BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.334 of 2016

Date of Instt. 28.07.2016

Date of Decision: 06.03.2018

Rajinder Singh Sabharwal S/o Sh. Kishan Singh R/o NB-137, Sodal Road, Jalandhar.

..........Complainant Versus

LIC Corporation of India Divisional Office, Jeewan Parkash Building, Model Town-2, Jalandhar.

..….…Opposite Party

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh (President)

Smt. Harvimal Dogra (Member)

Present: Sh. Rahul Sharma, Adv Counsel for the Complainant.

Sh. Bhupesh Vaid, Adv Counsel for the OP.

Order

Karnail Singh (President)

1. This complaint is presented by the complainant, wherein alleged that the daughter of the complainant namely Puneet Kaur took an insurance cover for Rs.3,00,000/-, vide policy No.133467221 on 15.02.2012 and due to the death of the policy holder Puneet Kaur, being unmarried, as such, the complainant being father filed the complaint. The complainant is also nominee of the insurer Puneet Kaur. The daughter of the complainant during the period of the policy developed a tumor and she was admitted to hospital on 17.03.2012 and she was discharged from the hospital on 02.04.2012. Unfortunately, daughter of the complainant the insurer Puneet Kaur died. After her death, the complainant filed the claim, but the claim was rejected on the ground that she has not disclosed her medical help at the time of insurance cover. The rejection of the claim is attached. The complainant again filed a review of the claim at Zonal Office, New Delhi against the said claim. The complainant approached the Ombudsman, vide letter dated 10.05.2016 and the claim was rejected. The insurance policy of the daughter of the complainant was valid from 15.02.2012 for one year. The OP has not reimbursed the amount as per the policy scheme. No doubt, the observation given by the Bhargav Advance Gyane Surgery Cancer Center that the insurer having swelling in abdomen since November 2011, weakness from December 2011 etc. Those not proclaimed that she was having knowledge about the cancer. The insured Puneet Kaur has not given any false information regarding her medical treatment. The complainant requested number of times to OP as well as made written request for the claim, but the OP refused with assigning a wrong reason and as such, the instant complaint filed with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay the insurance amount of Rs.3,00,000/- and further complainant is entitled for compensation of Rs.50,000/- for the deficiency in service on the part of the OP and also entitled for the cost of this complaint of Rs.10,000/-.

2. Notice of the complaint was given to the OP, who appeared and filed written reply and contested the complaint by taking preliminary objections that the present complaint is not maintainable in the eyes of law and same has not been properly verified as required under the provision of 'Consumer Protection Act' and further alleged that the complaint is not maintainable as the same is vague and evasive. It is further alleged that the complaint under reply is a gross abuse of the process of law. The complainant has filed the complaint with the sole motive of pressurizing and harassing the answering OP to submit to the unreasonable and mischievous demands of the complainant and even the complaint is not maintainable and further alleged that the complaint does not falls under the definition of 'Consumer Protection Act'. The true facts of the case are that Ms. Puneet Kaur was insured under the policy for Rs.3,00,000/- and table-term149-21. The duration of the policy is less than 2 years and LA died on 21.07.2013. The death claim was repudiated on 14.02.2015 by the Divisional Office. Again as per decision of Claims Review Committee at Zonal Office, New Delhi, the appeal of Rajinder Singh was dismissed on 30.07.2015, on the ground that liability of claim has been repudiated for valid and legal reasons. On merits, the factum in regard to purchase of insurance policy by the daughter of the complainant is admitted and the complainant is nominee of the policy is also admitted. The remaining allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.

3. In order to prove the case of the complainant, the complainant himself tendered into evidence affidavit Ex.CA alongwith some documents Ex.C-1 to Ex.C-4 and closed the evidence.

4. Similarly, counsel for the OP tendered into evidence affidavit Ex.OP/A alongwith documents Ex.OP1 to Ex.O15 and then closed the evidence.

5. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.

6. In this complaint, the version of the complainant is that his daughter Puneet Kaur took an insurance policy cover for Rs.3,00,000/- on 15.02.2012, which is valid up to 15.02.2014, but unfortunately, the daughter of the complainant died and insurance claim filed by the complainant was rejected by the OPs, vide repudiation letter Ex.C-2 dated 16.02.2015. Against that order, the complainant again filed a review before the Higher Authority, which was also rejected, vide order Ex.C3 dated 17.08.2015 and accordingly, the complainant has no any other alternative except to file the present complaint and in order to prove the allegation as made in the complaint, the complainant proved on the file his own affidavit Ex.CA.

7. The factum in regard to getting an insurance policy by Puneet Kaur as well as death of Puneet Kaur and repudiation of the claim of the complainant and review order passed by the Higher Authority are admitted. But the claim of the complainant has been rejected by the OP, simply on the ground that she has concealed her previous illness at the time of inception of the policy and as such, the OP alleged that the claim is rightly repudiated.

8. Now, question before us only, whether the insurance claim of the complainant has been rightly rejected by the OP or not, for that purpose, it is necessary to scan the repudiation letter Ex.C-2, wherein categorically mentioned that the insured did not give correct answer at the time of taking policy because she was suffering from Tumor in stomach and was taking treatment for it and even as per employer leave record, she took medical leave from 31.01.2012 to 29.02.2012 for 30 days and as such, she made deliberate in-correct statement and concealed the real facts and as such, the claim of the complainant is rightly repudiated, similar view has been taken by the Higher Authority in rejection letter Ex.C-3. In order to prove that the daughter of the complainant was having Tumor in abdomen prior to inception of the policy, the OP has brought on the file Report of Kahlon Hospital, which is dated 17.03.2012 Ex.OP-2. No doubt, in this report, the doctor has referred a Tumor and further produced on the file an other report of the same hospital Ex.OP-4 by the OP, wherein the doctor reported that Miss Puneet Kaur was operated on 17.03.2012 and she was under his treatment. Apart from the doctors report, the OP has also brought on the file Leave Details of Insured Puneet Kaur Ex.OP-3, Ex.OP-5 and Ex.OP-7 and Leave Applications Form Ex.OP-8 and Ex.OP-9 and also brought on the file some other letters, whereby the officer of the OP observed that the daughter of the complainant was having cancer prior to inception of the policy.

9. First of all, we like to discus the medical reports, produced on the file by the OP i.e. Ex.OP-2 and Ex.OP-4. The first report of the Kahlon Hospital Ex.OP-2 is dated 17.03.2012, whereas the insurance policy was obtained by the deceased insured Puneet Kaur on 15.02.2012 i.e. one month prior to aforesaid report of the doctor and similarly, the second other report of the doctor is without date, but in that report, it is categorically mentioned that the operation of the insured Puneet Kaur was conducted on 17.03.2012, means the operation was conducted by the doctor on the same date when he checked the insured Puneet Kaur, but both the reports of the doctor are after one month of the inception of the policy, there is not even a single report of the doctor that insured Puneet Kaur was having any Tumor problem or any other serious problem prior to 15.02.2012 i.e. the date of purchasing of the policy, so, it means that the insured Puneet Kaur was herself not aware about the Tumor/Cancer at the time of inception of the policy, if so then, how she can disclose the facts, which were not in her own knowledge and as such, we are of the considered opinion that the insured Puneet Kaur did not make any incorrect-statement to the official of the OPs.

10. We have also considered the other documents i.e. Leave Record of the insured Puneet Kaur, which was obtained from the employer i.e. Leave Detail Ex.OP-3, wherein almost leaves taken by the insured Puneet Kaur, have been recorded as Urgent Work and the Disputed Leave, which is referred in the Repudiation Letter is from 31.01.2012 to 29.02.2012, the said leave is also not mentioned as a Medical Leave and if, for the sake of argument, we considered that the said leave is taken as Medical Leave, as got cleared by the OP, vide letter Ex.OP-7, even then, simply taking a leave for medical does not construe that the said employee is facing a serious illness or having some serious disease like Tumor or Cancer, to prove that fact, the OPs are required to bring on the file specific evidence, but the OP has repudiated the claim illegally even in lack of any solid evidence, in regard to Tumor/Cancer to the insured Puneet Kaur, prior to purchase of the policy.

11. Furthermore, the OP has also made a stress that as per record of Kahlon Hospital, Jalandhar, the insured had Swelling of Abdomen since November, 2011, Weakness from December, 2011, Hair Growth since two years, Amenorroha since December, 2011, obviously, these factum have been narrated in the Kahlon Hospital's Report Ex.OP2 dated 17.03.2012, but in order to establish that the patient was having any disease since one year or two years prior, for that purpose, the OP has to bring on the file affidavit of the said doctor, with the detail, how he assess the disease previous date, but for the best known reason, the OP has not brought on the file any affidavit of the doctor of Kahlon Hospital. So, in the absence of any affidavit of the doctor, this version of the OP is not acceptable and accordingly, we find that the complainant is able to prove his case.

12. As an upshot of our above detailed discussion, the complaint of the complainant succeeds and accordingly, the same is partly accepted and OP is directed to pay insured amount of Rs.3,00,000/-, to the complainant alongwith interest @ 9% per annum from the date of repudiation i.e. 16.02.2015, till realization and further OP is directed to pay compensation to the complainant, to the tune of Rs.25,000/- and also directed to pay the cost of litigation of Rs.5000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.

13. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated                                                        Harvimal Dogra                                    Karnail Singh

06.03.2018                                               Member                                                 President