Haryana

Kurukshetra

299/2016

Sanjeev Kumar - Complainant(s)

Versus

LIC - Opp.Party(s)

Prem Pal Sagar

22 Nov 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KURUKSHETRA.

                                                     Complaint Case No.299 of 2016.

                                                     Date of institution: 07.11.2016.

                                                     Date of decision: 22.11.2018.

Sanjeev Kumar aged about 40 years, son of Sh. Uma Dutt, resident of House No.914/2, Azad Nagar, Kurukshetra.

                                                                        …Complainant.

                        Versus

1. Life Insurance Corporation of India, SCO No.9, 10, 11, Sector-17, Kurukshetra through its Branch Manager.
2. Life Insurance Corporation of India, # 489, Model Town, Karnal, through its Divisional Manager. 

….Respondents.

BEFORE     Smt. Neelam Kashyap, President.

                Ms. Neelam, Member.

                Sh. Sunil Mohan Trikha, Member.

Present:     Sh. Prem Sagar, Advocate, for the complainant.   

                Ms.Meenakshi Sharma, Advocate for the OPs.

               

ORDER

                This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Sanjeev Kumar against Life Insurance Corporation of India, the opposite parties.

2.            Brief facts of the present complaint are that the complainant has obtained a LIC’s Health Protection Plus Plan (Table 902) Policy bearing No.177537479 dt. 29.03.2011.  It is alleged that unfortunately on 12.02.2014, the complainant fell ill and was suffering from difficulty in speaking, right sided limbwealan etc. and firstly, the complainant was taken to Aggarwal Nursing Home, Kurukshetra for check up where he was referred to Max Hospital, Mohali.  The complainant got admitted in Max Super Specialty Hospital, Mohali in emergency and after that the complainant got admitted and treated in P.G.I. Chandigarh from 15.02.2014 to 24.02.2014.  It is further alleged that the complainant has spent a sum of Rs.2,00,000/- on his treatment, medicines and other expenses.  It is further alleged that the complainant lodged the claim with the Ops and submitted all the necessary documents but the Ops repudiated the claim of complainant.  So, it is a clear cut case of deficiency in service on the part of Ops and prayed for acceptance of complaint with the direction to Ops to pay the claim amount alongwith interest @ 18% p.a. and further to pay Rs.1,00,000/- as compensation for harassment and mental agony as-well-as Rs.11,000/- as litigation charges. 

3.            Upon notice, the OPs appeared before this Forum and contested the complaint by filing their reply raising preliminary objections with regard to locus-standi; maintainability; cause of action; estoppel; that the present complaint is bad for mis-joinder and non-joinder of necessary parties; that the hospital authorities where the complainant has allegedly taken the treatment is a necessary party which have not been arrayed in the present complaint; that the complainant has concealed the true and material facts from this Forum.  The true facts are that on scrutiny and examination of the hospital treatment form and PGI treatment records for the treatment taken in the period 15.02.2014 to 24.02.2014 submitted for reimbursement to the answering Ops, it has been found that the complainant had history of headache since 2008 and suffering from heart disease (AWMI) An Interial Myocardial Infarction in 2010 which the complainant knowingly, deliberately and with malicious intention did not disclose the same in the proposal form in reply to the question No.2 while taking the policy.  There is no deficiency in service on the part of Ops.  On merits, the objections raised in the preliminary objections are reiterated and so, prayed for dismissal of complaint.

4.             In support of his case, the complainant has tendered into evidence affidavit, Ex.CW1/A and documents Ex.C1 to Ex.C23 and thereafter, closed the evidence.

5.             On the other hand, the counsel of Ops has tendered into evidence affidavit, Ex.RW1/A and documents Ex.R1 to Ex.R6 and thereafter, closed the evidence on behalf of Ops.

6.             We have heard the Counsel for both the parties and perused the record carefully.

7.             The learned counsel for complainant contended that the complainant has taken the health policy from the Ops on 29.03.2011 and had paid premium at that time and was regularly paying the installments.  Unfortunately, on 12.02.2014 the complainant fell ill and admitted in the Max Hospital, Mohali and after that he was got admitted in P.G.I. Chandigarh from 15.02.2014 to 24.02.2014.  The complainant has spent a sum of Rs.2,00,000/- on his treatment, medicines and other expenses.  The complainant has submitted the claim with the Ops and submitted all the necessary documents but the Ops repudiated the claim of complainant vide repudiation letter (Ex.R6) on the grounds of pre-existing illness irrespective of prior medical treatment or advise and total hospitalization period less than 2 hours.  The counsel of complainant contended that the said repudiation of claim is wrong and illegal and prayed that the claim may kindly be awarded.

8.             On the other hand, learned counsel for the Ops contended that at the time of taking the policy, the complainant has filled-up the proposal form, which is Ex.R1 in which he has declared himself to be fit and fine but the complainant was suffering from heart disease before taking the policy, which is clear from the document Ex.R4.  He has also drawn our attention towards the treatment record of P.G.I., Chandigarh, Ex.R3, wherein in the brief summary, the diseases of hypertension, CAD: Old AWNU-2010 and Post PTCA to LAD have been shown to the complainant.  He has also drawn our attention towards the treatment record, Ex.R4 wherein it has been mentioned that “Coronary artery stunting in 2010” was done to the complainant.  The counsel of Ops has placed reliance upon the case law titled as C.N.Mohanraj Vs. NIA, Legal Digest, April, 2013 bearing revision petition No.2314/2012 decided by Hon’ble National Commission on 08.10.2012, wherein in para No.14, it has been held that “Thus, looking from any angle, I have no hesitation in coming to the conclusion that the statement made by the petitioner/insured in the proposal form as to the state of his health was palpably untrue to his knowledge.  Thus, there was clear suppression of the material facts with regard to the health of the insured, and, therefore, respondent was fully justified in repudiating the insurance contract.  Similarly, the counsel of Ops also placed reliance upon the case law titled as Senior Divisional Manager, LIC of India Vs. Smt. Satwant Kaur Sandhu, Legal Digest, April 2011 bearing revision petition No.3138 of 2006, date of decision: 0.01.2011 (NC); Roshan Akhtar Vs. Regional Manager, Zonal Office, LIC, date of decision: 28.10.2014 and Satish Kumar Vs. LIC, Legal Digest, July, 2013 bearing revision petition No.4678/2009, date of decision: 20.05.2013.

9.             From the pleadings, evidence of the case and on perusal of record, it is clear that the policy in question was taken by the complainant in the year 2011, whereas the complainant was suffering from heart problem in the year 2010 i.e. mentioned in the treatment record of P.G.I., Chandigarh.  From the document Ex.R4, it is clear that “Coronary artery stunting in 2010” was done to the complainant.  So, in the facts and circumstances of the case, it is clear that at the time of taking the policy, the complainant was suffering from heart problem and the said pre-existing disease was suppressed by the complainant.  Hence, we are of the considered view that the Ops have rightly repudiated the claim of complainant.

10.            Thus, as a sequel of above discussion, we find no merit in the present complaint and accordingly, the same is hereby dismissed.  A copy of said order be supplied to the parties free of cost.  File be consigned to record-room after due compliance.     

Announced in open court:

Dt.:22.11.2018.  

                                                                        (Neelam Kashyap)

                                                                        President.

 

 

(Sunil Mohan Trikha),           (Neelam)       

Member                             Member.