Delhi

East Delhi

CC/499/2016

AMRESH - Complainant(s)

Versus

LIC of India - Opp.Party(s)

07 Feb 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. No. 499/2016

 

	Smt. Amresh W/o Lt. Sh. Rajinder Prasad Manishi R/o 12/289, Kalyanpuri, Delhi-92	….Complainant
Versus
	Life Insurance Corpn. Of India Delhi Divisonal Office-II 9th Floor, Scope Minar, Laxmi Nagar, N. Delhi-92	……OP

 

Date of Institution: 22.09.2016

Judgment Reserved on: 31.01.2023

Judgment Passed on: 07.02.2023

                  

QUORUM:

Sh. S.S. Malhotra (President)

Ms. Rashmi Bansal (Member)

Sh. Ravi Kumar (Member)

 

Order By: Rashmi Bansal (Member)

 

The present complaint is filed by the complainant against the OP for repudiation of LIC claim of her husband’s life insurance policies along with compensation for causing harassment and mental agony and litigation cost.

1. It is the case of the complainant that her late husband was insured by OP and had three insurance policies bearing number 124782424 dated 27.04.2008 for the sum assured of Rs.2,50,000/-; 125493158 dated 10.07.2012 for the sum assured of Rs. 1,87,500/-; and 126629242 dated 19.08.2013 for the sum assured of Rs.2,00,000/, Annexure CW1/ B (colly). It is submitted by the complainant that her husband, was admitted on 01.08.2014 in Max Super Speciality Hospital, Delhi for treatment and during the treatment on 03.08.2014, he died. The information about the death of her husband was duly conveyed to the OP along with all relevant documents which were required for the settlement of the claim in relation of the insurance policies amount. The complainant submits that the OP has refused to pay the death claim of the complainant on the ground of concealment of the material facts by the insured i.e. the husband of the complainant, at the time of purchasing the above stated insurance policies. The copy of the reply to the claim dated 09.05.2015 regarding policy bearing number 125493158, and 126629242, dated 30.11.2015 & regarding policy bearing number 124782424 are Annexure CW1/C. Complainant further submits that the policies in question had been purchased by the husband of the complainant after necessary verification by the OP. The Complainant protested against the repudiation and requested the officials of OP for settlement of her claim but the same was also rejected. The complainant states that she has suffered mental pain and agony due to negligence of the OP towards non-payment of the policies amount, and praying for release of the same along with compensation and litigation cost. The complainant has relied upon the judgement of Hon'ble SCDRC, Delhi in Oriental insurance Company Limited versus Romesh Suri and another and also, Hon'ble NCDRC in Life Insurance Corp. of India Vs Jaswinder Kaur dated 05.08.2019.
2. OP has filed its reply admitting the issuance policies but stated that present complaint is not maintainable as there is no deficiency in service of any kind on the part of OP as the complainant has not approached this Commission with clean hands and has suppressed the true and material facts having mala fide intention and ulterior motives on her part to achieve her illegal goal and to extract money from the OP, without having any legal right since the policyholder/insured, in his life time, suppressed the true and material facts regarding his ill-health from the OP at the time of taking the policies in question. The OP submits that the deceased/the policy holder/ insured, had been suffering from Muscular Dystrophy from last 10 years and did not disclose this fact in his Proposal Form and has furnished false information therein just to avail the benefits arising out of the said policies for his interest and committed a fraud upon the OP for which no law permits. Therefore, the death claim of the complainant was repudiated on the ground of suppression of material facts regarding prior adverse (critical) health status of policy holder. The appeal filed by the complainant was rejected by the LIC’s Zonal Office Claims Dispute Redressal Committee on 31.03.2016, duly communicated to the complainant.
3. The complainant has filed the Rejoinder reiterating the stand taken in complaint. Both the parties have filed their respective evidence along with documents.
4. In support of it’s case, the OP has filed the following documents.

1. The copy of Proposal Form of policy bearing number 124782424, along with medical certificate/history of the policy holder, Ex. RW1/A ;
2. The copy of the policy bond bearing number 1254,93158 and medical certificate of the policyholder, Ex. RW1/B;
3. The copy of Proposal Form of policy bearing number 126629242, along with medical certificate/history of the policy holder, Ex. RW1/C;
4. the copy of the leave record and leave application form of policy holder, Ex. RW1/D;
5. Death, summary and treatment documents of Policy Holder of Max Hospital, Ex. RW1/E(colly);
6. The copy of the repudiation letter dated 09.05.2015 and 30.11.2015, Ex. RW1/ A and B(colly);

5. This Commission has perused the documents available on record carefully.
6. The above stated policies are not in dispute. Perusal of the documents show that before issuing the life insurance policies to the insured, form containing questions pertaining to the health and medical history of the proposer was given to the insured which required a specific disclosure as to whether the proposer had undergone any treatment. The proposer answered the queries in the negative. Further a query regarding specific disease or disorder suffered was also responded to, by the insured in negative and stated usual state of health as good.Thereafter the above stated life insurance policies were issued to the insured.

The specific queries which were asked by the OP were follows.

11(a) - During the last five years, did you consult a medical practitioner for any ailment or requiring treatment for more than 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 the last five years? – No

11(d)- Are you suffering from or have you ever suffered from ailment pertaining to liver, stomach, heart, lungs, kidney, brain or nervous system? – No

11(e)- Are you suffering from or have you ever suffered from diabetes, tuberculosis, high blood pressure, low BP, cancer, epilepsy, hernia, hydrocel, leprosy or any other disease? – No

11(f)- Did you ever have any bodily defect or deformity?– No.

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

7. The OP has filed form number 5152, dated 01.01.2015 signed by Doctor from Max Super Speciality Hospital, the medical attendant of the deceased, and the Medical Attendant’s Certificate mentioning that the policyholder was suffering from Muscular Dystrophy from last 10 years. This is observed from the Medical Attendant’s Certificate filed by OP with respect to above stated policies, the cause of death is mentioned as pulmonary haemorrhage and type-2 respiratory failure and the same is corroborated from form number 5152 vide it’s column 8(1), wherein muscular dystrophy is mentioned as the disease other than the disease that caused death of the policy holder.
8. The Hon'ble Supreme Court in – Sulbha Prakash Motegaonkar and Ors. v. Life Insurance Corporation of India, Civil, Appeal No. 8245/2015 decided on 5th October, 2015, wherein the assured suffered myocardial infraction and succumbed to it & the claim was repudiated by the insurance company on the ground that there was a suppression of a pre- existing lumbar spondylitis and in that background, it was held that the alleged concealment was of such a nature that would not dis-entitle the deceased from getting his life insured. In other words, the pre-existing ailment was clearly unrelated to the cause of death.
9. Further, on the basis of the disclosures made by the complainant in the Proposal Form with regard to his status of the health, the OP has considered the same and issued the policy in question to the policy holder. The OP of its own did not go for the medical examination of the complainant in order to satisfy itself before issuing the life insurance policy, as to whether the medical and health condition of the assured was such which did not warrant issuance of a life insurance policy to him and did not decline the proposal of the assured as a prudent insurer. Since insurance company is under obligation to conduct a medical test, if it is necessary, before giving the insurance and if it opts for not going to conduct some medical test, then at a later stage, it cannot claim that the insured has concealed some information w.r.t. his health and is liable to pay the insurance and cannot deny it’s liability on the ground of concealment of past disease.Therefore, the OP is not right in repudiating the policies in question on the ground of concealment of the material facts, particularly those facts, which has no connection with the cause of death. The documents on record reveal that the cause of death is different from the disease with which the policy holder was suffering. Moreover, life insurance is for the insuring the life and upon the death of the insured the amount assured has to be paid to the nominee of the policy holder.
10. There was no evidence filed by the OP to show that the pre-existing condition of Muscular Dystrophy was the cause of pulmonary haemorrhage with type 2 respiratory failure, which is the cause of death of the complainant or the policy holder had any pre -existing pulmonary haemorrhage related illness, disease or condition.
11. Therefore, this Commission is of considered opinion that there is deficiency in service on the part of the OP in repudiating the claim of Complainant and thus is liable to pay the insurance amount of the above stated policies total amounting to  Rs. 6,37,500/-   along with interest @ 6% p.a. from the date of filing of the complaint till the actual realisation of the amount by the complainant and compensation of Rs. 20,000/- for causing mental harassment and agony to the complainant and Rs.10,000/-  towards litigation cost. The above stated amount is to be paid to the complainant within one month from the date of receiving the copy of this order, failing which the OP is liable to pay the interest at the rate of 10% p.a. on the above stated all entire amount till the actual realisation, by the complainant.
12. The file be consigned to record room after providing the copy of the order as per rule of CPA 1986.
13. The complaint could not be decided within time due to heavy pendency of the cases.
14. The order contains 07 pages each bears our signature.