BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

1. Manish Kumar aged about 35 years
2. Lakhwinder Singh
3. Sandeep Kumar sons of late Sh. Jeeta Ram
4. Ratni Devi widow of Late Sh. Jeeta Ram
5. Baro Devi widow of late Sh. Dayala Ram

All R/o Vill. Kullarpur, Tehsil Naraingarh, Disttt. Ambala.

          ……. Complainants

Versus

1. Life Insurance Corporation of India, Branch Naraingarh Near Subhash Chowk, through its authorized Signatory/Branch Manager

2. The Zonal Manager, LIC of India, Jeevan Bharti, Towar-11, 124, Connaught Circus, PB No. 630, New Delhi-110001,

3. Life Insurance Corporation of India, Divisional Office, PO Box No. 106, Jeevan Parkash, 489 Model Town Karnal 132001 through its Branch Manager/Authorized Signatory.                                                                          

 ….…. Opposite Parties.

Before:       Smt. Neena Sandhu, President.

                     Smt. Ruby Sharma, Member,

          Shri Vinod Kumar Sharma, Member.           

Present:      Shri Munish Bakshi, Advocate, counsel for the complainants.

                     Shri Shubham Aggarwal Advocate, counsel for the OPs.

Order:        Smt. Neena Sandhu, President.

                   Complainants have filed this complaint under Section 35 of the Consumer Protection Act, 2019 (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 make the payment of the above said policy to the tune of Rs. 8,00,000/- to the complainants.
2. To pay a sum of Rs.50,000/- due to the negligence and deficiency in services along with interest @18% p.a. from the date of filing the present complaint.
3. To pay a sum of Rs.50,000/- as general and special damages for mental pain and suffering and etc.
4. To award cost of litigation of Rs. 20,000/-.
382.  

Grant any other relief which this Hon’ble Commission may deems fit.

2.             Brief facts of the case are that complainants no. 1 to 3 are sons of late Sh. Jeeta Ram and complainant no. 4 is widow of late Sh. Jeeta Ram and complainant no. 5 is the mother of late Sh. Jeeta Ram. During his life time Sh. Jeeta Ram S/o Sh. Dayala Ram  had purchased a life insurance policy No. 171422311 for twenty years from the OPs and completed the said policy and thereafter purchased again one another policy from the OPs.  Late Sh. Jeeta Ram purchased life insurance policy bearing no. 129591282 from the  OPs  in the year 2019 on yearly installment of Rs.12,838/- for sum assured Rs.8,00,000/- and Sh. Jeeta Ram deposited two installment of basic premium @ Rs.12,838/- each for the year 2019 and 2020 and deposited instalment of basic premium on March 2019 and March 2020 @ Rs.12,838/- yearly to  the OPs. The date of the commencement of the risk was from 30.03.2019. Son of Jeeta Ram S/o Dayala Ram i.e. Manish Kumar was appointed as nominee in the above said policy in question by the late Sh. Jeeta Ram. At the time of purchasing the insurance policy no. 129591282 Sh. Jeeta Ram was hale and hearty and was perfectly all right. Prior to issuance of the policy, Jeeta Ram was properly medically checked by the doctor of the OPs’ choice. Jeeta Ram never remained under the treatment of any doctor earlier and was enjoying good health and was not suffering from any disease nor was having any knowledge of it.  Sh. Jeeta Ram son of Sh. Dayala Ram suffered heart attack and was referred to Civil Hospital Naraingarh. Stunt was affixed in his heart at Government Hospital Ambala Cantt in February 2020 and thereafter, he was hale and hearty and was enjoying good health. However, Sh. Jeeta Ram  died on 13.05.2020 and  the OPs  were immediately informed about his sudden death and requested to release the insured amount of. Rs.8,00,000/- but to no avail.  The OPs sent one letter dated 27.07.2020 through registered post to complainant no.1 for repudiating all the liabilities under the above said policy and all the money paid under the policy stood forfeited despite the fact that Jeeta Ram was not under the treatment of any doctor earlier and had not suppressed any material and relevant information in his proposal form.  Legal notice dated 15.09.2020 served upon the OPs also was of no use. However, the OPs  sent one letter dated 23.09.2020 to complainant no. 1 that relevant papers under above claim are being called for from Regional Office Karnal so as to place the appeal along with the facts before Zonal Office claims Disputes Redressal Committee. The complainant no.1 sent one reminder dated 09.12.2020 in reply to the letter of the  OPs  dated 23.09.2020 to the Zonal Manager LIC of India Jeevan Bharti Tower 11, 124 Connaught Circus PB No. 630 New Delhi that the complainants are ready to assist the  OPs  regarding the matter and appeal for the speedy disposal of their claim. Thereafter the appeal of the complainants was dismissed with direction to uphold with refund of premium vide letter dated 31.03.2021 sent by the OPs to the complainants. The OPs wrongly and illegally declined the claim of Jeeta Ram only to defeat the genuine rights of the complainants. Hence this complaint.
3.           Upon notice, OPs appeared and filed written version wherein they raised preliminary objections to the effect that  the present complaint is an abuse of the process of law and has been filed without any cause of action having arisen in favour of the complainants and against the OPs; the complainants have concealed material facts from this Commission; the complaint is frivolous false, and vexatious; the matter in dispute involves complex and disputed question of law and facts which requires voluminous evidence to be recorded before the decision of the case; the matter in dispute cannot be decided in a summary way and the proper remedy for the complaint is the Civil Court etc. On merits, it has been stated that  the deceased-Sh. Jeeta Ram had taken Policy bearing no. 129591282 for sum assured of Rs.800000/- under Plan & Term 822- 10 ( LIC'S ANMOL JEEVAN II) (without profit) with date of commencement as 06.03.2019. The said policy was taken from Branch Office Naraingarh in which yearly premium was payable amounting to Rs.10880/- and only two instalments of premium were paid and life assured expired on 13.05.2020. The Policy was taken on 30.03.2019 hence the duration of Policy was only 1 year 1 month and 13 days from the date of commencement of risk and the claim was examined under Section 45 of Insurance Act 1938 which says "a policy of life insurance may be called in question on the ground of fraud, at any time within three years from the date of issuance of policy or the date of commencement of risk or the date of revival of policy or the date of the rider to the policy, whichever is later on the ground of fraud". Hence investigation was conducted and during investigation it was revealed that the deceased life assured was not having good health prior to taking policy as he was known case of Hypertension (HTN) & Type 2 Diabetes mellitus (Type2DM) and Coronary Artery disease (CAD). As per Discharge & Follow up card of Government Medical College Hospital Sector 32, Chandigarh the life assured visited to hospital on 29.01.2020 with complaint of chest pain, dizziness and had history of Diabetes Mellitus since 4 years, with hypertension, alcohol, smoking and past history of CAD (Coronary artery disease) for 3 years whereas this material information was not disclosed in the Proposal form dated 03.03.2019 rather false answers were given to following questions as under:-

11(a) During the last five years did you consult a Medical Practitioner for any ailment requiring treatment for more than a week ? NO

11 (b) Have you ever been admitted to any hospital or nursing home for general check up, observation, treatment or operation? NO

11 (d) Are you suffering from or have you ever suffered or undergone investigation in the past or have you been advised to undergo investigation or treatment for the following ailments. No

2. Hypertension, Hypotension, rheumatic fever, pain in chest, breathlessness, palpitation any disease of heart or arteries? No

9. Diabetes/suffering from Diabetes or have you ever passed sugar,albumin,pus or blood in urine/goiter/Thyroid & other endocrine disorder No

11(g) What has been your usual state of health ? GOOD

Thereafter the life assured gave a declaration in the proposal form as under:-

"I, Jeeta Ram, the person whose life is here being proposed to be assured do hereby declare that the foregoing statements and answers have been given by me after fully understanding the questions and the same are true and complete in every particular and that I have not withheld any information and I do hereby agree and declare that these statements and this declaration shall be the basis of contract of assurance between me and Life Insurance Corporation of India and that if any untrue averment be contained therein, the said contract shall be dealt with as per provisions of Section 45 of the Insurance Act 1938 as amended from time to time."

(a) That the life Insurance Corporation of India believing the information with regard to the state of health of life assured and the declarations to be true and correct issued the insurance policy to the life assured Sh. Jeeta Ram subject to specific terms and conditions.

(b) That the contract of insurance is a contract of "UTMOST GOOD FAITH" technically known as "UBERIMMA FIDES". According to this doctrine the proposer who is one of the parties of the contract, is presumed to have knowledge, which are not accessible to the Corporation, who is the other party to the contract. Therefore, proposer (life assured) is bound to the disclose everything affecting the judgment of the insurer (other party to the contract of insurance), no matter howsoever unimportant it may seem to him/her (proposer).

(d) In view of evidences on record the claim was not found payable as per Policy Conditions mentioned in Policy bond which reads as under:-

Policy condition No.5:

Forfeiture in certain events: In case the premiums shall not be duly paid or in case any condition herein contained or endorsed hereon be contravened or in case it is found that any untrue or incorrect statement is contained statement, documents in the proposal/personal declaration and connected any material information is withheld, then and in every such case but subject to the provisions of Section 45 of

[22:11, 1/5/2024] Raju Gogna: the Insurance Act 1938, wherever applicable this policy shall be void and all claims to any benefit in virtue hereof shall cease immediately and nothing shall be payable."

The competent authority after examining the whole record has repudiated the claim with forfeiture of all money received under the policy and decision has been conveyed to complainants vide detailed letter dated 27.07.2020. In the said letter the complainants were informed the address of appellate authority and he preferred appeal before the Zonal Manager and the ZOCDRC (Zonal Office Claim Disputes Redressal Committee) has reviewed the claim of claimant. This committee also consists of one external member from Judiciary and the committee after examining the whole record decided to upheld the decision of repudiation by giving relief of refund of premium and the decision of the committee was duly conveyed to the complainants vide letter dated 31.03.2021 and an amount of Rs.21760/- has also been refunded to nominee (complainants) on 30.04.2021. It has been held by the Hon'ble National Commission in LIC of India vs Sunita Sharma CPR Pg No.31-1994 (1) that if claim has been repudiated by insurance Co. through a speaking order and reasons are not irrelevant & extraneous than it is not a case of deficiency and repudiation is valid. It is wrong that at the time of purchasing the policy the assured was hale and hearty or that he never remained under any kind of medical treatment. At the proposal stage medical examination of the life assured was conducted by the empanelled doctor of LIC. This examination is based on general appearance and feedback given by the life assured himself regarding his state of health and at the time of medical examination the life assured answered gave wrong answers, whereas the life assured was suffering from Hypertension, Diabetes and Coronary heart disease, but this material information which was in the knowledge of life assured was concealed with the intent to deceive the Corporation, hence the claim has been repudiated. Rest of the averments of the complainant were denied and prayed for dismissal of the present complaint with costs.

4.           Learned counsel for the complainants tendered affidavit of complainant No.1 as Annexure CW1/A alongwith documents as Annexures C-1 to C-10 and closed the evidence on behalf of the complainants. On the other hand, learned counsel for OPs tendered affidavit of Pawan Kumar Ror, Marketing Manager of the OPs-Life Insurance Corporation of India, Divisional Office, Karnal as Annexure OP-A alongwith documents Annexures OP-1 to OP-41 and closed evidence on behalf of the OPs.
5.            We have heard the learned counsel for the complainants and learned counsel for the OPs and have also carefully gone through the case.
6.           Learned counsel for the complainants submitted that by repudiating the genuine claim of the complainants i.e. legal heirs of the insured, on bald grounds, despite the fact that he was not suffering from any pre-existing disease, the OPs have committed deficiency in providing service. In support of his contention, the learned counsel for the complainants placed reliance on the judgment dated 16.10.2023, rendered by Hon’ble Punjab and Haryana High Court, Chandigarh, in the case of Star Health and Allied Insurance Company Limited Vs. Anant Ram & Another.
7.           On the other hand, Learned counsel for OPs while reiterating the averments made in the written version, submitted that since the insured deceased patient was suffering from pre-existing disease i.e. DM (+) and P/H/P CAD- 3 years back, as is evident from the  discharge summary, Annexure OP-4 prepared by the doctor concerned, which fact stood concealed at the time of obtaining the insurance policy in question, as such, in view of this non-disclosure of material information, the contract of Insurance becomes void and no claim was payable under the policy in question.
8.           It is not in dispute that when the insured took treatment from the hospital- Govt. Hospital,  Sector 32, Chandigarh, as he suffered heart attack and also when he died, he was covered under the insurance policy in question. Therefore, the only moot question which falls for determination before this Commission is, as to whether the claim of the complainants being legal heirs of the deceased-insured was rightly rejected by OPs or not. It may be stated here that the OPs repudiated the claim of the complainant vide repudiation letter dated 27.07.2020, Annexure OP-4, on the main ground that DLA was known case of HTN & T2DM and CAD before taking proposal. He did not, however disclose these facts in his proposal form. It was found mentioned in the discharge summary- Annexure OP-16 issued by Government Medical Collage and Hospital,  Sector 32B, Chandigarh, as DM (+) and P/H/P CAD- 3 years back, which fact stood concealed at the time of obtaining the insurance policy in question, therefore, in view of this non-disclosure of material information, the contract of Insurance becomes void and no claim was payable under the policy in question.
9.           It is significant to mention here that not even an iota of cogent and convincing evidence, in the shape of any medical record of the insured-deceased, of any hospital, proving that he took treatment for the said DM (+) and P/H/P CAD from any hospital/doctor before issuance of the policy in question or that he was in the knowledge of the said disease, has been placed on record by the OPs. In case it is not so, then mere reference in the discharge summary- Annexure OP-16  issued by Govt. Hospital,  Sector 32, Chandigarh,  is not sufficient to come to the conclusion that the insured had concealed any material facts regarding his any of the disease or he was suffering DM (+) and P/H/P CAD- 3 years back. This finding of this Commission is backed by the ration of law laid down by the Hon’ble Punjab and Haryana High Court Chandigarh, in the case of Star Health and Allied Insurance Company Limited Vs. Anant Ram & Another, (Supra) wherein it was held that:- mere mentioning in the prescription by the doctor in his clinical assessment details about the previous history of similar complaint would not amount to establishing a concealment.  
10.           The Hon’ble National Commission, in the case of LIC of India Vs. Joginder Kaur 2005 CPJ-78, 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 Shri 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.
11.           Furthermore, it is significant to mention here that a similar question as to whether, the notes of a doctor on medical record, in the absence of his  name/affidavit can be treated as primary piece of evidence or not for repudiation of insurance claim, fell for determination before the Hon’ble National Commission in the case titled as LIC Of India vs P.R. Sumanagala on 15 February, 2018, Revision Petition No. 2942 Of 2009,  wherein, the ground of repudiation of claim on such similar ground was nullified.
12.           In our considered opinion, it was required of the OPs to lead any independent evidence of the treating Doctor of the alleged pre-existing disease i.e. DM (+) and P/H/P CAD- 3 years back with which the insured was allegedly suffering from, before issuance of the policy in question, to prove this fact. Our this analysis is sustainable because of the principle of law laid down by the Hon'ble National Commission in Revision Petition No. 200 of 2007 "Mr. Satinder singh V/s. National Insurance Co. Ltd., decided on 24/01/2011 wherein it has been observed as under:-

"…. It has by now become a well settled proposition of law that recording of the history of a patient in the above stated manner, does not become a substantive piece of evidence unless a very cogent and convincing evidence has been brought on record to establish that insured was suffering from a pre-existing for which he had been taking treatment or remained admitted to some hospitals. The records or doctor of such a hospital should be proved/examined…”

13.           Under above circumstances, it is held that the OPs failed to prove their case that the insured was suffering from any disease- DM (+) and P/H/P CAD- 3 years back, before issuance of the policy in question.  It is therefore held that by repudiating the genuine claim of the complainants the OPs are deficient in providing service. From the perusal of policy document, Annexure OP-1, it is evident that the Deceased Life Assured (DLA) was insured for Rs.8,00,000/-, thus the OPs are liable to pay the said amount to the complainant alongwith interest from the date of repudiation i.e 27.07.2020. 
14.           In view of the aforesaid discussion, we hereby allow the present complaint and direct the OPs, in the following manner:-
    1. To pay to the complainants the sum assured amount of Rs.8 lacs, alongwith interest @6% p.a. from the date of repudiation of claim i.e. 27.07.2020, onwards.
    2. To pay Rs.5,000/- as compensation for the mental agony and physical harassment suffered by the complainant.
    3. To pay Rs.3,000/- as litigation expenses.  

          The OPs are further directed to comply with the aforesaid directions within the period of 45 days, from the date of receipt of the certified copy of the order, failing which the OPs shall pay interest @ 8% per annum on the awarded amount, from the date of default, till realization. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

   Announced:- 10.01.2024