered by the policy holder at the time of opening of the policy. Hence, O.P., LIC of India has no any authority to repudiate claim on the fabricated ground of suppression of material fact as it is crystal clear from the post mortem report that deceased’s death was not caused due to ailments as arbitrarily alleged by the LIC of India.

Section 45 of the Insurance Act postulates repudiation of such policy within a period of two years. By reason of the aforementioned provision, a period of limitation of two years had thus been specified and on the expiry thereof the policy was not being called in question inter alia on the ground that certain facts have been suppressed which were material to disclose or that it was fraudulently been made by the or that policy holder knew at the time of making it that statement was false. Statute therefore it provides for the limitation for valid repudiation of an insurance policy. It takes into account the social security aspect of the matter. Moreover, the ailment referred by the Insurance Company has no connection with the death of the insured. Death was because of syncope resulting from coronary insufficiency and not because of either fracture in neck or loose motion, chest infection for which the insured had taken leave from wok. There is no history of these ailments in respect of the deceased in the record produced by the LIC. It is indeed callousness on the part of the LIC to have put the widow of the deceased to considerable inconvenience and mental agony by not settling the claim in time. In fact repudiation on the ground is totally untenable. The repudiation of claim caused serious prejudice to the widow. In this regard the complainant has referred the decision of National Dispute Redressal, New Delhi in first appeal No.122/1995.

In this case written argument of all the opposite parties filed jointly on 14.07.2023.

Narrating briefly the story of the case the opposite parties in their written argument have submitted that the claim submitted by the complainant against the policy No.443293159 and policy No.443926461 respectively were presented earlier and pre-matured and hence the case was referred to Jorhat Divisional Office (O.P. No.3) by the office of the opposite party No.4 for taking appropriate decision as O.P. No.4 is the Branch Office and not capable of taking final decision in respect of early pre-matured claim.

 

Sl. No.	Policy No.	Sum Assured	Date of Commencement	Duration of the policy till death of the life Assured
1	443293159	₹75,000/-	19-11-2008	2 years, 8 months, 11 days
2	443926461	₹1,87,500/-	09-02-2010	1 year, 5 months, 21 days

 

The competent authority of the opposite parties have repudiated the claim on 21.07.2012 under section 45 of the Insurance Act, 1938 due to withholding all the material information of facts at the time of submission of the proposal by the deceased life assured. The competent authority of the O.P. has arrived at the decision of repudiation of the claim after going thoroughly through the postmortem report as well as sick leave report of the employer, i.e. Oil India Ltd. Duliajan from where it reveals that the deceased Nityananda Gogoi had been suffering from chest infection prior to the proposal, i.e. from 26.08.2008 to 08.09.2008. The deceased availed sick leave from 26.05.2006 to 06.09.2009 for fracture of neck femur and from 11.08.2008 to 15.08.2008 for loose motion and these facts were deliberately concealed in Sl. No.11 of the proposal form.

Exhibit-‘B’ is the letter of repudiation and document No.1 is the sick leave report of the employer. The deceased life assured had not disclose anything regarding his previous ailments either in himself in the proposal form or to the Medical Examiner of the opposite parties. Any suppression of the material facts warrants repudiation of the claim as per section 45 of the Insurance Act, 1938. They have submitted that as for medical examination conducted by the Medical officer of the opposite parties the scope of the Medical officer is restricted to visible impairments of the proposer and his/her disclosure of ailments, if any, unless the proposer discloses his/her previous ailments, it will be next to impossible to identify any ailments as non-pathological tests are being conducted. These  opposite parties in their written argument have stated that the contract of insurance is perse difeffent from the ordinary forms of contract and the insurance contract is based on the principles of ‘Uberrima fide’ – i.e. utmost good faith. Here the contract is based on the information provided by one party of the contract, i.e. the proposer/life assured. Based on the information provided by him/her in the proposal form as well as the information gathered from Medical Examiner’s report to whom he/she divulges information about the state to his/her health, the Corporation undertakes to write the risk based solely and solely on the information furnished by the proposer. Based on this information the Corporation decides to accept or decline the proposal or at times even an alternative plan is suggested considering overall information. This is done in an scientific manner and this practice is adopted by the insurers the world over. Moreover as contract of Insurance is dependent upon condition of health non-disclosure of above vitiated a contract rendering in null and void ab initio. The opposite parties have claimed that the information in both the proposal forms for both the policies in column No.11 submitted by the deceased assured were blatant lie. They also claimed that on investigation it was found that all the answers given in column No.11 of the proposal form were false as the opposite parties hold proof to show that the deceased life assured had been suffering from chronic chest infection and had undergone treatment at Oil India Hospital, Duliajan for which he availed sick leave for 123 days from 26.05.2006 to 06.09.2006 ; 11.08.2008 to 15.08.2008 and 26.08.2008 to 08.09.2008. However, he did not disclosed these facts in the proposals/statements. The deceased life assured expired due to syncope resulting from chronic coronary insufficiency.

The opposite parties have submitted in their written argument that the complainant preferred an appeal before the Insurance Ombudsman, Guwahat vide complaint No.GUW-L-029-1314-0045 and the Insurance Ombudsman also awarded decision in favour of LICI, vide order dated 26.12.2013 (Document No.iv) is the copy of the order of the Insurance Ombudsman, Guwahati. They claimed that there was neither negligence on the part of the opposite parties nor they showed any sort of inefficiency to ascertain the actual facts of the claim and to repudiate the claim and so the opposite parties are entitled to get cost of the case along with compensation from the complainant. They have claimed that the case of the complainant is not maintainable and liable to be dismissed with cost. In support of their written argument a xerox copy of the Consumer Case No.2279 of 2018, Dr. Poonam Makhija Vs. Life Insurance Corporation of India decided by National Consumer Disputes Redressal Commission, New Delhi.

 

Points for decision

 

1. Whether the complainant is a consumer under Consumer Protection Act.
2. Whether this Commission has proper jurisdiction to try the case.
3. Whether the opposite parties are liable for deficient and negligent service.
4. Whether the complainant is entitled to get the reliefs as prayed for.

Decisions and reasons thereof

1. On examination of complaint petition, W/S, evidence in affidavit along with annexed documents, we have seen that the husband(since deceased) of the complainant late Nityananda Gogoi during his life time purchased two LIC policies (the O.Ps.) and paid the policy premiums in terms of money and the complainant was the nominee of those two LIC policies and hence there is no iota of doubt that the complainant is a consumer of the opposite parties under Consumer Protection Act.
2. The complainant is residing permanently in Tipling under Dibrugarh District of Assam within the jurisdiction of this Commission and O.P. No.4 and 5 are functioning in Dibrugarh District within the jurisdiction of this Commission. The total relief claimed by the complainant is ₹2,62,500/- (Rupees two lakh, sixty two thousand five hundred)only. Hence, this Commission has proper territorial and pecuniary jurisdiction to try this case.
3. Regarding deficiency of service of the Opposite Parties, we have found that the husband of the complainant late Nityananda Gogoi expired on 30.07.2011 at Oil India Hospital, Duliajan and after his death the complainant had put forward her claim as a nominee of the said policies with the O.P. for the sum assured value/death benefit value sum assured. She visited the office of O.P. No. 4 and 5 several times but concerned Managers failed to give any satisfactory reply and finally both of them asked her to contact O.P. No.3. Accordingly, the complainant visited O.P. No.3 and presented her claim and submitted both the original LIC policies as asked for by O.P. No.3. But O.P. No.3 vide their letter No.JDO/DCL/Repdn/618/619, dtd. 21.07.2012 informed her that all her claims were repudiated on account of deceased having withheld material information regarding his health at the time of proposal of the policies. It has been deposed by the complainant in her evidence in affidavit that as advised by O.P. No.3 on 27.09.2012 she sent a letter to O.P. No.2 to obtain relief in respect of her claim but O.P. No.2 never replied to her letter dated 27.09.2012 and reminder thereof dated 15.11.2012. These letters have been exhibited as exhibit No.5 & 6. From perusal of exhibit ‘A’ of the O.P., postmortem report, it is established that the case of death of the deceased life assured was syncope resulting from coronary insufficiency.

 

              The Complainant as an alternative way approached the Insurance Ombudsmen at Guwahati and made a representation on 16.01.2013 for consideration of her claim. But unfortunately the Insurance Ombudsmen also decided her representation on 26.12.2013 and upholding the decision of O.P. No.3 repudiated the claim of the complainant. In their order Insurance Ombudsmen observed that the life assured suppressed the material information regarding his illness at the time of filing the proposal form which were quite material for consideration at the time of accepting the proposal. The Insurance Ombudsmen also opined that the insurer has rightly repudiated the claim of the policies and no interference is called for from that authority.

              Having no alternative the complainant has filed her complaint before this Commission. On careful perusal of all the documents we have seen that the information given by the deceased policy holder in column No.11 were rightly quoted by the O.Ps. in their W/S, Evidence, supported by their exhibit No. C & D. But we have found nothing to establish that these questions were actually put to the insured/policy holder and also to establish that the answers were actually given by the insured/policy holder.

                  The O.P. throughout their submissions has submitted that the deceased life assured had been suffering from chronic chest infection and had undergone treatment at the OIL hospital, Duliajan for which he availed sick leave. But there is nothing before this Commission to believe this submission of the O.P. Their exhibit-I, the certificate of employer and document No.(i) do not reflect any specific information for what purpose the deceased policy holder availed sick leave. We find it quite difficult to understand on what basis the O.P. has submitted that the deceased life assured had been suffering from chest infection and had undergone treatment. If for argument shake we take it into consideration that the deceased life assured had been suffering from chest infection, we found no nexus between the material fact/disease which was not disclosed and the cause of death for which the Insurance Company repudiated the claim on the ground of suppression of material fact/non-disclosure of pre-existing ailment was not correct.

                  In this regard we want to discuss the cause of death of the deceased life assured as detailed in postmortem report as syncope resulting from coronary insufficiency. Syncope is defined as fainting or passing out. Someone is considered to have syncope if he/she become unconscious and go limb, then soon recovers. For most people, syncope occurs in a great while, if ever, and is not a sign of serious illness. Syncope is the medical term for fainting or passing out. It is caused by a temporary drop in the amount of blood that flows to the brain. This leads to loss of consciousness and muscle control. Stroke is only rarely the true cause of syncope. Syncope is an alarming event carrying the possibility of serious outcome including sudden cardiac death.

           Coronary insufficiency is an inability of the coronary arteries to deliver an adequate blood supply to the myocardium, resulting in angina pectoris and heart failure. Causes responsible for coronary insufficiency are build-up of fats, cholesterol and other substances in and on the artery walls, a condition called atherosclerosis usually cases coronary artery disease.

            From all these discussions it is very much clear that the cause of death of the deceased policy holder was syncope resulting from coronary insufficiency which has no relation to the ailments – fracture in neck, loose motion or chest infection for few days long before taking the policies are in noway related to the cause of death, i.e. syncope due to coronary insufficiency. We believe that P.M. report is a valid and legally acceptable document to know the exact cause of death, particularly when a patient is brought to hospital on death. Our Hon’ble Supreme Court, as quoted by the complainant, in Life Insurance Corporation of India-vs- Smti. G.M. Charnnabasmura observed that the burden of proving that the insured had made false representation and suppressed material facts was undoubtedly on the Life Insurance Corporation of India. But in the instant case LICI has miserably failed to bring the doctor who have examine the policy holder at the time of taking the policies and even did not call the attending doctor of the concerned hospital where the deceased was admitted last. The document No.(i) of the O.P. does not bear any specific reason for sick leave. We also found that the P.M. report which is a vital document for justified adjudication of the matter, the Insurance Ombudsmen remained silence on this point. Seems that this document is totally ignored.

            The Divisional Bench of our Apex Court in Civil Appeal No.8245 of 2015 in Sulbha Prakash Motegaonkar and others –vs- Life Insurance Corporation of India has observed that since the alleged concealment was not of such a nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified. In a series of judgement our Hon’ble National Commission relying on the judgement of Sulbha Prakash Motegaonkar and others has observed that if there is no nexus between the material fact/disease which was not disclosed and the cause of death, the Insurance Company’s action of repudiating the claim on the ground of suppression of material facts/non-disclosure of pre-existing ailment is not correct.

            On the basis of all above discussion we find the opposite parties are liable for their deficiency in solving the claim of the complainant.

4. We have unanimously come to the conclusion that the complainant is entitled to get the reliefs claimed by herself in her complaint. Hence, this Commission directs the O.P., Life Insurance Corporation of India, Naharkatia Branch to pay to the complainant :-

 

1. A sum of ₹75,000/- (Rupees seventy five thousand)only being the sum assured value of policy No.443293159.
2. A sum of ₹1,87,500/- (Rupees one lakh eighty seven thousand five hundred)only being the death benefit sum assured under policy No.443926461.
3.  A sum of ₹20,000/- (Rupees twenty thousand)only for physical harassment and mental agony and
4. A sum of ₹ 10,000/- (Rupees ten thousand)only being the cost of litigation.

                  All the above amount be deposited into the credit of this Commission by the opposite party, Life Insurance Corporation of India, Naharkatia Branch within 30(thirty) days from the date of receipt of this judgement and order, failing which an interest @ 9% per annum on the awarded amount will have to be borne by the opposite party.

                  The instant C.C. No.21.2015 is accordingly disposed of on contest.

                        Send copy of this judgement and order to the opposite party for compliance. Complainant is to take step.