Haryana

Ambala

CC/12/2018

Smt Kewla Devi - Complainant(s)

Versus

LIC - Opp.Party(s)

Sandeep Kashyap

12 Jun 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA.

 

                                                                      Complaint case no.        : 12 of 2018

                                                          Date of Institution         : 04.01.2018

                                                          Date of decision    :  12.6.2019.

 

 

 Smt. Kewla Devi w/o Late Sh. Ram Manorath R/o H. No.5, Indra Park, Ambala Cantt.

    ……. Complainant.

          Vs.

1. Senior Divisional Manager, Divisional Office, LIC of India, Model Town, Karnal.
2. The Chief Manager, Branch Office, LIC of India, Jawahar Lal Nehru Marg, Ambala Cantt.
3. Smt. Vijay Kumari, (LIC agent No.04891-161), r/o H.No.213-L, Ajit Nagar, Ambala Cantt.

 

 .…. Opposite Parties.

 

 

Complaint U/s 12 of the Consumer Protection Act, 1986

 

 

Before:        Smt. Neena Sandhu, President,                                            

                   Smt. Ruby Sharma, Member,

Shri Vinod Kumar Sharma, Member.

                  

 

Present:        Sh. Sandeep Kashyap, Advocate, counsel for complainant.

 Sh. Shubham Aggarwal, Advocate, counsel for OPs No.1&2.

Sh. R.K. Jindal, Advocate, counsel for OP No.3.

 

 

Order:        Smt. Neena Sandhu, President

Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘Ops’) praying for issuance of following directions to them:-

1. To pay Rs. 60,000/- being the death claim under the policy alongwith the bonus accrued thereupon along with penal interest@15% p.a. for the period of default of the payment of the death claim.
2. To pay Rs.25,000/- as compensation for the mental agony and physical harassment suffered by her.
3. To pay Rs. 11,000/- as litigation charges.
4.  

any other relief whichthis Hon’ble Forum may deemfit.

 

                   In nutshell, brief facts of the present complaint are that the husband of the complainant  late Shri Ram Manorath was employed as a Head Mali since 08.02.1990 with the Municipal Corporation, Ambala Cantt. The OP No.3 had approached and motivated the deceased husband of complainant to take insurance of Rs. 60,000/-, upon which, he got insured himself from the OP for a sum of Rs. 60,000/- vide policy no.177950470 under table and term 14-11 with monthly mode of payment of premium under the salary saving scheme of the OP. The said policy commenced with effect from 08.10.2013. The OP No.3, had obtained his signatures on the unfilled proposal form, which was filled in later on by it and on the basis of said proposal form, the OP No.2 issued the policy in question. During the subsistence of the above said policy, the policy holder died on 18.04.2016, due to breathlessness. The complainant being the nominee under the policy, approached the OP No.2, for the death claim   and all the relevant documents were duly submitted to it. But the OP No.1 vide its letter no. claim/REP/M/Con-3years/16-17/102 dated 23.03.2017 repudiated the death claim. The complainant felt aggrieved by the said decision of the OP No.1 and visited the office of OP No.2 at Ambala Cantt. and requested for the payment of the death claim, but all in vain. By not paying the genuine claim amount, the OPs have committed deficiency in service. Hence, the present complaint.

2.               Upon notice, OPs No.1 & 2 appeared through counsel and tendered written version, raising preliminary objections regarding maintainability and jurisdiction. On merits, it is stated that the Deceased Life Assured (hereinafter referred to as DLA) had taken three other policies apart from policy no.1177950470 i.e. policy no. 177950671, 171846710 & 177950786. The OP Corporation had immediately disbursed the claim of Rs. 45,650/- to the complainant under policy no.171846710 through NEFT on 05.07.2016, as the duration of policy was more than three years from the date of commencement of risk. It is stated that the DLA did not disclose the material facts regarding his health at the time of filling up the proposal form under policy. Claim intimation letter and claim forms under the above mentioned policies and on receipt of the same, the OP Corporation examined the claim raised by the complainant in accordance with the provision of Section 45 of the Insurance Act, 1938, The OP Corporation while examining the claim paid relies upon claim investigation report & claim form no. 3816 i.e. the treatment certificate issued by the attending physicians. As per the treatment certificate issued by the physician Dr. C.K. Mittal, Mittal Nursing Home, Ambala Cantt, the insured had himself disclosed that he had suffered from breathlessness for 4 years. In the said hospital, he was admitted on 11.04.2016, in serious condition and was treated for COPD (Chronic Obstructive Pulmonary Disease). Prior to this, he was also admitted in Amrit Sanjivni Hospital, Ambala on 18.12.2015 with complaint of Cough, Breathlessness and Respiratory failure with duration of illness for 2-3 years with history of frequent admission at other hospitals. Policy was taken on 08.10.2013 and prior to that, the DLA was not having good health prior to taking policy. However, at the time of taking the policy, the DLA had answered the questions regarding his ailment in negative. Thus, the OP Corporation had rightly repudiated the claim of the complainant and intimated her through letter dated 23.03.2017. Thus, there is no deficiency in service on the part of the OPs and prayed for dismissal of the present complaint.

Upon notice, OP No. 3 appeared through counsel and tendered written version, raising preliminary objections qua complaint is not maintainable; no cause of action; suppressed material facts; bad for non-joinder and mis-joinder; the complaint is false, frivolous. On merits, it is stated that the DLA filled the proposal form for taking the policy in question on 07.10.2014 and at that time, he was suffering from the disease of breathlessness and had taken treatment from the doctors and the same was the cause of his death. However, the DLA did not disclose about the said disease at the time of filling the proposal form intentionally and had given false answers to the question mentioned in the proposal form regarding his health. Had the DLA disclosed about the said disease, in the proposal form, the OPs No.1 & 2 would not have issued the policy in question to him. The OPs No.1 & 2 came to know about the disease of breathlessness suffered by the DLA only from the Form No.3816 which is produced by the complainant to the OPs No.1 & 2 for settlement of claim. As such OPs No.1 & 2 rightly repudiated the claim under the policy in question. Thus, the complaint of the complainant is liable to be dismissed and there is no deficiency in service on the part of OPs.

3.                The counsel for the complainant tendered affidavit of the complainant as Annexure CW-1/A alongwith documents as Annexure C-1 to C-4 and closed the evidence. On the other hand, counsel for the OPs No. 1 & 2 tendered affidavit of Shri Surjit Singh, Administrative Officer, LIC, Jeevan Jyoti Building, Ambala Cantt. as Annexure OP-1/A alongwith documents as Annexure OP-1/1 to OP-1/5 and closed the evidence. The learned counsel for the OP No.3 tendered affidavit as Annexure OP-3/A and closed the evidence.

4.                We have heard the learned counsel of the parties and carefully gone through the case file and also the written arguments filed by the learned counsel for the complainant and the case laws referred by the ld. Counsel for the parties.  

5.                The learned counsel for the complainant has argued that DLA had taken an insurance policy bearing No.177950470 from the OPs No.1 & 2 for sum assured of Rs.60,000/-, having commencing date 08.10.2013. During the subsistence of the above said policy the policy holder died on 18.04.2016, due to cardiac arrest. The complainant being the nominee lodged the claim with OPs No.1 & 2 but they repudiated her genuine claim vide letter dated 23.03.2017. The said act of the OPs amount to deficiency in service. To support his contention, the ld. counsel for the complainant relied upon the case laws titled Life Insurance Corporation of India & Ors Vs. Ram Murti, 2010 (1) CLT, Page No.333 (NC); Life Insurance Corporation of India Vs. S. Hymavathi, III 1995 CPJ, Page No.42 (NC); SBI Life Insurance Co. Ltd. Vs. Harvinder Kaur & Anr., III (2014) CPJ, Page No.552 (NC); Sr. Divisional Manager, LIC & Ors. Vs. Smt. J. Vinaya, I (2003) CPJ, Page No.50 (NC); LIC Vs. Budh Ram, 2004 (1) CLT, Page No.125 (SC) and Abdul Latheef & Others Vs. The LIC & Ors., 2014 (3) CLT, Page No.386 (NC).

                    The learned counsel for OPs No.1 & 2 has argued that the DLA had taken the policy in question by concealing the material facts regarding his health, therefore, the complainant is not entitled to get any benefit as per the terms and conditions of the policy and the OPs No.1 & 2 have rightly repudiated the claim of the complainant. To support its contention, the ld. counsel for the OPs No.1 & 2 relied upon the case laws cited in Revision Petition No.2482 of 2008, Decided on 31.7.2015 titled as LIC & Ors Vs. Surinder Kaur (NC) and Revision Petition No.602 of 2009, decided on 10.12.2014 titled LIC Vs. Murala Siva Parvathi.

                   The learned counsel for the OP No.3 has argued that at the time of taking the policy in question, the DLA had duly filled and signed the proposal form, but he did not disclose the factum of suffering from disease of breathlessness and had given false answers to the questions mentioned in the proposal form regarding his health. He forwarded the proposal form of the complainant to the insurance company, thus, no deficiency in service is attributable against him and the complaint filed against him may be dismissed with cost.

6.       Admittedly, the DLA had taken the policy in question for sum assured of Rs.60,000/- on 08.10.2013 from the OPs No.1 & 2. From the perusal of copy of proposal form Annexure C-1, it is evident that the questionnaire regarding the personal history with regards to health of DLA contained in column No.11. The DLA had given reply to the questions mentioned at Sr. No.a to h & j in negative and to the question at Sr. No.i “What has been your usual state of health”, it has been written “good”. The plea of the OPs is that the DLA was suffering from pre-existing disease before taking the policy in question but he did not disclose the said facts at the time of taking the policy in question. To corroborate this fact the OPs have placed on record the photocopy of prescription slip/patient summary of Amrit Sanjivani Hospital, Ambala, Annexure OP-1/5 and photocopy of the treatment certificate issued by Mittal Nursing Home, Ambala, Annexure- OP-1/4. From the perusal of the above referred prescription slip, it is evident that the DLA was admitted in the said hospital on 18.12.2015 and was treated for COPD (Chronic Obstructive Pulmonary Disease) and breathlessness. In the said prescription slip, it is also mentioned that the DLA was suffering from the said disease for the last two years. From the treatment certificate issued by Mittal Nursing Home, Ambala, it is apparent that the DLA was admitted in the said hospital on 11.04.2016 in serious condition & was treated for COPD (Chronic Obstructive Pulmonary Disease) and was referred to GHMC, Sector 32, Chandigarh. It may be stated here that except the prescription slip issued by Amrit Sanjivani Hospital, Ambala and certificate issued by Mittal Nursing Home, Ambala, the insurance company has not been able to lead any evidence to prove that the DLA had taken treatment from any other hospital prior to taking the policy in question. The affidavit of the treating doctor, who has recorded the patient history of the DLA, has not been produced on record. The entire defence revolves around the copy of the prescription slip which is not supported by any document to show that the complainant was taking the treatment for the disease referred to above, for the last two years from any hospital. Even in the certificate of hospital treatment Annexure C-2, in Column No.11 i.e. history of illness as per record, the Sr. Resident Doctor of the Department of Medicine, GMCH, Chandigarh, who recorded the history of the DLA, had not mentioned, since how long the DLA was suffering from the problem of breathlessness and COPD. So merely on the basis of past history mentioned in the photocopy of the prescription slip, which is not supported by any cogent evidence, it cannot be said that the DLA was taking treatment from some other hospital prior to taking the policy in question. In case SBI Life Insurance Co. Ltd. Vs. Harvinder Kaur & Anr. (Supra), wherein, the Hon’ble National Commission has held that Concerned doctor who allegedly treated insured and recorded that patient was admitted with history of pulmonary hypertension for last two years and was not examined by petitioner to prove photocopy of discharge card relied upon by the petitioner nor affidavit of doctor has been filed – Foras below were right in declining to rely upon the photocopy of discharge card produced by petitioner to establish that petitioner while obtaining insurance policy concealed the fact that he was suffering from pulmonary hypertension- Repudiation not justified. In the case LIC of India Vs. Joginder Kaur 2005 CPJ-78, the Hon’ble National Commission has held that simple allegations made by the petitioner that the deceased was alcoholic; was suffering from diabetes mellitus, and jaundice, etc. would not be sufficient. The  unproved case history recorded  by some person on the date of admission of Sh. Bachan Singh, the deceased, would not be cogent and convincing evidence to repudiate  the claim unless it was coupled  with medical report  for the treatment prior  to submission of proposal form. Further in the case of Religare Health Insurance Co. Ltd. Vs. Swarn Kanta Jain 2018(30 CLT-441, the Hon’ble State Commission Punjab has observed that the history recorded in the discharge summary cannot be taken as an evidence. Mere averments in the discharge summary is not sufficient to conclude that insured was in the knowledge that she was suffering from the disease of sacroidosis with unveitis-It is also matter of concern that in India number of people continued to live for number of years without notice of any disease for which they are the suffered and it comes to light only during investigation or at the time of treatment-claim was wrongly rejected.

7.                Keeping in view that the ratio of the law laid down in the aforesaid judgments and the facts and circumstances of the present case, we are of the considered view that the insurance company has not been able to prove the allegation on the basis of which they have repudiated the claim of complainant. Thus the repudiation of the claim done by insurance company is held to be unjustified and amounts to deficiency in service on its part. It is not disputed that the DLA was insured for a sum of Rs.60,000/- and complainant was appointed as a nominee under the policy in question. Therefore, the OP No.1 & 2 are liable to pay the said amount to the complainant being nominee alongwith interest. The OPs No.1 & 2 are further liable to compensate the complainant for the mental agony and physical harassment caused to her alongwith the litigation expenses. It may be stated here that neither any specific allegations has been levelled by the complainant against the OP No.3, nor it has been proved, therefore, complaint filed against him is liable to be dismissed.

8.                 In view of the aforesaid discussion, we dismiss the present complaint against the OP No.3 and allow the same against OPs No.1 & 2. The OPs No.1 & 2 are directed in following manner:-

1. To pay of Rs.60,000/- to the complainant alongwith interest @7% per annum w.e.f. 23.3.2017 i.e. the date of repudiation of claim, till its realization.
2. To pay Rs.5,000/- as compensation for mental agony and physical harassment suffered by the complainant.
3. To pay a sum of Rs.3000/- as cost of litigation.

 

9.                The OP No.1 & 2 are further directed to comply with the order within the period of thirty days from the date of receipt of certified copy of this order. Certified copies of this order be sent to the parties concerned, free of costs, as per rules. File be indexed and consigned to the Record Room.

Announced on:12.6.2019.

 

 

 

          (Vinod Kumar Sharma) (Ruby Sharma)     (Neena Sandhu)

              Member                        Member             President