BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 233 of 2016
Date of Institution : 14.9.2016
Date of Decision : 30.5.2017
Smt. Sukhi Devi, aged about 48 years widow of Shri Ramji Lal, resident of village Chakkan, Tehsil Rania, District Sirsa.
….Complainant.
Versus.
1. Life Insurance Corporation of India, through its Divisional Manager, Divisional Office at Rohtak.
2. Branch Manager/ Principal Officer, LIC of India, Branch office at Mandi Dabwali (situated near State Bank of India, Chautala Road, Mandi Dabwali, Tehsil Dabwali, District Sirsa.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SMT. RAJNI GOYAT ………PRESIDING MEMBER.
SH. MOHINDER PAUL RATHEE ……MEMBER.
Present: Sh.P.K. Mehta, Advocate for the complainant.
Sh.K.K.Relan, Advocate for the opposite parties.
ORDER
The case of the complainant in brief is that husband of the complainant namely Ramji Lal son of Purkha Ram, resident of village Chakkan had purchased one policy of Rs.1,00,000/- from opposite party-corporation vide LIC policy No.178784585 on 15.11.2013 under Money Pay Back Scheme of the op-corporation and deposited installment in this regard on 15.11.2013. The complainant is nominee of the life assured. Unfortunately the husband of complainant died on 29.5.2014 and after his death, the complainant being nominee filed all the requisite documents to the opposite party for payment of insured sum but the op has not given the reply and ultimately the op vide letter dated 13.4.2015 has repudiated the claim of the complainant, which is wrong, illegal, against law and facts and same is liable to be set aside. It is further averred that Ramji Lal has not concealed anything from opposite party while getting the insurance policy. That it is also well settled law that once the LIC has accepted premium and having entered into an agreement without verifying fact, insurance company cannot wriggle out from the liability merely by saying that contract was made by concealment. The complainant is legally entitled to get the claim of the insurance alongwith interest @18% per annum from due date till the final realization besides compensation of Rs.20,000/- for harassment etc. That even thereafter the complainant approached and requested the ops to make the payment of insurance with other benefits but all in vain and ops have finally refused to admit the claim of the complainant about two days back. Hence, this complaint.
2. On notice, opposite parties appeared and filed written statement taking preliminary objections regarding maintainability; cause of action; suppression of material facts; no consumer dispute is made out and that complainant did not avail the departmental remedy of filing representation against the repudiation of the claim before the Zonal Office, New Delhi before filing this complaint and that complaint is not within the period of limitation. On merits, it has been submitted that ops issued a policy No.178784585 to Shri Ramji Lal son of Shri Purkha Ram and date of commencement of policy was 15.11.2013, under Plan and Term: 75-20-20 for sum assured of Rs.1,00,000/- and as per the record of ops, the name of nominee in the policy is Sukhi Devi i.e. complainant. It has been further submitted that para no.2 of the complaint is wrong and denied to the extent that repudiation is wrong and illegal because the competent Authority has repudiated all liability under the policy on account of the deceased having withheld correct information regarding his health at the time of effecting the assurance with the ops. As the deceased life assured was diagnosed of severe anemia with bleeding tendency, chest infection and respiratory distress from Sarvodya Multi speciallity Hospital, Hisar before he proposed for above said policy. In this connection, in the proposal for insurance dated 15.11.2013 signed by the deceased on 15.11.2013, the deceased had answered the following questions as under:-
- During the last five years, did you consult a medical practitioner for any ailment requiring treatment for more than a week?
Answer – No-
- Have you ever been admitted to any hospital or nursing home for general check up, observation, treatment or operation?
Answer- No-
- Have you remained absent from place of work on ground of health during last five years?
Answer- No-
- Are you suffering from or have ever suffered from diabetes, tuberculosis, high BP, low BP, Cancer, Epilepsy, Hernia, Leprosy or any other disease?
Answer- No-
- Are you suffering from or have ever suffered from ailment for pertaining to lever, stomach, heart, lungs, kidney, brain or nervous system.
It has been further submitted that all these answers were false as the ops hold indisputable proof (all medical leave along with medical certificate since November, 2011) to show that the DLA was diagnosed of severe anemia with bleeding tendency, chest infection and respiratory distress from Sarvodaya Multispecialty Hospital, Hisar before the proposal of this policy. The deceased Ramji Lal did not disclose these facts in his proposal instead he gave answer therein as stated above. The competent authority has repudiated the liability under the above policy on genuine ground. Hence, nothing is payable under the policy. Remaining contents of the complaint have also been denied.
3. In evidence, complainant produced her affidavit Ex.C1, death certificate of deceased Ramji Lal Ex.C2, copy of repudiation letter dated 13.4.2015 Ex.C3, copy of claim form Ex.C4, copy of policy schedule Ex.C5. On the other hand, ops produced affidavit Ex.R1, copy of policy Ex.R2, copy of repudiation letter Ex.R3, copy of proposal form Ex.R4, copy of investigation report Ex.R5 and copies of treatment records etc. Ex.R6 to Ex.R19.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. There is no dispute that husband of complainant namely Ramji Lal, since deceased had obtained an insurance policy from the opposite parties on 15.11.2013 and name of nominee in the policy in question is mentioned as Smt. Sukhi Devi i.e. complainant. The premium of Rs.699/- was to be paid by the life insured on monthly basis. The sum assured amount in the policy is mentioned as Rs.1,00,000/-. It is also not in dispute that life assured paid premium till his death i.e. he paid premium for seven months. The life assured Ramji Lal expired on 29.5.2014 as is evident from the death certificate Ex.C2. The claim submitted by the complainant for the death claim of her husband has been repudiated by the opposite parties vide letter dated 13.4.2015 on the ground that deceased life assured was diagnosed of severe anemia with bleeding tendency, chest infection and respiratory distress from Sarvodaya Multispecialty Hospital, Hisar before he proposed for the above policy and that he had made incorrect statements and withheld correct information regarding his health at the time of taking policy. To justify the repudiation of the claim of the complainant, the ops have produced report of Sh. Ashwani Sethi ABM (S) LIC of India as Ex.R5 wherein it is mentioned that “case may be doubtful due to sick leave of last three year before commencement of policy”. The opposite parties have also produced copy of certificate of Dr. Jagmohan Singla, Medical Superintendent of Sarvodya Multispecialty Hospital, Hisar dated 29.6.2012 as Ex.R7 wherein it is mentioned that “It is to certify that Mr. Ramji Lal s/o Sh. Purkha Ram aged 50 Y/M, R/o VPO Chakkan, Teh. Rania, Distt. Sirsa was admitted on 27th June 2012 Vide IPD No.20738/6/12 with diagnosis of Severe Anaemia with bleeding tendency with chest infection with respiratory distress. Besides this, the opposite parties have also produced copies of medical records of Ramji Lal for some other diseases as Ex.R6, Ex.R8 to Ex.R11, copy of leave record Ex.R12, copy of medical certificate Ex.R13 and copies of medical records as Ex.R14 to Ex.R20 to prove that deceased Ramji Lal was suffering from various diseases before taking of the policy in question and had taken leave from his department and that he gave wrong answers to the questions regarding his health in the proposal form. However, the opposite parties have failed to substantiate their plea with reliable, relevant and cogent evidence. No affidavits of the doctors who treated the husband of the complainant for the alleged diseases have been placed on file. Even no affidavit/ evidence of the agent who filled the proposal form (Ex.R4) has been placed on file. The agent who filled in the proposal form was the best person to prove that he asked specific questions about health of the insured at the time of proposal but he gave wrong answers. Without examining the agent who filled in the proposal form, it cannot be said that deceased life assured withheld the correct information regarding his health. Moreover, the disease of severe anemia with bleeding tendency with chest infection with respiratory distress as mentioned in the copy of certificate dated 29.6.2012 Ex.R7 has no concern with the cause of death of the life assured as he died on 29.5.2014 due to heart attack and there is nothing on record to prove that life assured was a patient of heart and was taking treatment for the said disease before taking of the policy in question. The other diseases i.e. hernia, COPD, backache L/S spine, bronchitis and renal stone etc. mentioned in the medical records produced by the ops have also no nexus with heart attack which is the cause of death of the life assured. Moreover, as already mentioned above the said medical records is not proved by leading cogent and reliable evidence as no affidavit of any treating doctor has been placed on file. The taking of excess leave by a service man is also no ground for rejection of the claim. The answer mentioned against the column No. 11 (i) that “what has been your usual state of health” in the proposal form Ex.R4 is not readable. Hence, it is not clear what is written against this question. The Investigator appointed by the opposite parties has also not out rightly rejected the claim of the complainant and has only mentioned that case may be doubtful due to sick leave of last three year before commencement of policy. In our considered opinion the cause of death is heart attack and not any pre-existing disease and the Investigator has created doubt in column No.15 of the report Ex.R5, therefore, benefit of doubt goes in favour of the complainant. The authority cited by learned counsel for complainant in case titled as Birla Sun Life Insurance Co. Ltd. Vs. Kiran Prafull Bahadure, I (2015) CPJ 473 (NC) is fully applicable to the facts and circumstances of the present case as in that case also it was held that only reason i.e. suppression of pre-existing disease on account of which claim of complainant had been repudiated by petitioner company could not be substantiated. The authorities cited by learned counsel for the opposite parties in cases titled as LIC of India Vs. Jyothi Sudhir, Revision Petition No.1134 of 2016 and Ritesh Chopra & anr. Vs. Tata AiaLife Insurance Co. Ltd. revision petition No.1052 of 2015 decided on 19.1.2016 are not applicable in this case. In these circumstances, we are of the considered view that opposite parties have wrongly and illegally repudiated the genuine claim of the complainant.
6. Learned counsel for the opposite parties has contended that vide repudiation letter dated 13.4.2015, it was suggested to the complainant that if she is not satisfied with the decision of the ops then she may send her representation within three months for consideration of her claim to Zonal Office but the complainant has not availed this opportunity and has directly filed the present complaint and as such the present complaint is not maintainable. But we are not convinced with this argument because by not filing any representation against the repudiation letter, the right of the complainant to file complaint before this Forum is not forfeited. As such this contention is hereby repelled.
7. Thus, as a sequel to our above discussion, we allow the present complaint and direct the opposite parties to pay a sum of Rs.1,00,000/- i.e. amount of sum assured to the complainant within a period of one month from the date of receipt of copy of this order. We also direct the opposite parties to pay a sum of Rs.10,000/- as compensation including litigation expenses to the complainant. This order should be complied by the opposite parties jointly and severally within a period of one month, failing which complainant will be entitled to interest @8% per annum on the amount of sum assured i.e. Rs.1,00,000/- from the date of filing of present complaint i.e. 14.9.2016 till actual realization. A copy of this order be supplied to the parties free of cost. File be consigned to record room after due compliance.
Announced in open Forum. Presiding Member,
Dated: 30.5.2017. Member. District Consumer Disputes
Redressal Forum, Sirsa.
