Before the District Consumer Disputes Redressal Forum, Rohtak.

                                                                    Complaint No. : 548.

                                                                    Instituted on     : 18.09.2017.

                                                                    Decided on       : 13.06.2019.

Smt. Anita, aged 40, w/o Sh. Surender Singh s/o Sh.Chand Ram, resident of village kharawar, Pana Durgan, Tehsil and District Rohtak.
 

                                                                    ..………..Complainant.

                                                Vs.

Life Insurance Corporation of India having its Divisional Office at 3,4,5, SCO  Sector-1, Rohtak through its Divisional Manager.

……….Opposite party.

COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.

BEFORE:  SH.NAGENDER SINGH KADIAN, PRESIDENT.

                   SH. VED PAL, MEMBER.

                   DR. RENU CHAUDHARY, MEMBER.

Present:       Sh.Rajesh Sharma, Advocate for the complainant.

                   Sh. Puneet Chahal, Advocate for opposite party.

                                      ORDER

NAGENDER SINGH KADIAN, PRESIDENT:

1.                          Brief facts of the case are that the complainant’s husband had got his life insured with the respondent for a sum of Rs. 500000/- vide policy No. 178747331 in the year 2012. That Sh.Surender Singh was expired on 09.06.2016 due to brain stroke on 05.06.2016. After his death, complainant filed the claim alongwith all the requisite documents with the opposite party to make the payment of sum assured  to the complainant. That complainant has spent an amount of Rs.223614/-  on the treatment of her husband at Paras Hospital at Gurgaon. But the opposite party has declined the claim of the complainant on the plea of suppression of material facts on 07.02.2017.  That the act of opposite party is illegal and there is deficiency in service on the part of opposite party. As such, it is prayed that opposite party may kindly be directed to pay Rs.500000/- as amount of insurance alongwith interest @ 18% per annum from the date of filing of complaint till realization and Rs.100000/- as compensation, Rs.11,000/- as litigation expenses and Rs.1000/- as misc. expenses to the complainant.

2.                          After registration of complaint, notice was issued to the opposite party. Opposite party in its reply has submitted that the opposite party issued a policy bearing no.178747331 on the life of Sh. Sruender Singh s/o Chand Ram with date of commencement 21.03.2012, nominee is Anita. That DLA was not in good health condition at the time of revival of above insurance policy. He had not disclosed this adverse history in the form no.680(Declaration of Good health) which was taken at the time of revival of the policy. The competent authority has repudiated the liability under the above policy on genuine ground. That the aforesaid policy has not completed three years from the date of revival i.e. 29.04.2016, which is prior to the date of death of LA. That as per form no.3784 and 3816 of Paras Hospital, LA was k/c/o Hypertension for last 5 years but he had not disclosed this information while reviving the policy. LA  was suffering from seizures, shock, diabetes dyslipidemia, CVA-post circulation stroke as per 3784 & 3816 and medical certificate from Paras Hospital, Gurgaon. This suppression of material facts, which have had a bearing on the granting of risk, was clearly done with intent to mislead the Corporation. Hence, it has been decided to repudiate all the liabilities and in terms of provisions of section 45 of the Insurance Act, 1938, an amount of Rs.150247/- was refunded on 09.03.2017 as an amount of premiums deposited at the time of Revival and paid up value of the policy towards full and final settlement of above claim.  All the other contents of the complaint were stated to be wrong and denied and dismissal of complaint has been sought.

3.                          Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C23 and has closed his evidence on dated 05.12.2018. Ld. counsel for the opposite parties tendered affidavit Ex.RW1/A and documents Ex.R1 to Ex.R10 and closed his evidence on 08.05.2019.

4.                          We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.

5.                          After going through the file and hearing the parties it is observed that the respondent officials believed on the certificate issued by Paras Hospital which is Ex.R7 and after considering this document they came to the conclusion that the deceased was suffering from Hypertension and the deceased LA has submitted false information at the time of taking the policy. As per Ex.R2 the following questions were given in negative by the complainant:

 These are the main grounds on which the claim of the complainant was repudiated. As per respondent officials, all the questions were answered as ‘No’ by the deceased LA at the time of purchasing of the policy. After perusal of the documents placed on record by the parties, we came to the conclusion that deceased LA has not submitted any false and fabricated information with the respondent because the respondent officials failed to prove that the deceased LA was ever operated for accident or any other injuries. They also failed to prove that the deceased was suffering from any illness/disease which required treatment for a week or more.  No supporting evidence has been placed on record by the opposite party to prove that the deceased LA has disclosed any wrong fact about his health.

5.                          As per document Ex.C10, Case summary issued by the Paras Hospital, it has been mentioned that the deceased was diagnosed for Posterior Fossa Infarct, comatose on ventilator, DM-II, Dyslipedemia, Shock, Seizure and as per examination report, the deceased was having temperature-104.4F, Pulse rate 116/Min, BP 170/60mmHg, meaning thereby the blood pressure of the deceased was normal at the time of his admission.  As per this history of the patient, he was shifted from PGIMS to Paras Hospital Gurgaon and he was a known case of DM-II. The DM-II is not a critical illness(incurable or critical disease). Moreover, as per document Ex.R7, issued by Paras Hospital, it has been disclosed that the deceased was a known case of Hypertension but this fact has not been mentioned in the case summary Ex.C10 so there is a contradictory view taken by the Paras Hospital. Moreover, as per Ex.R7, Hypertension was disclosed before the treating doctor by the relative of the deceased LA. So without any supporting document, it cannot be believed that the deceased was suffering from DM-II and hypertension at the time of his death, whereas the patient was admitted in the Paras Hospital on 05.06.2016 and discharged on 09.06.2016. The respondent officials also failed to provide the previous history of his treatment or any supporting evidence to prove that the deceased was suffering from any ailment prior to 05.06.2016. Regarding these facts, Hon’ble National Commission, New Delhi in order dated 31.05.2019 titled as  Reliance Life Insurance Co. Ltd. Vs. Tarun Kumar Sudhir Halder has held that: “The onus to prove the pre-existing disease lies on the Insurance Company and no supporting documents have been filed by the Insurance Company in support of their assertion”. The law cited above is fully applicable on the facts and circumstances of the case. As such, the repudiation of claim by the opposite parties is not justified and the complainant is entitle for the claim amount as per policy. It is also on record that as per document  Ex.R1, an amount of Rs.150247/- towards policy no.178747331 has already been paid by the opposite party to the complainant through Transaction No.8727 dated 09.03.2017. 

6.                          In view of facts and circumstances of the case, complaint is allowed and it is directed that opposite party shall pay the claim amount of Rs.500000/- less Rs.150247/- i.e. to pay Rs.349753/-(Rupees three lac forty nine thousand seven hundred fifty three only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 18.09.2017 till its actual realization and shall also to pay Rs.5000/-(Rupees five thousand only) as compensation and Rs.5000/-(Rupees five thousand only) as litigation expenses to the L.Rs of life assured Sh.Surender Singh, which shall be disclosed by the complainant before the opposite party within one week and thereafter, the opposite party shall pay the awarded amount to the L.Rs. of deceased L.A. in equal share within one month from the date of decision. It is also made clear that the amount after disbursement on account of minors(if any), should be deposited in any nationalized bank till their majority and will be paid to them on attaining the age of majority.

7.                         Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.

Announced in open court:

13.06.2019.

                                                          ................................................

                                                          Nagender Singh Kadian, President

                                                          ..........................................

                                                          Ved Pal Hooda, Member.

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                                                          Renu Chaudhary, Member.