BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION KANGRA AT DHARAMSHALA, H.P.

                                                  Date of Institution: 19.03.2021

                                                  Date of final hearing: 12.04.2023

                                                  Date of Pronouncement: 02.05.2023

Consumer Complaint No.-122/2022

IN THE MATTER OF

Priya W/o Late Sh. Ravi Kumar S/o Sh. Hem Raj, R/o Village Amlela, Tehsil Jawali, District Kangra, H.P.

(Through:  Mr. Abhishek Gupta Advocate)

                                                                      ….........Complainant

Versus

1. LIC of India, through its Senior Divisional Manager, Block No. 14,15 SDA Complex Shimla, H.P. through its Divisional Officer Shimla

2.  LIC of India Branch Office Jassur, Distict Kangra, H.P. through its Manager.

(Through: Mr. Rajeshwar Sapehya, Advocate)

……....Opposite Parties

CORAM:                                                         

President:   Mr. Hemanshu Mishra

Members:    Ms. Arti Sood & Sh. Narayan Thakur

Present:-    

Mr. Abhishek Gupta Advocate for the complainant.

Mr. Rajeshwar Sapehya, Adv. for the opposite parties.

PER: Mr. Hemanshu Mishra, President:-

JUDGMENT

                    The complainant has filed instant complaint seeking direction to the opposite party(s) as under:-

I.                  That the opposite party be directed to pay double the amount of sum insured as per the term rider amounting to Rs. 12,00,000/- with interest @ 18% pa, benefits of the second rider at the earliest, with other benefits in the said policy with interest @ 18% from the month of February 2019 in favour of complainant.

II.                 That the opposite party be directed to pay an amount of Rs. 20,000/- as compensation for harassment to the complainant as under such mental condition, she had to run form pillar to post.

III.                That the opposite party be directed to give an amount of Rs. 10,000/- as legal expenses to the complainant.

2.                 Facts giving rise to filing of this complaint are that the complainant being widow of late Sh. Ravi Kumar who was working as Junior Engineer in HPSEB expired on 20.01.2019 at DMC Hospital Ludhiana Punjab. He was insured under Policy No. 154672351 and the premium of policy along with cost of additional riders was duly paid as per the agreement of policy. As per the complainant in the month of December 2018, during the subsistence of the said policy, the insured/ husband of the complainant suffered illness and was admitted at RPGMC Tanda-Kangra for investigation and thereafter he was referred for further management/ treatment he was taken to Dayanand Medical College Ludhiana, Punjab, where he unfortunately expired on 20.01.2019. As per the complainant the insured was 28 years of age at the time of his death and as per procedure/ policy document the complainant represented before the officers of the opposite party for disbursement of claim amount along with riders opted, as per the policy document, but her claim was repudiated by the opposite party illegally and unlawfully on the grounds that the said policy had not completed 3 years from the commencement period and there was concealment of facts in the proposal form, therefore, alleging deficiency in the service of opposite parties the complainant filed the present complaint.

3.                 Upon notice, opposite parties appeared through counsel and contested the complaint and took preliminary objections qua maintainability of complainant, Hon’ble Forum has no jurisdiction in the matter, suppression of material facts etc. and on merits denied the contents of the complaint and submitted that the said policy had not completed three years from the date of commencement period and there was concealment of facts in the proposal form and the claim of the complainant has rightly been repudiated, therefore, there is no deficiency in the services of the opposite parties, with these averments the opposite parties prayed for the dismissal of the present complaint.

4.                That the complainant has filed rejoinder denying the contents of the reply filed by opposite parties and reiterating those of complaint.   

5.                That the parties were called upon to produce their evidence and both the parties lead their evidences in support of their contentions.

6.                 We have heard learned counsel for the parties and also gone through the case file carefully.

7.                 Opposite party vide annexure C-5 has repudiated the claim of the complainant on 02.01.2020, which is reproduced as under :-

Re: Policy No.154672351 on the life of

Lt. Sh. Ravi Kumar (Decd.)T-T 833-21(18)

This has reference to your claim under the above mentioned policy on the life of Lt. Sh. Ravi Kumar received by us on 12.07.2019.

In this connection, we have to inform you that afore stated Policy has not completed three years from the date of commencement of risk, which is 15.11.2018 to date of death of life assured. As such, we have examined the claim keeping in view of the provisions of section 45 of Insurance Act 1938.

While examining the claim, we note from the proposal form dated 15.11.2018 that the deceased life assured had answered the following questions as noted herein below

11(a) During the last five years did you consult a Medical Practitioner for any ailment 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(d) Are you suffering from or have you ever suffered from ailments pertaining to Liver, Stomach, Heart, Lungs, Kidney, Brain or Nervous System?                        No

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

We may, however, state that all the aforesaid answers were false as can be seen from the following document:

Discharge Card from RPGMC, Tanda Deceased was suffered from Hepatitis B Virus in 2017 and was treated for the same at RPGMC Tanda.

This suppression of material facts, which had a bearing on the granting of risk, was clearly done with intent to mislead the corporation, Hence it has decided to repudiate all the liabilities and in terms of provisions of section 45 of the insurance act, 1938, we are refunding premiums under the policy amounting to Rs.5494/- towards full and final settlement of the your claim. 

8.                 The entire repudiation of the claim stands on the proposal form dated 15.11.2018, where, as per opposite party, deceased life assured suppressed the material facts and has mislead the Life Insurance Corporation.  The proposal form which is annexure-C-7 and annexure OP-3 reveals that in declaration by the proposer no name of the proposer has been mentioned in the declaration and name of the place is missing in this declaration also. Even the signature of the person whose life is proposed to be assured is undated and full name of the person has not been mentioned therein.  Even address and occupation of the witness is missing.  The signatures of the medical examiner are missing in this proposal form whereas in the last line of proposal form it was specifically written that the signature should be affixed in the presence of Medical examiner.  Minute scrutiny of proposal form also reveals that in para-4B name of present employer has been mentioned as “eleckicty deptt.” Instead of Electricity Department.  Mobile phone number of sub agent has not been mentioned in the proposal form.  Unnamed incomplete declaration itself entail that the statement and declaration shall be basis of contract of assurance between insured and LIC and if any untrue averment is contained therein, the said contract shall be dealt with as provision of section 45 of insurance laws (Amended Act, 2015).  But here declaration is incomplete meaning thereby it is no declaration. Despite of incomplete declaration or no declaration, the opposite party has received premium of Rs.2,747/- from the complainant twice.

9.                 Medical Fitness Certificate for Non Gazetted Appointment dated 16.04.2018 was issued by Sr. Medical Officer of Zonal Hospital Dharamshala, where it was certified that the deceased life assured was not having any disease (communicable of otherwise) constitutional weakness or bodily infirmity. The complainant in the present case is the wife of deceased life assured, who was merely 20 years of age at the time of commencement of policy.  The Deceased life assured was having knowledge of any existing disease then marriage with complainant was not possible . Because it can easily be presumed that no person will marry when he was suffering from any serious ailment.

10.        In the death certificate, the reason for the death is cardiopulmonary arrest.  The opposite party has concluded that answers were false in proposal form which can be seen from the discharge card issued by Dr.RPGM College Tanda, where it has been mentioned that deceased suffered from hepatitis B Virus in 2017 and treated for same at RPGMC Tanda. The earlier disease mentioned has no significant impact to the death of deceased life assured. Even in the absence of original record of hospital or affidavit of the concerned doctors the theory purported by the opposite party seems unrealistic.

11.                 The discharge card of Dr. RPGM College shows that deceased life assured remained admitted in Dr. RPGM College Tanda from 29.12.2018 to 16.01.2019.  The insurance policy was issued prior to the date of admission in the hospital and patient was referred to higher institution for further management.  It is not known who has filled the proposal form.  The deceased life assured has subsequently died and the agent of the Life Corporation of India Sh. Rajat Sharma has not filed any affidavit from where it can be ascertained that proposal form was filled as per the instructions of the deceased life assured.  The opposite party failed to explain why in the declaration; name of deceased life assured was not mentioned.  What prevented them to get the signature of medical officer on the proposal form and had the deceased life assured was suffering from fever for 2 ½ months prior to 29.12.2018, then why deceased life assured was not medically examined prior to issuance of policy.  Even affidavit of treating doctor of RPGMC College Tanda, who has signed the discharge card/treatment summary, has not been annexed with the reply or in evidence by the opposite party.  The opposite party annexed annexure-OP-2 certificate of hospital treatment, but the affidavit of doctor who has signed this certificate is also missing. The most important information regarding history of the deceased was remained unexplained in column 5b i , which is reproduced as under:-

12.               Now in the absence of affidavit of the doctor, who has recorded the history, it cannot be ascertained who gave the history of deceased life assured to the doctors in Ludhiana as not recorded in the said certificate, So we observe that the opposite party has repudiated the claim of the complainant without application of mind in cursory manner, which is deficiency in service.  Complainant has relied upon judgment passed by Hon’ble Apex Court of India reported in 2022(1) Apex Court J 0685, Civil Appeal No.8386 of 2015 decided on 06.12.2021 titled Manmohan Nanda Versus United India Insurance Company Ltd.  Here, Hon'ble Supreme Court of India has held that:

If inspite of blank column, insurance company accepts the premium and issues a policy, then at a later stage Insurance Company cannot say that there is suppression or non disclosure of a material fact;

(vi) Once the policy has been issued after assessing the medical condition of the insured, the insurer cannot repudiate the claim by citing an existing medical condition which was disclosed by the insured in the proposal form;

13.               Hon’ble H.P. State Consumer Disputes Redressal Commission, Shimla in F.A No.310/2018 reported in Latest HLJ 2021 (HP)(1) 274 has held that:

The opposite parties have not produced the hospital record showing that the deceased life assured remained admitted in DMC & Hospital, Ludhiana and treated in the said hospital for the alleged diseases. The opposite parties have also not filed the affidavit of the doctor who had treated the I deceased. In these circumstances, certificate of hospital treatment dated 31.10.2017, Annexure OPS 1&2/R-2 is of no legal consequence and as such the same has also been rightly discarded by the learned District forum.

14.               On the other hand, opposite parties have relied upon judgment passed by Hon'ble Supreme Court of India in Civil Appeal No.3397/2020 titled Bajaj Allianz Life Insurance Co. Ltd. and others Versus Dalbir Kaur. The facts of this case are entirely different from the present complaint.  As such this citation is of no help to the opposite parties.  The opposite party has received two premiums of Rs.2,747/- and later on refunded Rs.5,494/-.  In our opinion, the opposite party is required to pay entire sum assured of Rs.6,00,000/- to the nominee of the deceased life assured after deducting Rs.5,494/-, which was wrongly refunded to the complainant. 

15.               Accordingly, the complaint is allowed and opposite parties are jointly and severally directed to pay a sum of Rs.5,94,506/- to the complainant along with interest @ 9% per annum from the date of complaint i.e. 19.03.2021 till its realization.  Apart from this, opposite parties are also jointly and severally directed to pay compensation to the complainant to the tune of Rs.30,000/-, besides litigation cost quantified as Rs.15,000/-.

16.               Applications pending, if any, stand disposed of in terms of the aforesaid judgment.

17.               A copy of this judgment be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986/2019. The judgment be uploaded forthwith on the website of the Commission for the perusal of the parties.

18.               File be consigned to record room along with a copy of this Judgment. 

                                                                      (Hemanshu Mishra)

                                                                       President

(Narayan Thakur)                     (Arti Sood)

                     Member                                   Member

Pronounced on: 02.05.2023