DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

PATIALA.

                                      Consumer Complaint No.113 of 16.3.2016

                                      Decided on: 8.3.219

Jaswinder Singh aged 45 years s/o Sh. Sewa Dass, R/o VPO Bhunnerheri, Tehsil and District Patiala.

                                                                   …………...Complainant

                                      Versus

1. Life Insurance Corporation of India, Unit-II, SCO-8-9, Chhoti Baradari, Patiala through its Branch Manager/Incharge.
2. Life Insurance Corporation of India, Divisional Office Sector 17-B, Chandigarh through its Sr. Div. Manager.

                                                                   …………Opposite Parties

                                      Complaint under Section 12 of the

                                      Consumer Protection Act, 1986.

QUORUM

                                      Sh. M.P.Singh Pahwa, President

                                      Smt. Inderjeet Kaur, Member

                                      Sh.B.S.Dhaliwal, Member      

ARGUED BY

                                       Sh.K.S.Sidhu, counsel for complainant.

                                      Sh.T.M.Sayal, counsel for OPs.

 ORDER

                                     M.P.SINGH PAHWA, PRESIDENT               

1. This is the complaint filed by Jaswinder Singh (hereinafter referred to as the complainant) against Life Insurance Corporation of India and another (hereinafter referred to as the OPs.
2. Briefly the case of the complainant is that his wife Amarjit Kaur got herself insured with the OPs and obtained Jeevan Anand Policy No.165123032, starting from 28.1.2012. She paid Rs.8796/- as installment of the premium. Jaswinder Singh was nominee. The sum assured was Rs.3lac. On 8.2.2013, his wife felt perennial pain and bleeding in rectum. She was immediately taken to Rajindra Hospital, Patiala, where she remained admitted from 8.2.2013 to 14.2.2013.Then she was referred to PGI Chandigarh on 14.2.2013 and remained admitted there till 21.2.2013. Several tests were conducted but her condition did not improve. Amarjit Kaur was again admitted in Rajindra Hospital, Patiala from 18.6.2013 to 22.6.2013 and thereafter was referred to D.M.C., Ludhiana and remained admitted there from 22.6.2013 to 9.7.2013. Her condition did not improve. Ultimately she expired on 10.7.2013 due to refractory septic and multiple organ failure.
3. The total expenditure for the treatment of the deceased was more than Rs.five lac. Complainant reported the claim with the OPs. They deputed investigators. Complainant completed all the formalities as desired by the OPs and Investigators.
4. It is alleged that the complainant was shocked to receive ‘no claim’ letter dated 31.3.2014 from the OPs with the remarks that “the deceased has made deliberate mis-statements  and withheld material information regarding her health at the time of effecting the assurance”
5. Thereafter the complainant visited the office of OP No.1 and explained that deceased was not suffering from ulcerative colitis/bleeding per rectum prior of taking policy. She gave true and correct information regarding her health but OPs did not listen. By this complaint, the complainant has prayed for direction to the OPs to pay claim of Rs.3lacs with interest till the date of payment, Rs.25000/- as compensation for harassment and Rs.25000/-as costs of the litigation. Hence this complaint.
6. Upon notice, OPs appeared through counsel and contested the claim by filing joint written reply. In reply the OPs raised preliminary objections that the policy bond bearing policy No.165123032 issued in favour of Amarjit Kaur was void ab initio on account of mis- statement and suppression of truth. As such the claim under policy has rightly been repudiated.
7. On merits, it is admitted that Amarjit Kaur has taken life insurance policy but it is further mentioned that the policy was taken by concealing material facts regarding disease while submitting the proposal form. It is also denied that the complainant is the legal heir of Amarjit Kaur. Thereafter the OPs have revealed that information regarding death of deceased life assured (DLA) was given by the complainant by submitting application alongwith death certificate. The cause of death was mentioned as “septic” and the complainant requested to settle the claim under the policy. Complainant submitted form no.3816 got filled from the respective doctors of the hospitals i.e. Rajindra Hospital, Patiala, PGI Chandigarh and D.M.C. Ludhiana. In these forms it is reported that DLA was a known case of ulcerative colitis since 2 ½ years back. The complainant is having record of hospitals treatment but the same has not been deliberately produced on the court file. The wrong history has been given that the DLA has got perennial pain only on 8.2.2013, thereafter was got admitted in Rajindra Hospital Patiala and so on. Infact in the hospitals true facts were got recorded that the DLA was a known case of ulcerative colitis.
8. It is further mentioned that the DLA had died within 1 ¼ month from the date of taking policy. It being an early claim, investigation was got done to verify the bonafide of the claim. While submitting the proposal form dated 17.5.2011 deceased life assured gave answers to the questions in negative regarding suffering from various diseases and claimed good health. During investigation it came to light that the DLA was a known case of ulcerative colitis before taking the policy in question on 10.2.2012.While taking the policy, it was well within the knowledge of DLA that she gave wrong answers while filing proposal form. The material information was very much necessary to be disclosed by DLA to assess the risk of acceptance of proposal. Had the DLA disclosed in the proposal form regarding her health, the additional requirement i.e. the tests or RA factor, haemo gram, deformity questionnaire were necessary to assess the risk and it was under the competency of the central office of the OP to decide the acceptance/refusal of risk, had the deceased life assured given right answers to t he questions whereby disclosing material information regarding her said disease. The insurance in question was fraudulently taken by the DLA by concealing material information. The factum of insurance being based on the principle of uberrima fides, it was incumbent upon the life assured to have faithfully disclosed that she had been suffering from the ailment. As it was a total case of intentional non discloser of material information, which resulted in wrong acceptance of proposal, the claim  of the claimant was rejected under the policy vide repudiation letter dated 31.3.2014. All other averments of the complainant are denied. In the end the OPs prayed for the dismissal of the complaint.
9. Parties were afforded opportunity to produce their evidence.
10. The complainant tendered into evidence his affidavit, Ex.CA, copy of insurance policy, Ex.C1, copy of discharge summary, Ex.C2, copy of OPD card, Ex.C3, copy of bills, Ex.C4, copy of operation record, Ex/C5, copy of treatment record, Ex.C6,C7, copy of ultra sound report, Ex.C8, copy of discharge summary,Ex.C9, copy of OPD card, Ex.C10, C11, copy of discharge summary,Ex.C12, treatment record, Exs.C13,Ex.C14, copy of death certificate, Ex.C15, copy of claimant statement, Ex.C16,ExC17, copy of letter dated 31.3.2014, Ex.C18, copy of order dated 6.8.2015,  passed by PLA,Ex.C19.
11. OPs tendered into evidence affidavit of V.K.Arora, Ex.OPA, copy of proposal form, Ex.OP1, copy of form No.3816,Ex.OP2, Ex.OP3,Ex.OP4, copy  of letter dated 31.3.2014,Ex.OP5,  copy of proposal review slip, Ex.OP6 , copy of agent report performa, Ex.OP7.
12. We have heard the ld. counsel for the parties and gone through the record of the case, carefully.
13. The ld. counsel for the complainant has submitted that material facts are not in dispute. It is not disputed that Amarjit Kaur, wife of the complainant got insured with the OPs under Jeevan Anand Policy, starting from 28.1.2012.Amarjit Kaur has died on 10.7.2013. The complainant being nominee and husband of DLA, lodged the claim with the OPs but the OPs repudiated the claim vide letter dated 31.3.2014 (Ex.OP5).As per this letter, the OPs have repudiated the claim on the ground that the DLA made deliberate mis statement and withheld material information regarding her health.DLA has not withheld any material information. Therefore, the repudiation of the claim is not justified.
14. It is further submitted by the ld. counsel for the complainant that the OPs have tried to justify the repudiation of the claim on the basis of form No.3816,Exs.OP2 to OP4.But these documents also do not support the stand of the OPs. The policy was availed w.e.f.20.1.2012.The OPs were required to prove that the DLA was suffering from some disease from 20.1.2012 and she was having knowledge of the same but there is no documentary evidence to prove this fact. Ex.OP2 proves that the DLA took admission w.e.f. 22.6.2013. Of course, it is mentioned that complaint of bleeding was since 30 months but it is further mentioned that there was no medical treatment. Similarly Ex.OP3 proves treatment from 8.2.2013 onwards. Of course in this document, it is also mentioned that the patient is diagnosed inflammatory bowel disease (ulcerative colitis) of 2 ½ years at the time of admission but this document also does not prove any treatment by the deceased and knowledge of the DLA regarding the disease. Ex.OP4 will also simply prove KCO ulcerative colitis P/w but it also does not prove that the deceased was in the knowledge of any disease. Therefore, the repudiation is not justified. OPs have illegally repudiated the claim. Complainant is also entitled to compensation and costs of the litigation. In support of these submissions, the ld. counsel for the complainant has citied III(2009) CPJ 453 Swaran Singh Multani Vs. L.I.C. of India, IV(2007) CPJ 244 Venkata Ravi Kishore Vs. Life Insurance Corporation of India &Anr., IV(2008) CPJ 89 (NC) Life Insurance Corporation of India & Ors. Vs. Kunari Devi, III(2008)CPJ 423 Pradeep Kumar Garg Vs. National Insurance Co. Ltd., II (2009) CPJ 119 (NC) National Insurance Co. Ltd. Vs. Balkhandi Lal Sharma.
15. On the other hand, the ld. counsel for the OPs has submitted that the contract of insurance is based on good faith to be exercised by both the parties. The DLA was under obligation to disclose all the material facts. The OPs have produced on record copy of the proposal form submitted by the DLA at the time of availing the policy. The DLA was specifically asked whether she is suffering from any disease but the categorical answer of the DLA was in negative. The complainant himself has admitted in the complaint that Smt.Amarjit Kaur died due to multiple organ failure. OPs have also produced the reports in form No.3816, Exs.OP2 to OP 4 .All these reports will prove that DLA was also suffering from ulcerative colitis for the last more than 2 ½ year i.e. much before availing the policy. Ex.OP2 shows that the DLA was suffering from bleeding per rectum since 30 months. This report is dated 22.6.2013. It leads to inference that DLA was suffering from this disease even in January/2011. Similarly report, Ex.OP3 shows that DLA took treatment from 8.2.2013 onwards and as per this document the deceased was suffering from 2-5 years back. Ex.OP4 is dated 10.7.2013.As per this document also DLA was known case of ulcerative colitis, which shows that the deceased was in the knowledge of disease but she has intentionally concealed this fact. As such the policy was availed by mis representation. OPs have justified to repudiate the claim.
16. We have given careful consideration to the rival submissions.
17. The admitted facts are that Amarjit Kaur wife of the complainant availed insurance policy from the OPs w.e.f.13.2.2012. The sum assured was Rs.3lac. Amarjit Kaur hereinafter referred to as DLA died on 10.7.2013.Complainant being nominee of DLA lodged claim with the OPs and the OPs have repudiated the claim vide letter dated 31.3.2014, Ex.OP5. A perusal of this letter revealed that the OPs have repudiated the claim on the ground that DLA had made deliberate mis statement and with-held material information regarding her health at the time of effecting insurance.
18. Therefore, the entire controversy revolves around the fact whether DLA was suffering from any disease and whether she has withheld this information from the OPs.
19. The onus to prove this fact was upon the OPs. The OPs have relied upon the report in form No.3816, Exs.OP2 to OP4. Now it has to be seen whether these reports prove the stand of the OPs.

Ex.OP2 relates to the treatment from 22.6.2013.The condition of the patient at the time of admission is reported as C/o bleeding per rectum since 30 months. Non responsive to medical treatment and severe in nature. This document simply proves that complainant was suffering from bleeding per rectum. There is nothing on the record to prove that deceased was well conversant in medical science. This information is regarding simple problem from which it cannot be inferred that the DLA was aware of the fact that she is suffering from ulcerative colitis. There is also nothing on the record to show that the DLA has earlier taken treatment for ulcerative colitis. Ex.OP3 is regarding treatment from 8.2.2013 onward. As per this document also, the condition at the time of admission was complaint of inflammatory bowel disease. Of course it is mentioned (ulcerative colitis) but from this document it cannot be inferred that the DLA reported that she is suffering from ulcerative colitis. Her simple complaint was regarding inflammatory bowel disease. The next document is Ex.OP4. This document also proves that complainant reported, it is case of ulcerative colitis. Abdominal distension. All these reports are regarding treatment in the year 2013 onwards. There is nothing on record to prove that complainant took any treatment for ulcerative colitis before availing the policy. It is apparent that DLA reported problem of bleeding and not of ulcerative colitis. In these circumstances, the conclusion is that the OPs have failed to prove that the DLA was suffering from ulcerative colitis and she was having knowledge of this fact. In these circumstances repudiation of claim is not justified.

20. For the reason recorded above, we partly accept the complaint with Rs.5000/-as litigation expenses. The OPs are also directed to pay Rs.3,00,000/-,the sum assured of the policy. As the OPs have wrongly repudiated the claim, therefore, the complainant is entitled to interest as compensation on the amount of Rs.3,00,000/-  @ 12% per annum from the date of repudiation i.e. 31.3.2014.

The OPs are directed to comply the aforesaid order within a period of 45 days from the date of the receipt of the certified copy of this order. Certified copies of this order be sent to the parties free of cost under the Rules. Thereafter, file be indexed and consigned to the Record Room.

ANNOUNCED

DATED:8.3.2019         

          B.S.Dhaliwal                  Inderjeet Kaur             M. P. Singh Pahwa

             Member                           Member                                      President