PER SHRI.S.S. PATIL – HON’BLE MEMBER
1) This is a complaint regarding the deficiency in service on the part of Opposite Parties as the Opposite Party No.1 has repudiated the insurance claim of the Complainants and Opposite Party No.2 collected Rs.50,000/- from the Complainant for issuing the 8 Life Insurance Policies to the deceased husband of the Complainant No.1.
The facts of this case, as alleged by the Complainants are that the Complainant No.1 is the widow of decease insured Shri.Ismail Jan Mohammed Patel (I.J.M.Patel for brevity) and Complainant No.2 to 3 are the children of the deceased I.J.M. Patel and Complainant No.1. Opposite Party No.1 is the Insurance Company while Opposite Party No.2 is its LIC Agent.
2) The Complainants further submitted that the deceased Shri. I.J.M. Patel, the husband of the Complainant No.1 obtained 8 death claim polices (Insurance Policies covering the Life of Shri. I.J.M. Patel) from Opposite Party No.1 through Opposite Party No.2. The numbers of these policies are 881062484/85/86/87/88/89/90/91. The sum insured under each policy was Rs.1 Lac. These polices commenced from 22/03/02. Out of these 8 policies 1st 4 policies were Jeevan Mitra Double Cover Endowment + Profit + Accident benefit and in case of untimely death the nominee were to receive double the amount insured as such, the Complainants were to receive 8 Lacs Rupees under the above said 4 policies and they were to receive 4 Lacs Rupees under the remaining 4 policies in the event of the untimely death of the insured I.J.M. Patel.
3) The Complainant has further stated that in the month of December, 2002 the insured was suffering from fever and he was admitted in the Holy Spirit Hospital at Andheri on 30/12/02. He died on 16/01/03. After his death the Complainant No.1 filed the claim through Opposite Party No.2 alongwith all the required papers. It is the contention of the Complainant No.1 that she had informed Opposite Party No.1 that the insured was admitted in Punamiya Hospital. She has forwarded this information to Opposite Party No.2. The Complainants have claimed total amount of Rs.12 Lacs under the said 8 policies. However, the Opposite Party No.1 vide it’s letter dtd.06/12/03 repudiated the claim on the ground that, the deceased insured had withheld the correct information regarding his health, at the time of effecting the assurance and further informed the Complainant No.1 to approach the Zonal Officer if she was not satisfied with the decision of Opposite Party No.1. The Opposite Party also sent a letter dtd.16/12/03 addressed to Opposite Party No.2 informing her that the Complainant’s claim was repudiated on the ground that the said deceased insured suffered from Ischemic Heart Disease with left Ventricular failure for which he had consulted a medical man. No such ground was communicated to the Complainant No.1.
4) Being aggrieved by the repudiation by the Opposite Party No.1 the Complainant No.1 approached Zonal Office Claims Review Committee which also upheld the above decision of repudiation. Then she approached the Insurance Ombudsman but in-vain. The Ombudsman came to the conclusion that the deceased I.J.M. Patel had suppressed the material facts from the Opposite Party No.1 and the Insurance Ombudsman rejected the claim for deliberate suppression of the material facts regarding the health of the insured.
5) The Complainant No.1 again approached General Office of the LIC to reconsider her claim on humanitarian ground but the Mumbai Division Office II of LIC upheld the rejection of the Opposite Party No.1 vide its letter dtd.11/12/07.
6) Finally, the Complainants have prayed for the payment of Rs.12 Lacs under the 8 above said policies together with 12 % interest p.a. from the date of filing this claim till its realization. The Complainants also prayed for 1 Lac compensation for mental torture etc. and Rs.25,000/- for cost of this complaint.
The Complainants attached the xerox copies of relevant papers such as, the confidential report of the Agent, Proposal Form filled by the Insured, medical papers of Holy Spirit Hospital (30/12/02 to 16/01/03) certificate of death dtd.20/01/03 Letter of repudiation dtd.16/12/03 from Opposite Party Hospital papers from Punamiya Nursing Home (25/08/96 to 01/09/06) in respect of the deceased insured Shri.I.J.M. Award by Insurance Ombudsman dtd.23/08/2006. Certificate of Dr.Mehul Shah, certificate of treatment/consultation issued by the Opposite Party, letter dtd.11/12/07 from Opposite Party and letter from under Secretary to Govt. of India dtd.27/11/07.
7) The complaint was admitted and notices were issued to the Opposite Parties. Opposite Party No.1 appeared through its Ld.Advocate and filed its written statement- cum-affidavit wherein it stated that the contract of insurance is based on principles of Uberima fides i.e. utmost good faith. In this case also the contract of insurance was based on the information provided by the proposer i.e. the insured. On this information given in the proposal form, as well as the information gathered from medical examiner’s report, the Opposite Party undertakes to cover the risk based solely on information furnished by the insured in the proposal form i.e. the information given by the proposer is the basis of the contract of insurance and therefore, it should be true and in good faith. Wrong or misleading information vitiates the contract of insurance. On this information, the insurer company decides to accept or reject the proposal or at times even an alternative plan is suggested considering the overall information.
8) It is also contended by the Opposite Party No.1 that the contract of insurance is null and void, as per the terms and conditions of the policy if it is found out that the insured had concealed the material information and the insurer has also right to forfeit the moneys which have been paid in respect of the policies.
9) The Opposite Party No.1 has further submitted that the cause of action had arisen on 16/12/03 i.e. on the date of which the claim of the Complainants was rejected. The Complainants should have filed the complaint within period of two years from the date of repudiation. The complaint has been filed on 03/04/08. Therefore, this complaint for the insurance claim is time barred and hence this complaint should be dismissed on this ground of limitation.
10) The Opposite Party has admitted that, the insured Mr.I.J.M. Patel has submitted two proposals dtd.05/03/02 for insuring on his own life for eight polices alongwith the agent’s confidential report and medical examiner’s confidential report. Accordingly Opposite Party No.1 issued 8 Life Insurance Policies having numbers as mentioned in the complaint. The Opposite Party has also admitted that the insured Shri.I.JM. Patel died on 16/01/03. As the claim arose within two years from the date of inception of these Insurance Policies, the Opposite Party No.1 has initiated the investigation in to the cause of death of the insured. During the investigation, it was revealed that the insured was admitted in Punamiya Nursing Home, Dadar on 25/08/1996 and was discharged on 01/09/96. The insured was admitted in this nursing home for weakness. Body ache and breathlessness, sweting, rash over both feet abdomen, and back. It was diagnosed that the insured was suffering from Ischemic Heart disease with Left Ventricular failure (IHD with LVF).
11) It is the contention of the Opposite Party No.1 that the fact that the insured was suffering from Ischemic Heart Disease with left Ventricular failure was not disclosed by the insured in his proposal form dtd.05/03/02. Had this fact was brought to the notice of the Opposite Party No.1, or this fact was mentioned in the proposal form, filled in by the insured either it would have called for further medical papers from the insured or would have issued the policies or would have issued the same with altered conditions.
12) The Opposite Party No.1 further submitted that, after considering the above fact of concealing the material facts from it, Opposite Party No.1 repudiated the claim of the Complainant and it was informed to the Complainant vide its two letters dtd.16/12/03. It is the contention of the Opposite Party that, the Complainant withheld the correct information about his health i.e. the disease he suffered, which was the material information affecting the insurance. Therefore, the Opposite Party No.1 is not liable to pay anything under the policies.
13) The Opposite Party No.1 has clarified in its para no.21 that the insured’s policy’s bearing no.881062484, 86 and 87, were only Jeevan Mitra Double Cover Endowment + Profit + Accident Benefit Policies and other 5 policies were not Jeevan Mitra Double Cover Endowment + Profit + Accident Benefit Policies. These policies were Asha Deep Policies with Profits.
14) The Opposite Party No.1 has finally denied the prayers of the Complainants and it prayed that the complaint be dismissed with compensatory cost. It attached the xerox copies of the following documents in support of its written statement.
i) The proposal form filled up by the insured Shri. I.J.M. Patel.
ii) Medical examiner’s confidential report.
The Complainant also later on submitted the xerox copies of the following documents.
i)The proposal form, indoor papers of deceased from Holy Spirit Hospital where he died. Death certificate of the insured, Repudiation letters from the Opposite Party No.1 dtd.16/12/03, case papers of Punamiya Nursing Home where the insured had taken treatment and where he was admitted in the year 1996 from 25/08/96 to 01/09/96. (Discharge summary). Award by Insurance Ombudsman dtd.23/08/2006.
15) The Complainant also submitted the rejoinder and written argument wherein they reiterated facts mentioned in the complaint and denied the facts in written statement of Opposite Party No.1. The Opposite Party No.1 also submitted the written arguments wherein it reiterated the facts mentioned in its written statement. We heard both the Ld.Advocates for both the parties and perused all the above said papers submitted by both the parties and our findings are as follows.
16) While going through all the above said papers, we observe that the insured Shri.Ismail Jan Mohammed Patel had obtained 8 insurance policies from the Opposite Party No.1 through Opposite Party No.2 who is the authorized agent of the Opposite Party No.1. All the 8 policies have insured the life of Shri. Ismail Jan Mohammed Patel. These policies commenced from 28/03/02 and 22/03/02. Before inception of these policies the insured was admitted with Punamiya Hospital from 25/08/96 to 01/09/96. The front page of the Discharge Summary of this Hospital, submitted by the Complainants themselves mention as “Diagnose” IHD with LVF element, Drug reaction with secondary infection i.e. the insured was admitted for 3 reasons. One – IHD with LVF element, second – drug reaction and third – secondary infection. The perusal of the proposal form clearly shows that this fact was not mentioned in this form filled in by the insured at the time of seeking the insurance cover. The contract of Insurance being utmost good faith, we shall not hesitate to say, that the insured has certainly concealed this material fact in respect of his health from Opposite Party No.1.
17) At the same time, the documents submitted by the Complainants also clearly show that their claim was repudiated by Opposite Party No.1 vide its letter dtd.16/12/03. This fact was also admitted by the Complainants in para no.3 and subsequently in (para No.14 and 22 of the complaint). We perused this letter dtd.16/12/03 of Opposite Party No.1 addressed to the Complainant No.1. The Opposite Party No.1 has clearly stated the reasons for repudiation of the claim and it also clearly repudiated the claim on 16/12/03. Thus, the cause of action i.e. the right to make the complaint before this Forum arose on 16/12/03. As per the legal provision in Sec.24(A) of the Consumer Protection Act, 1986, the Complainant should have filed the complaint before this Forum within 2 years from 16/12/03. However, the Complainants have filled this complaint on 03/04/08 i.e. after more than 5 years from the date of repudiation of the claim and there is no application for condonation of this delay in filing the complaint. Therefore, this complaint is certainly barred by limitation. Hence the order -
O R D E R
i)Complaint No.53/2008 is hereby dismissed as barred by limitation
ii)No order as to cost.
iii)Copy of this order be furnished to both the parties.
