Delhi

North East

CC/273/2015

Kamla Devi - Complainant(s)

Versus

Life Insurance Corporation of India - Opp.Party(s)

25 Oct 2018

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No.273/15

 

In the matter of:

 

	Kamla Devi W/o Late Yograj R/o B-84, Pratap Nagar Village Saboli-Delhi Also At: R/o House No. 324, Saboli Village Mandoli, Delhi-110093.	Complainant
	Versus
	The Branch Manager Life Insurance Corporation Unit 11M, 13-14, Plot No. 487 Julfe Bengal Main, GT Road Dilshad Garden, Delhi-110095	Opposite Party

 

DATE OF INSTITUTION:      JUDGMENT RESERVED ON:               DATE OF DECISION      :

04.08.2015 22.10.2018 25.10.2018

 

N.K. Sharma, President

Ms. Sonica Mehrotra, Member

 

Order passed by Ms. Sonica Mehrotra, Member

ORDER

1. The genesis of the present complaint in terms of factual matrix laid down by the complainant is that her deceased husband Yograj (DLA) was working as a driver with a private tourist company namely Bharat Tourist Pvt Ltd and had taken Jeevan Saral Policy bearing No. 124246315 from OP w.e.f 18.03.2008 up to 18.03.2023 on payment of premium of Rs. 2426/- payable half yearly as opted for by him. The DLA paid three premiums of Rs. 2426/- each to OP in March 2008, September 2008 and March 2009 and renewal premium receipts have been attached to this effect. As per the policy conditions, in the event of death of the DLA, Rs. 1Lac was payable to his nominee who in the present case is the complainant herein in capacity of his wife. The DLA expired on 17.06.2009 in GTB Hospital due to heart attack at the age of 55 years. The complainant lodged a death claim with the OP on 19.08.2009 stating therein that he suffered a heart attack a day before his death when he was complaining of chest pain and was admitted at GTB Hospital. The complainant also filed letter dated 14.12.2009 from the employer of the DLA with the OP for process of claim. However the OP neither reimbursed the said claim nor repudiated the same despite several follow up letters written by the complainant dated 28.11.2009, 21.04.2010, 15.05.2010, 21.06.2010, 22.08.2010 and finally a legal notice dated 04.06.2015. The complainant personally visited the office of OP but the OP gave mere assurances to the complainant to enquire in to the matter and to reimburse the claim after completion of official formalities but did not process the claim. Therefore the complainant was constrained to file the present complaint alleging negligence and deficiency of service on the part of OP and dishonest intention of not making payment of legitimate dues of the complainant and has prayed for issuance of directions against the OP to release the claim of Rs. 1,00,000/-  alongwith interest @18% from the date of claim till realization in favour of the complainant alongwith Rs. 1,00,000/- as compensation for mental agony and harassment and Rs. 20,000/- as cost of litigation.

Complainant has attached copy of D/L and employment proof of her deceased husband (DLA), copy of death certificate of DLA issued by MCD Delhi, copy of death certificate of DLA issued by GTB Hospital, copy of policy schedule of OP alongwith premium receipt and premium renewal receipts, copy of claim form with statement of claimant dated 19.09.2009, copy of certificate by employer dated 31.07.2009 alongwith covering letter as employment proof by Managing Director, copies of letter dated 28.11.2009, 21.04.2010, 15.05.2010, 21.06.2010, 22.08.2010 and copy of legal notice dated 04.06.2015 with postal receipts.

2. Notice was issued to the OP on 03.09.2015. Written statement was filed by OP on 27.11.2015 in which the OP took the preliminary objection that the DLA before proposal for assurance had suffered from Hypertension/ Diabetes, Coronary Artery Disease and Chronic Obstructive Pulmonary Disease since last 4 years, 3 years and 5 years respectively as the same are apparent from claim form no. 3784 and 3816 i.e. medical attendant certificate and certificate of hospital treatment respectively completed by the Doctors of GTB Hospital Delhi which diseases the DLA did not disclose in the proposal form / personal statement signed on 18.03.2008 at the time of applying for Life Insurance Policy despite knowledge and gave false answers with regard to his health. The OP took the defence that the liability to pay death claim stood repudiated on ground of suppression of material facts about past illness suffered by DLA in pursuance with Section 45 of Insurance Act and the DLA died on 17.06.2009 within 1 year 2 months and 28 days from the date of risk commencement i.e. 18.03.2008. Therefore the OP had repudiated the claim of the complainant vide letter dated 06.05.2011 with an option to send a representation within a month for reconsideration of claim to their zonal office which the complainant did not avail of. The OP denied any unfair trade practice or deficiency in service or any cause of action arising in favour of the complainant in view of willful concealment of preexisting diseases by the DLA despite personal knowledge of the same and giving false answers with regard to his health and prayed for dismissal of the complaint. OP had attached copy of repudiation letter 06.05.2011, copy of proposal form duly filled and signed by DLA dated 18.03.2008, copy of medial attendant certificate / form no. 3784 filled by GTB Hospital and copy of certificate of hospital treatment / form no. 3816 filled by GTB Hospital.
3. Rejoinder was filed by the complainant in rebuttal to the defence taken by the OP in which the complainant submitted that the repudiation letter dated 06.05.2011 was never intimated by the OP before filing the same with the written statement and that her husband / DLA was a layman familiar with Hindi Language and was not aware of the contents of proposal form which was filled by the agent of OP and the complainant merely signed the same without OP describing details of the policy or producing benefit illustration as laid down by IRDA thereby breaching its Rules. The complainant denied the DLA having suffered from any such preexisting disease before taking the policy or willfully concealing them by giving false answers with regard to his health and submitted that the said diseases are not printed on the policy documents / proposal form to disentitle the complainant from claiming her insurance claim. The complainant further submitted that the OP as per its Rules should have medically examined the DLA before issuing policy documents but did not do so amounting to deficiency of service and is now trying deceive the complainant in the garb of material fact non disclosure for which there was no reason for DLA not to disclose if the agent of OP had asked him to provide information to be filled in proposal form since all the column was filled in English Language by the agent of OP himself. The complainant reiterated the grievance in the present complaint and prayed for relief.
4. Evidence by way of affidavit was filed by the complainant as well as OP. The OP exhibited copy of repudiation letter, proposal form, copy of medical attendant certificate and copy of certificate of hospital treatment as exhibit as RW1/1 to RW1/4.
5. Written arguments were filed by complainant and OP to reinforce / reemphasize their respective grievance / defence.
6. We have given our anxious consideration to the rival contentions of both the parties and documentary evidence placed on record and relied upon by them in their respective grievance / defence.

It is not in dispute that the Life Insurance Cover was granted to was given / extended to by OP to the DLA w.e.f 18.03.2008 to 18.03.2023 on biannual payment of premium of Rs. 2426/- which was paid by complainant and received by OP till March 2009 for two successive due dates and on receipt of premium for sum assured Rs. 1,00,000/- covering the DLA with his wife namely Smt. Kamla Devi, the complainant herein as the nominee. The factum of hospitalization of the complainant at GTB Hospital, Delhi on 17.06.2009 is also not in dispute. However, the OP has repudiated the claim of the complainant on the basis of medical documents procured from GTB Hospital, Delhi where her deceased husband was diagnosed with COPD, type 2 DM, CAD and HTN preexisting 3 to 5 years ago when first observed which diseases the OP has alleged that the complainant had not disclosed to OP at the time of filling the proposal form for taking the Life Insurance Cover under the head personal history.

However on close scrutiny of the medical documents relied upon by the OP for repudiation of claim, the diseases have been mentioned merely on the basis of the hearsay from relatives. Further the Doctor signing the said document has put a ‘no’ against the column 8A ‘were you deceased usual medial attendant’ and has left column 9 ‘when and for what ailment did you treat the deceased during the three year preceding his last illness’ ‘blank’.

7. The Hon’ble National Commission in Judgment of Ravinder Singh Bindra V/s National Insurance Co. Ltd. I (2017) CPJ 498 (NC)  had held that In view of Insurance Co. not having produced any evidence or filed any document to show that the deceased was suffering from pre existing heart ailment or was treated for the same before date of proposal  which was essential to establish / prove the pre existing nature of the disease as contented by the Insurance Company as the onus to prove the same lies on it, the repudiation was held bad. Further the factum of concealment of hypertension were not sufficient ground amounting to suppression of any material information to repudiate the claim since it is not necessary that every person having hypertension shall suffer from heart disease.
8.  Further, the Hon’ble National Commission in the Judgment in Birla Sun Life Insurance Co. Ltd & Anr. V/s. Arvind Kaur I (2018) CPJ 301 (NC) had held that it was obligatory to insurer to either produce doctor who had allegedly treated the DLA  in Hospital or to have filed his affidavit or in the alternate it could have examine an official of hospital to prove / authenticate of photocopies which the insurance company relied upon before District Forum in support of its defence and in the absence of any such evidence, mere production of some unattested, unverified and unauthenticated photocopies could not have been the basis of holding the deceased been alcoholic and diagnosed with alcoholic liver disease thereby repudiating the claim. The Hon’ble National Commission in judgment of SBI Life Insurance Co. Ltd. V/s Baijnath Tanti II (2018) CPJ 95 (NC) observed that the Insurance Company have not filed any affidavit of treating doctor to substantiate its claim that the DLA was suffering from Tuberculosis before taking health cover and had suppressed the same at the time of submitting declaration of good health in connection with revival of Insurance Policy and held that as there is no affidavit of treating doctor was filed to prove the treatment record, the same cannot be relied upon to the exent of disallowing the death claim. The National Commission also observed in this Judgment that In cases of revival of policy, the company must have been satisfied with the evidence submitted by policy holder pertaining to health else would have rejected the revival which it is fully authorized to do so. The Hon’ble National Commission in recent judgment of Life India Corpn of India V/s P.R. Sumangala III (2018) CPJ 106 (NC) had held that In view of the fact that LIC had not filed any document or proof to show that the complainant had knowledge of disease of diabetes pre-existing before the date of proposal form and no record of treatment prior to taking of insurance cover was submitted by LIC, no question of suppression of the fact of his diabetes arises  as held by Hon’ble NCDRC in its earlier case decided in RP No. 2157/2014 New India Insurance Ltd. V/s Rakesh Kumar in which the Hon’ble National Commission has held that even if the complainant is diabetic he may not be knowing of his disease and the insurance company has to prove beyond doubt that he had knowledge of his illness of diabetes prior to filling of proposal form (i.e. pre existing in nature). In all the aforesaid cases the Revision Petitions were dismissed on ground of repudiation of claim not justified by Hon’ble National Commission.
9. The Hon’ble Supreme Court in the judgment of P. Venkat Naidu Vs. Branch Manager LIC Kurnool and Anr in Civil Appeal No. 7437/2011 decided on 26.08.2011 held that “since the respondent had come out with the case that the deceased did not disclose correct facts relating to his illness, it was for them to produce cogent evidence to prove the allegation.”
10.  In the present context, in light of observations made by Hon’ble National Commission in the above mentioned judgments, applied as relevant to the case in hand the OP has failed to produce and tangible evidence to prove with holding of information by DLA of his long standing ailments as also failed to place on record either any affidavit of the treating doctor who had treated the DLA for any of the diseases on the basis of which the OP repudiated the claim of the complainant or examined any official of said hospital to prove authenticity of medical documents which the OP relied upon before us in support of its defence and in the absence of any such evidence we don’t find force to validate the repudiation letter dated 06.05.2011 issued by OP to complainant for declining death claim of Rs. 1,00,000/- against policy no. 124246315 on grounds of pre existing COPD, diabetes, CAD and HTN merely on the basis of mere production of some unattested, unverified and unauthenticated photocopies of medical records of GTB Hospital, Delhi.  This should not be the approach of insurance company established for purpose of public welfare.
11.  We, therefore, find OP guilty of deficiency in service in wrongful, unjustified and unsubstantiated repudiation of the claim of complainant and allow the present complaint and direct the OP to pay a sum of Rs. 1,00,000/- to complainant towards death claim alongwith interest @ 9% from the date of filing of the complaint till realization. We further direct the OP to pay a sum of Rs. 8,000/- to complainant towards suffering of mental agony and harassment and Rs. 5,000/- towards litigation charges to the complainant.  
12.  Let the order be complied with by OP within 30 days of receipt of this order.
13.  Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005.
14.   File be consigned to record room.
15.   Announced on  25.10.2018

 

(N.K. Sharma)      President

(Sonica Mehrotra)  Member