Punjab

Sangrur

CC/490/2016

Sukhwinder Singh - Complainant(s)

Versus

LIC of India - Opp.Party(s)

Shri Ashish Garg

11 Jan 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.  490

                                                Instituted on:    16.08.2016

                                                Decided on:       11.01.2017

 

Sukhwinder Singh son of Arjan Singh, New Cheema Tent House, Cinema Road, Sunam, District Sangrur.

                                                                ..Complainant

                                Versus

1.     Life Insurance Corporation of India, Railway Road, Jiwan Jyoti Building,  Sangrur through its Manager.

2.     Life Insurance Corporation of India, Northern Zone, Divisional Office, Jiwan Parkash Building, Sector 17-B, Chandigarh through its Divisional Manager.

                                                        …Opposite parties

For the complainant  :       Shri Ashish Garg, Advocate.

For OPs                    :       Shri Amit Goyal, Advocate.

 

 

Quorum:   Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

 

Order by : Sukhpal Singh Gill, President

 

1.             Shri Sukhwinder Singh, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant obtained a health insurance policy from OP number 1 for 15 years which was for the period from 12.8.2009 to 12.8.2023 under which the complainant had to pay a premium amounting to Rs.12,000/- on yearly basis, but the Ops did not supply any terms and conditions of the policy.

 

2.             The grievance of the complainant is that he was admitted in Amar Hospital, Patiala on 31.12.2015 with complaint of multiple episodes of vomiting for four days and was discharged on 7.1.2016, where the complainant spent more than Rs.1,50,000/- on his treatment.  After that the complainant lodged the claim with Op number 1 for reimbursement of the amount, but the OP number 1 illegally and arbitrarily rejected the claim vide letter dated 22.7.2016 on the ground that as per the discharge summary, the patient is a chronic alcoholic.  Further case of the complainant is that he has been paying the premium regularly to the OPs since the inception of the policy in question. It is further averred in the complaint that before issuance of the policy, the complainant was even got medically examined by the doctor of OPs, as such it is stated that if the complainant would have been suffering from such chronic alcoholic then the same must have been noticed.  It is further averred that the complainant even suffered the problem after the period of six years of taking the policy, as such, rejection of the claim has been disputed by the complainant. Thus,  alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainant an amount of Rs.1,50,000/- along with interest @ 18% per annum from 31.12.2015 till realisation and further claimed compensation and litigation expenses.

 

3.             In reply filed by the OPs, preliminary objections are taken up on the grounds that the complaint is not maintainable in the present form, that the complainant has not come to the Forum with clean hands and has suppressed the material facts, that the complaint involves intricate questions of law and facts which require extensive evidence.  On merits,  it is admitted that the complainant had obtained the insurance policy number 163978383 i.e. LIC Health Protection Plus Plan.  It is further admitted that the complainant lodged the claim with the OPs and remained admitted in Amar Hospital, Patiala from 31.12.2015 to 7.1.2016 and the claim has been rejected.  It is stated that the complainant gave wrong answers to the questions raised by the OPs at the time of taking the insurance policy. As such, it is stated that the complainant is not entitled to any claim.

 

4.             The learned counsel for the complainant has produced Ex.C-1 copy of insurance policy, Ex.C-2 copy of discharge summary, Ex.C-3 to Ex.C-12 copies of bills and Ex.C-13 copy of repudiation letter and closed evidence. On the other hand, the leaned counsel for the OPs has produced OP-1 copy of proposal form, Ex.OP-2 copy of discharge summary, Ex.OP-3 copy of scan report, Ex.OP-4 copy of insurance policy, Ex.OP-5 copy of claim review statement, Ex.OP-6 and Ex.P-7 copies of repudiation letter, Ex.OP-8 copy of claim form, Ex.OP/9 affidavit and closed evidence.

 
5              We have carefully perused the complaint, written version of the opposite parties, evidence of the parties and heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

 

6.             The version of the complainant is that he had obtained a health insurance policy from OP number 1 for 15 years which commenced from 12.8.2009 and was valid upto 12.8.2023 under which the complainant was depositing the premium of Rs.12,000/- annually, which he deposited regularly, as is evident from the copy of the insurance policy, which is on record as Ex.C-1 (OP-4) for Rs.1,00,000/-.  During the subsistence of the insurance policy, the complainant was got admitted in the Amar Hospital, Patiala on 31.12.2015 and remained there upto 7.1.2016 with the complaint of multiple episodes of vomiting for four days and spent a sum of Rs.1,50,000/- on his treatment, but the OPs had repudiated the claim on the ground that as per the discharge summary, the patient is a chronic alcoholic.  On the other hand, the stand of the OPs is that the claim has rightly been repudiated on the ground that as per the discharge summary, the patient is a chronic alcoholic, which he did not disclose at the time of getting the insurance policy, as such, it is contended that the complainant is not entitled to get any claim and the claim is said to be rightly repudiated.

 

7.             After hearing the arguments of the learned counsel for the parties and on the perusal of the documents placed on record, we find that the complainant had successfully established his claim case.  We may mention that the OPs have miserably failed to produce on record any cogent, reliable and trustworthy evidence to show that the complainant was a chronic alcoholic.

 

8.             While repudiating the claim, the OPs have relied upon the discharge summary of  the patient to say that the complainant is a chronic alcoholic. We have also perused the copy of discharge summary, which is on record as Ex.C-2, wherein in the past history, it is stated that the complainant is a chronic alcoholic but at the same time in the column “Chief complaints: it is stated that the patient admitted with complaint of multiple episodes of vomiting for 4 days, history of headache with irrelevant talk, vertigo present, complaint of numbness of left side body.”  There is nothing mentioned about the period that the complainant is a chronic alcoholic.   As such, we are unable to go with the contention of the OPs that the complainant is a chronic alcoholic as no relevant evidence has been produced on the file by the OPs, as the burden to prove this fact is on the OPs. The learned counsel for the complainant has cited the judgment of the Hon’ble National Commission delivered in the Revision Petition No.2738 of 2008 in which it has been held that history recorded in hospital bed ticket is not to be treated as evidence as the doctor, recording the history has not been examined. The Hon’ble National Commission has mentioned that “To be noted that in support of which is stated in the case sheet neither the doctor who recorded their case sheet was examined nor his affidavit filed as also mentioned in its order by the State Commission.”  Further the learned counsel for the complainant has cited Surinder Kaur versus LIC Of India and others 2005(2) CPC 675 (NC), wherein it has been held that it is settled law that insurer is bound to prove the fact of concealment of fact at the time of filling up the proposal form. Courts cannot be satisfied with proof which falls short of showing that intentional misrepresentation was made with the knowledge of perpetrating fraud. Onus to prove material concealment would lie on the insurer as held in the LIC versus Smt. Promila Malhotra 2003(2) CPC 281 (NC).  Mere taking liquor daily does not prove that insured is suffering from an ailment.  In the present case, the OPs have produced nothing on record to show that the complainant was a chronic alcoholic except mere mention of the same in the history sheet recorded by Dr. of Amar Hospital, Patiala.  Further the Hon’ble National Commission in Life Insurance Corporation of India and others versus Kunari Devi 2008(3) CLT 650 (NC) has held that what is stated in the case sheet neither the doctor who recorded this case sheet was examined nor his affidavit filed, which is very much necessary.   The same is the position in the present case, as the Ops have produced no affidavit of such doctor who recorded the history sheet.

 

9.             Further it is the specific version of the complainant that the terms and conditions were never supplied by the Ops. In such like situation, reliance can be made on the citation of the Hon’ble Supreme Court of India delivered in Civil Appeal No.6895 of 1997 in the case of Modern Insulators Limited versus Oriental insurance Company Limited. The Hon’ble Supreme Court has held that “as the above terms and conditions of the standard policy wherein exclusion clause was included were neither a part of the contract of insurance nor disclosed to the appellant, respondent cannot claim the benefit of the said exclusion clause.”  The same is the position in the judgment of the Hon’ble National Commission pronounced in Oriental Insurance Company Limited versus Charan Dass 2012(3) CPR (NC) 618. In the light of the above citation, we find that the OPs have failed to tender any reliable and cogent evidence in support of his version that the terms and conditions were supplied as no document has been placed on record to show that the terms and conditions were ever made known to the complainant.

 

10.           The learned counsel for the OPs has further contended that the deceased had concealed the material information regarding  he being the chronic alcoholic, as such, the complainant is not entitled to get any insurance claim and it is stated that the claim has been rightly repudiated by the OPs.  To support such a contention, he has cited Life Insurance Corporation of India versus Krishan Chander Sharma 2007(1) CPC 590( (NC) wherein the Hon’ble National Commission has held that the repudiation of the claim as justified where the insured failed to disclose the pre existing disease at the time of getting the insurance policy.  But, in the present case, there is no such situation nor the Ops have proved on record that the deceased was suffering from any of disease at the time of taking the insurance policy.   We may mention here that since in the present case, the OPs have miserably failed to prove any pre existing disease or concealment of the material facts  by the insured at the time of getting the insurance policy, we feel that the above said rulings are at all not helpful to the case of the OPs.

 

11.           The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

 

12.           Now the question arises as to what amount the complainant is entitled as per the policy document. In the document Ex.C-2, it has been clearly mentioned that the policy is only for the amount of Rs.1,00,000/- , whereas the complainant has claimed an amount of Rs.1,50,000/- and has also produced the bills on record as Ex.C-3 to Ex.C-12. As such, we feel that the complainant is entitled to get an amount of Rs.1,00,000/- only from the OPs.

 

13.           In the light of above discussion, we allow the complaint and direct the Ops  to pay to the complainant an amount of Rs.1,00,000/-  along with interest @ 9% per annum from the date of filing of the present complaint i.e. 16.08.2016 till realisation. We further order the OPs to pay to the complainant a sum of Rs.10,000/- being the amount of compensation for mental tension and agony and a sum of Rs.5,000/- being the litigation expenses.

 

14.           This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.

                Pronounced.

                January 11, 2017.

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

                                                       

                                                              (Sarita Garg)

                                                                   Member

 

 

                                                        (Vinod Kumar Gulati)

                                                                   Member