Before the District Consumer Disputes Redressal Forum, Room No. 208 2^nd Floor, District Administrative Complex, Tarn Taran

Consumer Complaint No  :  09 of 2017

Date of Institution                      : 02.03.2017

Date of Decision               : 27.08.2019

Darshan Kaur w/o Sukhdev Singh son of Gurmukh Singh resident of V.P.O Kang, Tehsil Khadur Sahib, District Tarn Taran.

                                                ...Complainant

Versus

1. Life Insurance Corporation of India, Branch Office, Phillor at Old G.T. Road Near Bus Stand, Phillor, Tehsil Phillor, District Jalandhar through its Branch Manager/ Authorised officer,
2. Life Insurance Corporation of India, Branch Office Tarn Taran: Sarhali Road, Tarn Taran District Tarn Taran through its Branch Manager/ Authorised officer,
3. Life Insurance Corporation of India, Zonal Officer: Jeevan Bharti, Connaught Circus, New Delhi through its Zonal Manager.

…Opposite Parties.

Complaint Under Section 11, 12 and 13 of the Consumer Protection Act, 1986.

Quorum:               Sh. Charanjit Singh, President

Smt. Jaswinder Kaur, Member

For Complainant                     Sh. M.P. Arora Advocate

For Opposite Parties               Sh. D.K. Kondura Advocate

ORDERS:

Charanjit Singh, President;

1        The complainant Darshan Kaur has filed the present complaint under Section  11, 12 and 13 of the Consumer Protection Act (herein after called as 'the Act') against Life Insurance Corporation of India, Branch Office, Phillor at Old G.T. Road Near Bus Stand, Phillor, Tehsil Phillor, District Jalandhar through its Branch Manager/ Authorised officer and others (Opposite Parties) on the allegations of deficiency in service and negligence in service on the part of opposite parties with prayer to direct the opposite parties to pay the total minimum death benefit under the policy i.e. the sum of Rs. 1,50,000/- and the complainant has also prayed Rs. 50,000/- as compensation and Rs. 20,000/- as litigation expenses.

2        The case of the complainant in brief is that the opposite parties i.e. Life Insurance Corporation of India is dealing in the life insurance policies and for that purpose, they had spread out number of agents in the field for covering the life risks of common man and the opposite parties, in order to secure the business and for having monetary gains, usually allures and gives attractive offers to the common man at the time of giving policies and further assures the family members of the applicants that if any untoward incident occurred, the opposite parties will give all the benefits and the sum assured at the door step,  as the family will have to go nowhere and the services will be availed while sitting at home. The opposite parties present various life insurance Policies. The official of the opposite parties and agents approached the deceased Sukhdev Singh i.e. life assured and gave lucrative offers for having a life insurance policy and had told about the polices to the deceased and he was attracted to the offers made by the opposite parties/it’s agents. The deceased after discussing with the complainant & family members had proposed to assure his life vide proposal dated 28.9.2011 by the opposite parties vide the policy bearing No.133496993 and the opposite parties have issued the policy in favour of the deceased/applicant Sukhdev Singh. The date of commencement of the policy was 28.8.2011 and premium to be paid/ fixed was Rs.6,378/- and installments were fixed to be paid annually and the sum assured on maturity of the policy was fixed of Rs. 1,50,000/- and date of maturity of the policy is 28.8.2026 and he appointed nominee of the said policy to his wife i.e Darshan Kaur. The complainant is fully competent to file the present complaint. The deceased life assured has paid all the installments of the policy on time as per the stipulated schedule till his death and afterwards unluckily, the applicant/life assured died due to natural death on 7.10.2013 at his residence in the Village Kand, Tehsil Khadoor Sahib District Tarn Taran. The complainant had given the required information to the corporation regarding the death of Sukhdev Singh for obtaining the amount of sum assured on death under the policy bearing no.133496993 of the deceased Sukhdev Singh. All the requisite details, which is death certificate, forms and others information were provided to the officials of the opposite parties and the officials kept mum for many months since the death of the applicant Sukhdev Singh. The complainant has sent written request to the corporation for satisfying his claim and after some days the officials of the corporation have called the complainant to its office at Phillor. The complainant alongwith her son had gone to the office of the corporation and the officials have demanded certain verifications on the printed formats issued by the corporation from the employer of the deceased and further certain verifications to be issued by the doctor in order to verify certain facts regarding the assured/ deceased Sukhdev Singh. The complainant, alongwith her son had gone to the office of corporation and the officials have demanded certain verifications on the printed formats issued by the corporation from the employer of the deceased and further certain verifications to be issued by the doctor in order to verify certain facts regarding the assured/ deceased Sukhdev Singh. The complainant with the help of family members, has collected every demanded information by the opposite parties from the employer and the concerned doctor and has sent all the documents to the opposite parties through registered post. Thereafter, the opposite parties have again called the complainant & her son in its office at Phillor and have returned back of some kind of more verifications and they have to submit the required verifications once again. The complainant has again managed to collect every demanded information from the employer and from the doctor as well as from other sources with respect to the deceased as per the demand of the opposite party and have sent all the documents to the corporation and has sent all the documents to the corporation through registered post. The opposite parties have again called the complainant & her son in its office at Phillor and have returned back all the documents in an arbitrary manner and told them that their claim could not be settled at that time due to certain medical reasons of the deceased/life assured. The complainant has told the officials that the deceased/life assured was not suffering from any kind of disease at the time of issuance of the policy but the officials of the opposite party have not paid any heed towards her requests. The deceased life assured was not suffering from any kind of disease at the time of issuance of the policy due to which he could be ineligible for the policy. Further the deceased life assured had neither suppressed any kind of medical disease at the time of issuance of the policy nor there exists any medical record history which could tell any kind of pre policy disease of the applicant/ insured as the deceased life assured have neither suffering from any kind of disease nor has taken any treatment in this regard from any doctor before the issuance of the policy. The complainant had filed a complaint bearing No.:18 of 2016 titled as “Darshan Kaur Vs LIC” before this  Forum and this  Forum decided the complaint and has directed the LIC to decide the claim of the complainant within one month after receiving the documents from complainant and further burdened the LIC with the cost of Rs.10,000/-. The complainant has provided certified copies of all the original documents to the LIC after obtaining the same from this  Forum and afterwards, the LIC has demanded certain documents from the complainant vide its correspondence dated 05.10.2016 but after 3 days, the LIC has repudiated the claim very arbitrary and in harsh manner within 3 days. In earlier complaint, LIC has taken the plea that there is need of thorough investigations and LIC is doing investigations for the adjudication of the claim but very surprisingly, all the investigations have been conducted by the LIC within few days after the directions given by this Forum, which clearly shows that LIC is doing its business in a very arbitrary manner. The grounds, taken by the LIC for the repudiation of the claim of the complainant, are highly arbitrary and unbelievable. At the time of issuance of the policy all the necessary information related to the applicant and his family were taken by the officials of the opposite party and the officials, who collected the information and relevant documents, had verified the facts regarding health of the deceased through medical examination & personal investigation conducted by them regarding any ailment or severe disease, any surgery, operation or any medical assistance obtained or not and hence the correct information was given to the officials of the opposite parties. In order to grab the sum assured on death i.e. insurance claim money of the complainant, the opposite parties i.e. the corporation has repudiated the claim of the complainant on baseless grounds in a very arbitrary manner, which is never acceptable to the complainant. The pleas taken by LIC, are not tenable in the present case as the deceased died after 2 years from the issuance of the policy as such, no such kind of pleas can be base for repudiation of the claim as per settled provisions of law. Feeling dissatisfied by the act and conduct of the opposite parties, the complainant perforce has filed this complaint against the opposite parties.

3        After formal admission of the complaint, notice was issued to Opposite Parties and opposite parties appeared through counsel and filed written version contesting the complaint and it was pleaded that the insured is supposed to follow principles of insurance and one of the cardinal principle is “Principle of utmost good faith” i.e. insured will disclose all the material facts related to risk of his life at the time of taking the insurance. He should not conceal the facts about his health while taking an Insurance Policy and he should give correct answers to the question mentioned in the Insurance form application. The Life Insurance Corporation has floated many policies and Life Insurance products.  Sukhdev Singh deceased had got a policy Insurance bearing No.133496993 from commencement date 28.8.2011 and sum assured of Rs. 1.50 lacs with premium mode half yearly A2 Rs. 6,378/- with maturity date 28.8.2016 and made nomination in favour of his wife. The deceased life assured paid all the installments of the policy till his death and he died on 7.10.2013 as per the information supplied to the opposite party. Claim forms have been issued to the complainant. The death claim was submitted by the complainant but the complainant was requested to submit all the requirements relating to the early death claim. The evidence relating to suppression of material facts regarding health of the deceased have been collected by the insurer. The husband of the complainant got the insurance policy fraudulently by concealing the true facts regarding his state of health. The conduct of the respondent was not un-business like. The opposite parties were investigating the claim of the complainant from various angles and after due inquiry and investigation it has repudiated the claim put forward by the complainant. The claim has been rightly repudiated on the basis of evidence received related to suppression of material facts regarding health of the deceased and moreover, medical check-up by the insured is based on the answers replied by the life assured before the medical examiner. The claim has been repudiated after due investigation of the claim. The claim has been repudiated with a judicious mind. As per order of this Forum a sum of Rs.10,000/-was paid to the complainant. Sukhdev Singh life assured withheld the correct information from the opposite parties regarding his ill health prior to the date of proposal at the time of affecting insurance with the opposite parties. In this connection, Sukhdev Singh life assured in the proposal for assurance dated 29.9.2011 signed by him, he had answered the flowing questions as under:-

11(a) During the last 5 years did you consult a medical practitioner for any aliment requiring treatment for more that a week?                          No

11(b) Have you ever been admitted to any hospital or nursing home for general check up, observation, treatment or operation?                   No

11(c)  Have you remained absent from place of work on grounds of health during last five years ?                                                                  No

11(e)  Are you suffering from or have ever suffered from diabetics, TB High BP, Low BP, Cancer Epilepsy, Hernia, Hydrocele, Leprosy or any other disease?                                                                            No

11(i)  What has been your usual state of health?                                        Good

That the above stated answers given by the life assured were false and he gave wrong information regarding his health to the opposite parties. It has come to the notice of the opposite parties during inquiry and investigation that Sukhdev Singh life assured was not keeping good health prior to the date of proposal. He was serving in the office of market committee, Goraya District Jalandhar. As per record provided by secretary Market committee, Goraya, the deceased life assured was on medical leave from 8.8.2011 to 27.8.2011 (20 days) for his treatment from Gandhi Hospital, Phagwara by submitting Medical Certificates issued by the Hospital. As per discharged slip dated 12.8.2011 of Gandhi Hospital, Phagwara, he was suffering from Cancer of Penis and underwent operation of 8.8.2011. He also claimed reimbursement of hospital expenses for the said treatment. All the above record was before the date of proposal but despite having full knowledge of his illness and treatment thereof with medical leave of 20 days, he deliberately suppressed these material facts while making the proposal on 28.9.2011. By doing so, he affected our decision and obtained the insurance in a fraudulent manner. Had he disclosed actual state of his health in his proposal form, it would not have been accepted. The aforesaid facts clearly show that Sukhdev Singh life assured had made deliberate mis-statement and withheld correct information from the opposite parties regarding his illness of cancer and hospital treatment thereof with medical leave availed by him before the date of proposal with insurance and hence, in terms of the policy contract (Condition (5) Forfeiture in certain events of conditions and privileges of policy bond) and the declarations contained in the form of proposal for assurance, opposite parties repudiated the claim liability under the said policy No.13349693 and accordingly opposite parties are not liable for any payment. The complainant was informed about the said repudiation of claim vide registered letter dated 8.10.2016. However, in the last lines of the said letter it was made clear to the complainant that in case you disagree with the aforesaid decision and feel that the opposite parties have not considered any particular facts and circumstances in support of the claim, then the complainant may send any written representation along with all supporting documents within 3 months from the receipt of this letter to the Zonal office address for the reconsideration of the case, but thereafter no representation has been made to the opposite parties. Thus, the complainant is estopped to file any complaint against the opposite parties and all the other allegations in the complaint have been denied by the opposite parties and prayer was made for dismissal of the complaint with costs. 

4        To prove the case of complainant, Ld. counsel for the complainant has tendered in evidence affidavit of complainant Ex. C-1 alongwith documents Ex. C-2 to Ex. C-24 and closed the evidence. On the other hands, the opposite parties tendered in evidence affidavit of Ajaypal Singh Assistant Administrator officer of LIC Ex. OPs/1, affidavit of Virsa Singh Ex. OPs/2 alongwith documents Ex. OPs/3 to Ex. OPs/15 and closed the evidence.

5        We have heard the Ld. Counsel for the complainant and opposite parties and have gone through the evidence and documents placed on the file by the parties.

6        Ld. counsel for the complainant contended that opposite parties allured Sukhdev Singh (deceased) for getting the policy from them. The official of the opposite parties and agents approached the deceased Sukhdev Singh i.e. life assured. The deceased after discussing with the complainant & family members had proposed to assure his life vide proposal dated 28.9.2011 by the opposite parties vide the policy bearing No.133496993 and the opposite parties have issued the policy in favour of the deceased/applicant Sukhdev Singh. He further contended that the date of commencement of the policy was 28.8.2011 and premium to be paid/ fixed was Rs.6,378/- and installments were fixed to be paid annually and the sum assured on maturity of the policy was fixed of Rs. 1,50,000/-. The date of maturity of the policy is 28.8.2026 and he appointed nominee of the said policy to his wife i.e. Darshan Kaur. The complainant is fully competent to file the present complaint. The deceased life assured has paid all the installments of the policy on time as per the stipulated schedule till his death. He further contended that afterwards unluckily, the applicant/life assured died due to natural death on 7.10.2013 at his residence in the Village Kand, Tehsil Khadoor Sahib District Tarn Taran. The complainant had given the required information to the corporation regarding the death of Sukhdev Singh for obtaining the amount of sum assured on death under the policy bearing No.133496993 of the deceased Sukhdev Singh. All the requisite details, which is death certificate, forms and others information were provided to the officials of the opposite parties and the officials kept mum for many months since the death of the applicant Sukhdev Singh. He further contended that the complainant has sent written request to the corporation for satisfying his claim and after some days the officials of the corporation have called the complainant to its office at Phillor. The complainant alongwith her son had gone to the office of the corporation and the officials have demanded certain verifications on the printed formats issued by the corporation from the employer of the deceased and further certain verifications to be issued by the doctor in order to verify certain facts regarding the assured/ deceased Sukhdev Singh. He further contended that the complainant alongwith her son had gone to the office of corporation and the officials have demanded certain verifications on the printed formats issued by the corporation from the employer of the deceased and further certain verifications to be issued by the doctor in order to verify certain facts regarding the assured/ deceased Sukhdev Singh. The complainant with the help of family members, has collected every demanded information by the opposite parties from the employer and the concerned doctor and has sent all the documents to the opposite parties through registered post. Thereafter, the opposite parties have again called the complainant & her son in its office at Phillor and have returned back of some kind of more verifications and they have to submit the required verifications once again. The complainant has again managed to collect every demanded information from the employer and from the doctor as well as from other sources with respect to the deceased as per the demand of the opposite party and have sent all the documents to the corporation and has sent all the documents to the corporation through registered post. The opposite parties have again called the complainant & her son in its office at Phillor and have returned back all the documents in an arbitrary manner and told them that their claim could not be settled at that time due to certain medical reasons of the deceased/life assured. The complainant has told the officials that the deceased/life assured was not suffering from any kind of disease at the time of issuance of the policy but the officials of the opposite party have not paid any heed towards her requests. He further contended that the deceased life assured was not suffering from any kind of disease at the time of issuance of the policy due to which he could be ineligible for the policy. Further the deceased life assured had neither suppressed any kind of medical disease at the time issuance of the policy nor there exists any medical record history which could tell any kind of pre policy disease of the applicant/ insured as the deceased life assured have neither suffering from any kind of disease nor has taken any treatment in this regard from any doctor before the issuance of the policy. The complainant had filed a complaint bearing No. 18 of 2016 titled as “Darshan Kaur Vs LIC” before this Forum and this Forum decided the complaint and has directed the LIC to decide the claim of the complainant within one month after receiving the documents from complainant and further burdened the LIC with the cost of Rs.10,000/-. The complainant has provided certified copies of all the original documents to the LIC after obtaining the same from this Forum and afterwards, the LIC has demanded certain documents from the complainant vide its correspondence dated 5.10.2016 but after 3 days, the LIC has repudiated the claim very arbitrary and in a harsh manner within 3 days. He further contended that in earlier complaint, LIC has taken the plea that there is need of thorough investigations and LIC is doing investigations for the adjudication of the claim but very surprisingly, all the investigations have been conducted by the LIC within few days after the directions given by this Forum, which clearly shows that LIC is doing its business in a very arbitrary manner. The grounds, taken by the LIC for the repudiation of the claim of the complainant, are highly arbitrary and unbelievable. At the time of issuance of the policy all the necessary information related to the applicant and his family were taken by the officials of the opposite party and the officials, who collected the information and relevant documents, had verified the facts regarding health of the deceased through medical examination & personal investigation conducted by them regarding any ailment or severe disease, any surgery, operation or any medical assistance obtained or not and hence the correct information was given to the officials of the opposite parties. He further contended that in order to grab the sum assured on death i.e. insurance claim money of the complainant, the opposite parties i.e. the corporation has repudiated the claim of the complainant on baseless grounds in a very arbitrary manner, which is never acceptable to the complainant. The pleas taken by LIC, are not tenable in the present case as the deceased died after 2 years from the issuance of the policy as such, no such kind of pleas can be base for repudiation of the claim as per settled provisions of law. The complainant prayed that the present complaint may be allowed as prayed for.

7        Ld. counsel for the opposite parties contended that the insured is supposed to follow principles of insurance and one of the cardinal principle is “Principle of utmost good faith” i.e. insured will disclose all the material facts related to risk of his life at the time of taking the insurance. He should not conceal the facts about his health while taking an Insurance Policy and he should give correct answers to the question mentioned in the Insurance Form application. He further contended that Sukhdev Singh deceased had got a policy Insurance bearing No.133496993 from commencement date 28.8.2011 and sum assured of Rs. 1.50 lacs with premium mode half yearly A2 Rs. 6,378/- with maturity date 28.8.2016 and made nomination in favour of his wife. The deceased life assured paid all the installments of the policy till his death and he died on 7.10.2013 as per the information supplied to the opposite party. Claim forms have been issued to the complainant. The death claim was submitted by the complainant but the complainant was requested to submit all the requirements relating to the early death claim. The evidence relating to suppression of material facts regarding health of the deceased have been collected by the insurer. The husband of the complainant got the insurance policy fraudulently by concealing the true facts regarding his state of health. The conduct of the opposite parties was not un-businesslike. The opposite parties were investigating the claim of the complainant from various angles and after due inquiry and investigation, it has repudiated the claim put forward by the complainant. The claim has been rightly repudiated on the basis of evidence received related to suppression of material facts regarding health of the deceased and moreover, medical check-up by the insured is based on the answers replied by the life assured before the medical examiner. The claim has been repudiated after due investigation of the claim. The claim has been repudiated with a judicious mind. He further contended that as per order of this Forum a sum of Rs.10,000/-was paid to the complainant. Sukhdev Singh life assured withheld the correct information from the opposite parties regarding his ill health prior to the date of proposal at the time of affecting insurance with the opposite parties. In this connection, Sukhdev Singh life assured in the proposal for assurance dated 29.9.2011 signed by him, he had answered the flowing questions as under:-

11(a) During the last 5 years did you consult a medical practitioner for any aliment requiring treatment for more that a week?                          No

11(b) Have you ever been admitted to any hospital or nursing home for general check up, observation, treatment or operation?                   No

11(c)  Have you remained absent from place of work on grounds of health during last five years ?                                                                  No

11(e)  Are you suffering from or have ever suffered from diabetics, TB High BP, Low BP, Cancer Epilepsy, Hernia, Hydrocele, Leprosy or any other disease?                                                                            No

11(i)  What has been your usual state of health?                                        Good

He further contended that the above stated answers given by the life assured were false and he gave wrong information regarding his health to the opposite parties. It has come to the notice of the opposite parties that during inquiry and investigation that Sukhdev Singh life assured was not keeping good health prior to the date of proposal. He was serving in the office of market committee, Goraya District Jalandhar. As per record provided by secretary Market Committee, Goraya, the deceased life assured was on medical leave from 8.8.2011 to 27.8.2011 (20 days) for his treatment from Gandhi Hospital, Phagwara by submitting Medical Certificates issued by the Hospital. He further contended that as per discharged slip dated 12.8.2011 of Gandhi Hospital, Phagwara, he was suffering from Cancer of Penis and underwent operation of 8.8.2011. He also claimed reimbursement of hospital expenses for the said treatment. All the above record was before the date of proposal but despite having full knowledge of his illness and treatment thereof with medical leave of 20 days, he deliberately suppressed these material facts while making the proposal on 28.9.2011. By doing so, he affected our decision and obtained the insurance in a fraudulent manner. He further contended that had he disclosed actual state of his health in his proposal form, it would not have been accepted. The aforesaid facts clearly show that Sukhdev Singh life assured had made deliberate mis-statement and withheld correct information from the opposite parties regarding his illness of cancer and hospital treatment thereof with medical leave availed by him before the date of proposal with insurance and hence, in terms of the policy contract (Condition (5) Forfeiture in certain events of conditions and privileges of policy bond) and the declarations contained in the form of proposal for assurance, opposite parties repudiated the claim liability under the said policy No.13349693 and accordingly opposite parties are not liable for any payment. The complainant was informed about the said repudiation of claim vide registered letter dated 8.10.2016. However, in the last lines of the said letter it was made clear to the complainant that in case you disagree with the aforesaid decision and feel that the opposite parties have not considered any particular facts and circumstances in support of the claim, then the complainant may send any written representation alongwith all supporting documents within 3 months from the receipt of this letter to the Zonal office address for the reconsideration of the case, but thereafter, no representation has been made to the opposite parties. Thus, the complainant is estopped to file any complaint against the opposite parties. Ld. counsel for the opposite parties prayed for dismissal of the complaint. Ld. counsel for the opposite party has relied upon AIR 1975 Orissa 116 LIC Vs Manjula Mohanlal Joshi, 1961 PLJ 251titled Lakshmi Insurance Co. Ltd. Vs Bibi Padma Wati of Punjab High Court,  2008(1) CCC 206(S.C) P.C. Chacko & Anr Vs Chairman, Life Insurance Corporation of India & Ors.

8        In the present case, insurance in question is not disputed. It is also not disputed that the complainant died on 7.10.2013 during the currency of insurance policy. The opposite party has repudiated the claim of the complainant vide Ex. O.Ps/15 on the ground the deceased made deliberate mis-statement and withheld correct information from the insurance company regarding his illness of cancer and hospital treatment thereof with medical leave availed by him before the date of proposal, with fraudulent intention at the time of affecting the assurance and in terms of the policy correct (condition(5)- Forfeiture in certain events of conditions and Privileges of policy Bond) and the declarations contained in the form of proposal for assurance. We hereby, repudiate the claim liability under the said policy No. 133496993 and accordingly, they are not liable for the payment. The main stand of the opposite party in the present case is that the deceased was suffered from Cancer of Penis before taking the policy in question and to support their version, the opposite parties have placed on record claim enquiry report Ex. OPs/6 in which cause of death is mentioned as ‘Cancer’. The opposite party has also placed on record Discharge slip Ex. OPs/11 in which it has been certified that Sukhdev Singh has been operated for CA Penis. He advised rest for 1 month w.e.f. 12.8.2011. The opposite parties have also produced on record medical leave of Sukhdev Singh Ex. OPs/12. The opposite party has placed on record one certificate by employer i.e. Form No. 3787 in which it has been written that the Sukhdev remained on medical leave from 8.8.2011 to 27.8.2011 and from 3.12.2012 to 31.12.2012 and from 7.1.2013 to 27.1.2013 and the same is signed and stamped by Secretary Market Committee Goraya i.e. employer of Sukhdev Singh. But on the other hands, the complainant has tendered in evidence certificate by employer i.e. Form No. 3787  in which it has been written that Sukhdev Singh has not taken any medical leave w.e.f. 8.8.2011 to 27.8.2011  and same is also signed and stamped by Secretary Market Committee Goraya i.e. employer of Sukhdev Singh, As such,  the document Ex. OPs/12 has not given any help to the opposite parties. Moreover, the opposite parties have taken stand that the complainant has concealed the fact regarding his preexisting disease i.e. Cancer of penis. But the complainant has produced on record medical attendant’s certificate dated 31.10.2013 Ex. C-10 in which the cause of death of Sukhdev Singh has been mentioned as Cardiac arrest. It has also been written in Ex. C-10 that Sukhdev Singh had been suffering from his disease for 1 year. It is also mentioned in the Ex. C-10 that they first observed the deceased for the said disease for 1 year.  It has also been mentioned in Ex. C-10 that he attended him during the whole of its cause.  It is also mentioned in Ex. C-10 that for one year he is usual medical attendant of the deceased. The Ex. C-10 is given by Dr. Gagandeep Singh Medical attendant of the deceased Sukhdev Singh and the same is signed and stamped by Dr. Gagandeep Singh. In Ex. C-10, C-11 the said Doctor mentioned that Sukhdev Singh died due to cardiac arrest.  The complainant has also produced on record one letter Ex. C-12 in which the cause of death of the deceased in the application is mentioned as cancer and the said letter is mere signed by Darshan Kaur in Punjabi Language and the same is not written by Darshan Kaur with her hands. There is one another document i.e. claimant’s statement in which the cause of death of Sukhdev Singh is mentioned as Cardiorespiratory Arrest. The opposite parties themselves placed on record one document i.e. claimant’s Statement Ex. OPs/8 in which the cause of death of Sukhdev Singh is mentioned as Cardiorespiratory Arrest. The opposite parties have placed on record one document Ex. OPs/14 in which Dr. Gagandeep Singh has written the nature of ailment cancer. In Ex. OPs/14, Dr Gagandeep Singh has given the date of admission as 3.10.2013 and date of discharge as 21.10.2013 and in Ex. OPs/14 Dr. Gagandeep Singh himself mentioned the history of illness as per records one year. As such, if we calculate the duration of disease i.e. one year back comes to October 2012. But the deceased has taken the insurance in the month of August 2011 i.e. much prior to October 2012. Further, the opposite parties have placed on record one medical examiner’s confidential report  dated 28.11.2011, it shows that the Sukhdev Singh went to Doctor concerned of the opposite party for his medical tests and the concerned doctor checked his blood pressure, pulse rate etc. , but the said doctor has not conducted the medical test of Sukhev Singh at that time.

9        We have also gone through some judicial pronouncements relevant to the present case. In case M/s ICICI Prudential Life Insurance company Ltd. Vs Veena Sharma & Others 2014(4) CLT 507(NC), the Hon’ble National Commission held that it was for the insurance company to prove that complainant was suffering from pre-existing disease and has knowingly failed to disclose the same. The Hon’ble National Commission has also relied upon a case decided by the Hon’ble Supreme Court titled Balwinder Kaur Vs Life Insurance Corporation of India, Civil Appeal No. 7969 of 2010 decided on 13.9.2010, wherein it was held that the onus to prove that deceased had obtained policy by suppressing the material facts relating to his illness, was on the corporation at the time of taking policy and he deliberately suppressed the facts.

10      In case National Insurance Company Limited and Another Vs Balwinder Singh 2012(1) CLT 34, the Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh held that the appellants have not produced any evidence to prove that before the purchase of policy the insured/ respondent had taken any treatment from any doctor or any hospital and the insured/ respondent had the knowledge that he was suffering from the heart disease. This pronouncement was based upon the decision of the Hon’ble Apex Court in case titled LIC Vs GM Channabasamna, 1991(1) SCC 357  and of the Hon’ble National Commission in case titled LIC Vs Joginder Kaur and others, 2005(2) CLT 229. 

11      In case Kotak Mohindra Old Mutual Life Insurance Ltd. Vs Chander Isarsingh Dhansinghani & anr 2013(3) CLT 186, the Hon’ble State Commission Ahemdabad held that Doctor certificate without any affidavit of the doctor in support cannot be basis for repudiation of claim. It was held that the onus was upon the appellant to prove that the insured suppressed material facts. In this pronouncement citations Smt. Sunita Agarwal Vs LIC of India, III (2005) CPJ 446 = 2005 CTJ 874 relying on Supreme Court Judgment in case of Mithoolal Nayak, AIR 1962 SC 814, the Hon’ble MP State Commission were discussed.

12      In case Tarlok Chand Khanna Vs United India Insurance Co. Ltd. 2012(2) CLT 617(NC) wherein the Hon’ble National Commission held that onus to prove was on the respondent/ insurance company regarding preexisting disease. In that case insurance company repudiated the claim on the ground that replacement of knees cannot occur within days or months and infact takes years for the keens to degenerate to a condition where total replacement is medically advised. In this case, Tarlok Chand Khanna obtained a mediclaim insurance policy from the respondent/ Insurance company valid from 1.1.2002 to 31.12.2002 for a sum of Rs. 1,50,000/- for himself and his wife Smt. Kurana Khanna. Smt. Karuna Khanna developed pain in her knees and on 15.9.2002 she underwent surgery for knees replacement of her both knees at a total cost of Rs. 1,78,945/-. She died due to sudden Cardiac arrest in the hospital on 29.9.2002. The complaint to claim the expenses was dismissed by the District Forum on the ground that there is no affidavit of any doctor of Nayyar Hospital nor there is any death certificate issued by Cardiologist showing cause of death of the wife of the complainant as cardiac arrest on 29.9.2002. The Hon’ble State Commission also dismissed the appeal. Sh. Updip Singh, ld. counsel for revisionist contended before the Hon’ble National Commission that the onus to prove that she had a pre-existing disease was on the respondent who failed to file any expert medical or credible evidence in support of its case. The counsel for petitioner relied upon a case titled National Insurance Co. Ltd. Vs Raj Narain, 1(2008)CPJ 501(NC), wherein Hon’ble National Commission had observed as follows:-

“Most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer because the Insurance Company relies on their Clause 4.1 of the policy in a mala fide manner to repudiate all the claims. No claim is payable under the mediclaim policy as every human being is born to die and diseases are perhaps pre-existing in the system totally unknown to him which he is genuinely unaware of them. Hindsight everyone relies much later that he should have known from some symptom. If this is so every person should do medical studies and further not take any insurance policy.” In view of the above facts, the Fora below erred in saying that claim was rightly repudiated.  

          In a nutshell it was held that onus was on the insurance company to prove that insured was suffering from pre-existing disease at the time of purchase of policy.

13      In case United India Insurance Company Vs Safiya 2013(3) CLT 195, identical view was taken by Hon’ble Kerala State consumer Disputes Redressal Commission, Thruvananthapuram

14      In case Birla Sun Life Insurance Co. Ltd. Vs Manjeet in Revision Petition No. 1139 of 2014 (NC) decided on 23.2.2015, the life assured died on 1.11.2009. The insurance company repudiated the claim on the ground that he concealed the material facts of his suffering from diabetes mellitus at the time of submission of the proposal form. The District Form partly allowed the complaint. However, the Hon’ble State Commission dismissed the appeal preferred by the Insurance Company. The insurance company argued before the Hon’ble National Commission that the insured has concealed the fact of his being diabetes for the last 15 years. The claimant side had contended that the insurance proposal was accepted by the petitioner / opposite party after the medical examination of the life assured. The Hon’ble State Commission was of the view that the Sugar level was tested at the time of proposal form and it was found within range. The Hon’ble National Commission was of the view that the view of Hon’ble State Commission was fallacious because even in a case of person suffering from diabetes, the sugar level can be kept under control by regulating the diet and taking medicine oral or injectable. Therefore, the sugar level test by itself is not an assurance that the person is not suffering from diabetes. The Hon’ble National Commission held that the insured had concealed the material facts.

15      We have also gone through the ruling titled Birla Sun Life Insurance Company Ltd. Vs Kiran Prafull Bahadure 1(2015) CPJ 473 (NC) wherein the repudiation of claim was not held justified. In that case, the deceased husband of the complainant was suffering from Ischemic Heart Disease prior to his application for taking the insurance cover, whereas the husband of the complainant was died of natural death. The Hon’ble National Commission held that no evidence was produced by the insurance company that deceased was suffering from any heart disease since 10.2.2010. In that case the policy was taken on 19.5.2011 and deceased had deposited half yearly installment i.e. Rs. 15,000/- and died on 26.9.2011. Similar view was taken by the Hon’ble Chhattisgarh State Commission in case titled L.I.C. of India Vs Kanchan Thawait, wherein Hon’ble State Commission held that mere production of medical certificate is not sufficient to prove pre-existing disease.

16      We have also taken into consideration all other points raised before us by both the sides. The medical examination of Sukhdev Singh at the time of issuance of the policy has not been denied. Only plea taken by the Opposite Parties is that DLA had not disclosed the material information regarding his illness at the time of issuance of the policy, but we fail to understand who had prevented the Opposite Parties- Insurance Company to get the insured thoroughly examined before issuance of the policy, after all, the insurance company was to incur huge liability. It was required from the Opposite Parties- Insurance Company to get the insured thoroughly examined and then to issue policy which it has not done. It appears that at that time the goal of the Opposite Parties- Insurance Company was only to fetch business and it had forgotten its liability part. It is pertinent to mention here that no doctor has been examined to authenticate the medical treatment of Sukhdev Singh, DLA. The investigation which has now been done after the death of Sukhdev Singh, DLA should have been done at early stage before or at the time of issuance of the policy or within the stipulated period which was justified in repudiating or rejecting the insurance policy, but it has not been done for the reasons best known to the Opposite Parties. Section 45 of the Insurance Act, 1938 would not come to any help to the opposite parties. The claimants have taken this specific plea that Sukhdev Singh died due to cardiac arrest whereas the opposite parties have taken this plea that he died due to Ca Penis (Cancer). Therefore, in the absence of any specific evidence, which was to be adduced by the opposite parties, natural inference is that Sukhdev Singh died due to cardiac arrest. Moreover, if assumingly Sukhdev Singh was suffering from Ca Penis (Cancer) even then it was for the opposite parties to prove the nexus of that disease with the death of Sukhev Singh. Nothing of this sought has come on the record. In view of this, the stand of the opposite parties that the Sukhdev Singh deceased was suffering from disease Cancer Penis at the time of insurance policy but he has not disclosed the same to the insurance company at that time has given no help to the opposite parties because from the record on the file it proved that Sukhdev Singh died due Cardiorespiratory Arrest.

17      We have also gone through the Judgment of Apex Court titled as BIHAR SCHOOL EXAMINATION BOARD vs. SURESH PRASAD SINHA” IV (2009) CPJ 34 (SC), where the Hon’ble Supreme Court of India has held that “It is well settled that a little difference in facts or additional facts may make a lot of difference in the precedential value of a decision.”  So, keeping in view the supra judgment of Hon’ble Supreme Court of India, the rulings referred to by the Opposite Parties- Insurance Company which are on different facts, have no bearing to the facts of the present case because each case depends on its own facts and a close similarity between one case and another is not enough because even a single significant detail may alter the entire aspect, in deciding such cases and we respectfully of the view that rulings cited by the Opposite Parties- Insurance Company are not applicable to the facts of the present case. 

18      From the aforesaid discussion, it transpires that Opposite Parties have wrongly repudiated the claim of the complainant. As such, opposite parties are directed to make the death claim of Sukhdev Singh to the tune of Rs. 1,50,000 (One Lac and Fifty Thousand only only).  Complainant is also entitled to Rs.10,000/- ( Rs. Ten Thousand only) as compensation on account of harassment and mental agony and Rs 5,000/- (Rupees Five Thousand only) as litigation expenses from the opposite parties. Opposite Parties are directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation.  Copy of order be supplied to the parties free of costs as per rules. File be consigned to record room.

(Charanjit Singh)

                                 President             (Jaswinder Kaur)

                                                         Member