Chandigarh

DF-II

CC/976/2019

Reena Mittal - Complainant(s)

Versus

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

Mukand Gupta Adv. & Geeta Gupta Adv.

20 Jan 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

U.T. CHANDIGARH

 

 

Consumer Complaint No.	:	976/2019
Date of Institution	:	24.09.2019
Date of Decision	:	20.01.2023

 

                     

            

 

Reena Mittal wd/o Dinesh Kumar, aged 43 years, Anaj Mandi, Ward No.5, Bhwanigarh, District Sangrur.

                 ...  Complainant.

Versus

 

1.  Life Insurance Corporation of India, Jeevan Parkash, Sector 17-B, Chandigarh through its Divisional Manager.

 

2.  Life Insurance Corporation of India, Sangrur, through its Branch Manager.

 

…. Opposite Parties

 

BEFORE:
		SHRI AMRINDER SINGH SIDHU,	PRESIDENT
		SMT.PRITI MALHOTRA,	MEMBER
		SHRI B.M.SHARMA	MEMBER
Present:-
	Sh.Mukand Gupta, Counsel of the complainant Sh.Sandeep Bhardwaj, Counsel of the OPs.

 

   

ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.),LLM,PRESIDENT

1.   The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986, as amended up-to-date alleging therein that the husband of the complainant namely Sh.Dinesh Kumar (Life Assured) took a life insurance policy known as Jeevan Shikhar No.165916934 for sum assured of Rs.10,62,360/- from the OPs, valid from 09.05.2016 to 09.05.2031 and the complainant was nominee under the said policy.  Before purchasing the insurance policy, the doctor of the OPs also conducted the medical examination of her husband.  The LA suffered renal failure and admitted to Mayo Health Care Super Specialty Hospital, Mohali on 24.01.2017 and was put on dialysis and discharged on 30.01.2017.  The said hospital has also given a certificate that the LA was not referred to the hospital by any hospital but was walk-in patient for renal failure and was treated on 16.11.2016 and he was diabetic for one year.  Thereafter, the LA suffered from heart attack and died on 03.12.2017 (Annexure C-5). The complainant lodged the claim with the OPs and submitted the requisite documents. Dr.Manish Singla of Mayo Health Care Super Specialty Hospital, Mohali has also submitted the certificate in the form No.3816 stating therein that the patient was suffering from diabetic foot as well as hyper tension for the last three years.   However, after one and half years, the OPs have repudiated the claim  dated 03.05.2019 on the ground that as per the discharge summary of the hospital, the LA was not keeping good health and suffering from diabetes mellitus and had a surgical history of debridement left foot since the year 2010 and he had not disclosed all the health problems at the time of taking the policy and ordered to refund the premium amount to the complainant.  It has further been averred that the OPs have illegally and arbitrarily repudiated the claim. Alleging that the aforesaid acts of omission and commission on the part of the OPs amount to deficiency in service and unfair trade practice, the complainant has filed the instant complaint seeking directions to the OPs to refund the sum assured of Rs.10,62,360/- along with interest, compensation for mental agony and physical harassment as well as litigation expenses.
2. In their written version, the OPs while admitting the factual matrix of the case has pleaded that the complainant has concealed the fact with regard to other insurance policies as well as filing of other consumer complaints. It has further been stated that the life assured since deceased was also having another policy from the very same opposite parties i.e. policy no. 162659863 for sum assured of Rs.5,11,000/- with D.O.C. 28.11.2003 and said policy was lying lapsed since 11/2015. Since the life assured was aware of his condition as such instead of reviving the policy bearing no. 162659863, he intentionally opted for fresh insurance. Moreover, he also submitted proposals for fresh insurance under Proposal Numbers 512 & 514 dated 09.05.2016 against which Policy Nos. 165916934 & 165917282 were issued for Death sum assured of Rs.10,62,360/- & Rs.21,24,720/- respectively. The insured has not disclosed the correct information pertaining to his previous policies in the Proposal Forms in reply to Q.No.9 of the proposal forms. Had he given the correct information in the said Proposal Forms the opposite parties might have assess the risk differently and may have taken the Underwriting Decision accordingly. It has further been stated that in the Form no. 3783 (Claimant statement) submitted for claim under policy No. 165916934, she herself stated that duration of last illness of DLA was last 14 years. In Form no. 3783 (Claimant statement) submitted for claim under policy No. 165917282, she stated that duration of last illness of DLA was last 14 months. In Form no. 3783 (complainant's statement) submitted for claim under policy No. 162659863, she stated that duration of last illness of DLA was last 14 years. Even the discharge summary provided by Mayo Healthcare Super Specialty Hospital also shows the history of Diabetes Mellitus for 16 years. Moreover, In the Proposal Form, in reply to Q.No.11 (d), (c),(f) of the Proposal Form the DLA provided the wrong information related his health status.  It has further been stated that the mala fide is proven from the fact that the complainant had lodged claim under single paid up policy no. 162659863 only and thereafter lodged claim under policy no. 165916934 and 165917282 with heavy Death Sum Assured. The information related to life being proposed under two proposals was intentionally concealed in each of the proposal forms to defraud the opposite parties and now the filing of other complaint i.e. C.C No. 615 of 2019 titled as Reena Mittal versus LIC pending adjudication before the Hon'ble Consumer Disputes Redressal Commission, Punjab at Chandigarh has been concealed from this Commission.     It has further been stated that the medical examination conducted by the doctor is on the basis of the information and ailment disclosed by the insured and the insured had concealed the status of his health from the doctor and diseases concealed from the OPs were not in Annexure C-2 and as such the doctor was not supposed to conduct test for them. It has further been stated that the claim was rightly repudiated keeping in view the medical record of the LA and the terms and conditions of the insurance policy. The remaining allegations have been denied, being false. Pleading that there is no deficiency in service on their part, a prayer for dismissal of the complaint has been made.
3. The parties led evidence by way of documents/affidavits in support of their case.
4. We have heard the Counsel for the contesting parties  and have gone through the documents on record including the written submissions.
5. It is an admitted fact that the husband of the complainant namely Sh.Dinesh Kumar (Life Assured) took a life insurance policy known as Jeevan Shikhar No.165916934 for sum assured of Rs.10,62,360/- from the OPs, valid from 09.05.2016 to 09.05.2031 and the complainant (his wife) was nominee under the above said policy.  So, the complainant being beneficiary of the above said policy is consumer of the OP who are service providers in the present case. Moreover, the copy of the insurance policy issued by the OPs in favour of the husband of the complainant was duly placed on record by the complainant as Annexure C-1. Further, the doctor namely Dr.Uggar Sain Garg, MBBS who is on the panel of the doctors of the Life Insurance Corporation of India has duly conducted the medical examination of the L.A. on 09.05.2016 and found him medically fit to be insured and the insurance policy was issued to the LA. The copy of the medical examination report was duly placed on record by the complainant as Annexure C-2.  The LA suffered from renal failure and admitted to Mayo Health Care Super Specialty Hospital, Mohali on 24.01.2017 and was put on dialysis and discharged on 30.01.2017.  The said hospital has also given a certificate that the LA was not referred to the hospital by any hospital but was walk-in patent for renal failure and was treated on 16.11.2016 and he was diabetic for one year.  Thereafter, the LA suffered heart attack and died on 03.12.2017, which is duly proved from his death certificate (Annexure C-5). The complainant lodged the claim with the OPs and submitted the requisite documents. Dr.Manish Singla of Mayo Health Care Super Specialty Hospital, Mohali has also submitted the certificate in the form No.3816 stating therein that the patient was suffering from diabetic foot as well as hyper tension for the last three years.   However, the OPs have repudiated the claim  dated 03.05.2019 on the ground that the LA was suffering from pre-existing disease and as per the discharge summary of the hospital, the LA was not keeping good health and suffering from diabetes mellitus for 14 years and he had a surgical history of debridement left foot since the year 2010 and hypertension and taken other insurance policies besides this policy from the OPs and further, the OPs ordered to refund the premium amount to the complainant. The repudiation letter was placed on record as Annexure C-7.
6. Now the main issue in question is as to whether the claim of the complainant repudiated by the OPs is justified or not.
7. In order to find out answer to this question, it is observed that the OPs repudiated the claim of the complainant that the LA was suffering from pre-existing disease of diabetes mellitus for the last 14 years. The main contentions of the OPs are that since the LA has concealed the pre-existing disease, so his claim has rightly been repudiated as per the terms and conditions of the insurance policy. On the other hand, the learned counsel of the complainant has repelled the aforesaid contention of the OPs on the ground that at the time of availing services from the OPs, due medical examination of the LA was conducted and after confirming that the LA was not suffering from any disease, the OPs issued the policy in question in favour of the complainants.
8. The burden to prove the fact that the LA was suffering from pre-existing disease for the last 14 years was upon the OPs. A copy of the discharge summary of the Mayo Health Care Super Specialty Hospital, Mohali i.e. Annexure R-2  has been produced by the OPs but there is neither any affidavit of the concerned doctor in favour of the OPs nor compete particulars of the investigation recorded in the medical file of the patient (LA). There is no affidavit of the treating doctor of Mayo Health Care Super Specialty Hospital, Mohali to establish the fact on record regarding the pre-existing disease of the insured. In the absence of any affidavit of the treating doctor of the concerned hospital to the effect that the LA suffered from diabetes mellitus disease for 14 years, reliance cannot be made just on prescription slip or passing reference in the notes of treatment, consequently it can be safely held that the OPs failed to discharge the burden to prove that the LA was suffering from diabetes mellitus for last 14 years.  In New India Assurance Co. Ltd. Vs. Arun Krishan Puri, III(2009) CPJ 6 (NC), it was held that onus to prove the pre-existing disease of the insured at the time of taking the policy lay on the insurer. Further in the absence of verification of discharge summary by the doctor, who treated /issued the same, no reliance can be placed on it. In the absence of such evidence, the repudiation of the claim by the OPs cannot held to be justified.
9. Rather, the complainant has placed on record a certificate of the treating doctor namely Dr.Manish Singla of Mayo Health Care Super Specialty Hospital, Mohali as Annexure C-3 wherein the concerned doctor stated that the patient was not referred to the hospital by any hospital but was walk-in patient since November, 2016.
10. Moreover, the complainant has placed on record the medical examination report by the empaneled doctor namely Dr.Uggar Sain Garg, MBBS of LIC as Annexure C-2 holding that the LA was mentally and physical fit and after complete satisfaction, the OPs issued the policy to the LA/insured and received premium from the insured. Once the OPs issued insurance policy after conducting medical examination from their own doctor then they cannot take plea of pre-existing disease. Further, the complainant has placed on record very valuable document of Dr.Manish Singla of Mayo Health Care Super Specialty Hospital, Mohali  i.e. certificate (Annexure C-6) in the Form No.3816 stating therein that the patient was suffering from diabetic foot  as well as hypertension for the last three years, thus, falsify the claim of the OPs that the LA was suffering from diabetes mellitus for the last 14 years. So the complainant has proved on file that he was not suffering from pre-existing disease as alleged by the OPs. Moreover, if the LA was suffering from any diseases prior to issuance of the policy, in question, the same must not have escaped from the notice of the empanelled doctors of the Insurance Company namely Dr.Uggar Sain Garg, MBBs who found him mentally and physical fit before issuance of the insurance policy. However, no such investigation record has been produced by the opposite parties. The question of hiding of disease from Dr.Uggar Sain Garg, MBBS does not arise because amputation of left foot could not be hidden from a qualified doctor and he himself endorse in the medical examination  report that ‘cut in left leg’. So it is clear that left foot was  either not amputated at the time of medical examination of the LA due to diabetes mellitus disease or the doctor of the OPs i.e. LIC deliberately concealed this fact in his report. In both the situations, it is wrong on the part of the OPs and now they cannot take benefit of it.
11. The very object of ‘Medical Examination’ by a qualified doctor was to ascertain mental and physical health of the person to be insured and if he was suffering from pre-existing disease then report accordingly. So if the insurance companies and their doctors are playing with the ‘words of jugglery’ by writing seems to be mentally and physical fit instead ‘found to be mentally and physical fit’ without going into proper investigation then they should face the music of its consequences. It is observed that the LA never denied for any tests or investigations to be conducted upon him. Hence, the fault of ‘not conducting proper medical examination’ lies with the doctor of LIC and not innocent ‘insured’. Moreover, if the OPs-Company alleges that his ‘left foot’ was amputated 10 years ago then the question of hiding this fact does not arise because amputated ‘left foot’ could not be hidden from doctor as it was apparently visible. Moreover, the doctor has mentioned in his ‘medical examination report’ that he ‘seen the cut on left leg’. So it is clear that it is the doctor who is hiding the facts in his ‘medical examination report’ and not the LA.
12. In case Bajaj Allianz Life Insurance Co. Ltd. & Ors. Vs. Raj Kumar III (2014) CPJ 221 (NC), it was held by the Hon’ble National Commission that “usually, the authorized doctor of the Insurance Company examines the insured to assess the fitness and after complete satisfaction, the policy is issued. It was held that the Insurance Company wrongly repudiated the claim of the complainant.”
13.       Further, the plea of the OPs that the LA was having the past history of hypertension and, therefore, the complainant is not entitled for claim is also not tenable.  

         The Hon’ble Supreme Court in the case Biman Krishna Bose Vs. United India Insurance Company, civil Appeal No.3438 of 1995, has held that that if a person is suffering from hypertension, the insurance claim of the legal heirs of such a person cannot be repudiated on the ground that the life assured had suppressed this information from the Insurance Company. Moreover hypertension is not a material disease which is fatal in itself.

         The Hon’ble National Consumer Disputes Redressal Commission, New Delhi in Revision Petition No.3619 of 2013 – Satish Cahnder Madan Vs. M/s. Bajaj Allianz General Insurance Co. Ltd., decided on 11.1.2016 has held that “Hypertension is a common ailment and it can be controlled by medication – Claim was wrongly repudiated.”  

14.     The Hon’ble Supreme Court as well as Hon’ble National Consumer Disputes Redressal Commission, while adjudicating the matter on this substantial issue of repudiation of claim on the basis of suffering from Hypertension of insured person, has categorically ruled that Hypertension is not a material disease and is manageable by medication/meditation, change of life style etc. and as such, cannot be a ground for rejection of genuine claims.
15.     Further, we draw support from Life Insurance Corporation of India Vs. Sushma Sharma from II (2008) CPJ 213 wherein Hon'ble State Commission has held as under:-

    “So far as hypertension is concerned, no doubt, it is a disease but it is not a material disease. In these days of fast life, majority of the people suffer from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. If these diseases had been material Nand Lal insured would not have survived for 10 years after he started suffering from these medical problems. Like hypertension ,diabetes has also infected a majority of the Indian population but the people who suffer from diabetes and continue managing it under the medical advice, they survive for number of years and none of these diseases is fatal and as discussed above, if these diseases had been material deceased Nand Lal insured would not have survived for 10 years.”.

16.     We further draw support from Life Insurance Corporation of India Vs. Sudha Jain II (2007) CPJ 452 wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has held that “maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease”.
17.      In such a situation, the repudiation made by the OPs-Insurance Company regarding genuine claim of the complainant have been made without application of mind. It is usual with the insurance company to show all types of green pasters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

    “It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.  The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

18.     As regards, the plea of the OPs regarding taking other insurance policies by the LA from the OPs-Company is concerned, the same deserves to be ignored because  there is neither any legal bar to such availment of service nor the LA has any mala fide intention as he had availed/purchased the policies from the same company i.e. the OPs-LIC. Had he any mala fide intention on his part then he would have availed/purchased the policies from other companies hiding it from the OPs-LIC.  Hence, the repudiation of the claim on this ground is also not justified.
19.     In view of the above discussion, we hold that the OPs-Insurance Company have  wrongly and illegally rejected the claim of the complainant.
20.     Consequently, the present complaint deserves to be partly allowed and the same is accordingly partly allowed. The opposite parties are directed to pay the sum assured i.e. Rs.10,62,360/- to the complainant along with interest @ 9% p.a. from the date of repudiation of the claim i.e. 03.05.2019 till its actual realization. The OPs–Insurance Company is also directed to pay compensation to the complainant for causing mental tension and harassment to the tune of Rs.15,000/-. 
21. This order be complied with by the OP(s), within 60 days from the date of receipt of its certified copy, failing which the complainants shall be at liberty to get the order enforced through the indulgence of this Commission.
22. The pending application(s), if any, stands disposed of accordingly.
23. Certified copies of this order be sent to the parties as per rules. The file be consigned.

Announced 20/01/2023	Sd/-
	(AMRINDER SINGH SIDHU) PRESIDENT
	Sd/-
	(PRITI MALHOTRA) MEMBER
	Sd/-
	(B.M.SHARMA) MEMBER