Madhya Pradesh

StateCommission

FA/13/2181

RAHUL JAIN - Complainant(s)

Versus

LIC - Opp.Party(s)

06 Oct 2023

ORDER

M. P. STATE  CONSUMER  DISPUTES  REDRESSAL  COMMISSION,

PLOT NO.76, ARERA HILLS, BHOPAL

 

                                      FIRST APPEAL NO. 2181 OF 2013

(Arising out of order dated 19.09.2013 passed in C. C. No.19/2011 by District Commission, Sagar)

 

RAHUL JAIN,

S/O LATE SHRI MAHESH JAIN,

R/O 8, NADI ROAD, REHLI

TEHSIL-REHLI, DISTRICT–SAGAR (M.P.).                                                         ….       APPELLANT.

 

Versus

 

LIFE INSURANCE CORPORATION OF INDIA,

BRANCH NO.2, OPPOSITE KULPATI BUNGLOW,

UNIVERSITY ROAD, CIVIL LINE,

SAGAR (M.P.) THROUGH BRANCH MANAGER                                                 ….    RESPONDENT.   

                     

BEFORE:

                  HON’BLE SHRI A. K. TIWARI                  :   PRESIDING MEMBER

                  HON’BLE DR. SRIKANT PANDEY          :   MEMBER

                  HON’BLE SHRI D. K. SHRIVASTAVA     :   MEMBER

                     

COUNSEL FOR PARTIES :

                        Shri Ravindra Tiwari, learned counsel for the appellant. 

                Shri R. N. Chaturvedi, learned counsel for the respondent.            

                  

                                                  O R D E R

                                       (Passed on 06.10.2023)

                   The following order of the Commission was delivered by A. K. Tiwari, Presiding Member:

                  This appeal by the complainant/appellant is directed against the order dated 19.09.2013 passed by the District Consumer Disputes Redressal Commission, Sagar (for short ‘District Commission) in C. C. No. 19/2011 whereby the complaint filed by him has been dismissed.

 2.               Facts giving rise to this appeal, in brief, are that according to the complainant, he had obtained a health protection plus insurance policy no. 355317876 on 15.09.2009 from the opposite party-LIC.  He had

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abdominal pain and therefore he consulted local doctors who advised him to consult specialist. He therefore approached Asian Institute of Gastroenterology, Hyderabad where after some investigations and tests doctor advised him surgery. He remained admitted in the said hospital from 25.03.2010 to 03.04.2010 and underwent surgery on 29.03.2010. He remained under treatment till 15.04.2010. It is alleged that he lodged the claim along with requisite documents with the insurer claiming sum of Rs.1,18,724/-. The insurer vide letter dated 20.05.2010 repudiated the claim on false grounds. The complainant therefore alleging deficiency in service on part of the opposite party-LIC, filed a complaint before the District Commission, seeking expenses incurred in treatment Rs.1,18,724/-, compensation of Rs.1,00,000/- for mental and physical agony, Rs.1,00,000/- along with costs. 

3.                The opposite party LIC in their reply before the District Commission admitting the fact of issuance of insurance policy stated that the policy was issued on non-medical scheme under which no medical examination of the complainant was conducted. The complainant was suffering from the disease since last 10 years and the complainant had obtained the policy by suppressing the material fact of illness in the proposal form dated 15.09.2009. It is submitted that the complainant also did not file the claim within 30 days from the date of discharge from the hospital as per

 

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policy terms and conditions. On account of the above reasons, the claim was rightly repudiated and by doing so, no deficiency in service was committed by the LIC.

4.                After giving opportunity of hearing to both the parties, the consumer complaint has been dismissed by the District Commission vide impugned order.  Feeling aggrieved, the complainant/appellant has preferred the instant appeal.

5.                We have heard arguments advanced by learned counsel for the parties and perused the record.

6.                Learned counsel for the complainant/appellant argued that the LIC repudiated the claim of the complainant on the ground of pre-existing disease but the opposite party failed to produce any evidence in this regard to prove that the complainant was treated before taking the insurance policy. The District Commission relying on the discharge summary of Asian Institute of Gastroenterology has wrongly dismissed the complaint. The burden of proof regarding pre-existing disease of the complainant was on the LIC but the LIC failed to prove the same, even then the District Commission grossly erred in dismissing the complaint. He therefore prays that the impugned deserves to be set-aside and the appeal be allowed.

 

 

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7.                Learned counsel for the opposite party/respondent-LIC vehemently argued that as per discharge summary the complainant was having history of present illness since 10 years and that the material facts relating to previous disease of the life assured were concealed by him and the life assured failed to exercise good faith at the time of submitting the proposal form for issuance of insurance policy in question.  He therefore supported the impugned order passed by the District Commission and argued that the appeal deserves to be dismissed.

8.                To substantiate the complaint and defence, both the complainant and the opposite party filed their respective affidavits before the District Commission and on the side of the complainant set of documents including policy, medical bills was filed, while the opposite party has also filed documents including proposal form and discharge summary. 9.           We have perused the documents filed by the parties. The insurance company has repudiated the claim on the ground of pre-existing disease relying upon the discharge summary of Asian Institute of Gastroenterology, Hyderabad. We have gone through the discharge summary which is at page 51 in the record. The Discharge summary of the complainant of Asian Institute of Gastroenteroloy, Hyderabad dated 03.04.2010 clearly specified that “Patient presented with history of recurrent

 

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abdominal pain and fullness since last 10 years with increase in frequency over past 5 months, it is followed by vomiting after which patient gets relief. Patient has lost 10kgs weight over last 6 months, history of general weakness for 6 months.  Patient was treated empirically with ATT (9 months) for suspected abdominal tuberculosis 10 years ago.  No history of altered bowel habits/Jaundice. No history of diabetes/hypertension/any previous surgeries”. This clearly goes to show that the complainant was suffering from recurrent abdominal pain since last 10 years for which surgery was performed.

10.              At page 46, there is proposal form dated 14.09.2009 filed by the opposite party LIC. The said proposal form was filled by the complainant at the time of taking the policy. In the said proposal form, under the head E Health Details and Medical Information, the complainant has given answer in negative to the queries made with regard to his health condition. Thus at the time of taking the policy, he had suppressed the material information regarding his health.

11.              Thus, evidence available on record clearly indicate that the insured was suffering from pre-existing disease and he suppressed this material information in the proposal form in order to obtain the insurance policy. For the foregoing reasons, we are of the considered opinion that the

 

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repudiation of claim by the respondent insurance company is justified. The District Commission has not committed any error in dismissing the complaint. The impugned order is accordingly affirmed.

12.              In the result, the appeal is dismissed.  No order as to costs.

 

 

1. K. Tiwari)         (Dr. Srikant Pandey)      (D. K. Shrivastava)

    Presiding Member               Member                            Member