1. The present Revision Petition (RP) has been filed by the Petitioner against Respondent as detailed above, under Section 21(b) of Consumer Protection Act 1986, against the order dated 21.03.2018 of the State Consumer Disputes Redressal Commission, Haryana, Panchkula (hereinafter referred to as the ‘State Commission’), in First Appeal (FA) No.201 of 2017 in which order dated 06.01.2017, District Consumer Disputes Redressal Forum, Rohtak (hereinafter referred to as District Forum) in Consumer Complaint (CC) No. 460 was challenged, inter alia praying for setting aside the order passed by the State Commission in Appeal No. 201 of 2017 and the order passed by the District Forum on 6th January 2017 be declared as legal, good and according to the facts and circumstances of the case and OP/insurance company be directed to pay the amount according to the order of District Forum. 2. While the Revision Petitioner (hereinafter also referred to as Complainant) was Respondent and the Respondent (hereinafter also referred to as OP/Insurance Company) was Appellant in the said FA/201/2017 before the State Commission, the Revision Petitioner was Complainant and Respondent was OP before the District Forum in the CC No. 460. Notice was issued to the Respondent on 28.09.2018. Parties filed Written Arguments/Synopsis on 04.09.2023 (Petitioner) and 24.08.2023 (Respondent) respectively. 3. Brief facts of the case, as emerged from the RP, Order of the State Commission, Order of the District Forum and other case records are that: (i) Mr. Surender Kumar, Complainant’s husband (deceased/ insured) purchased Insurance Policy –New Jeevan Anand (with profits) from the Respondent Life Insurance Corporation of India (OP/Insurance Company) on 19.03.2014 for a sum assured of Rs.3,00,000/-. (ii) On 25.05.2014, the deceased/insured was admitted in PGIMS, Rohtak for (i) chest pain (ii) abdominal pain and (iii) Myalgia. The deceased/insured died on 26.05.2014. The claim was repudiated by the Insurance Company on the ground that the insured did not disclose the fact that he was a patient of Chronic Kidney Disease. He was taking treatment from PGIMS, Rohtak. Hence, the complainant filed a complaint before the District Forum. 4. Vide Order dated 06.01.2017, in the CC No.460, the District Forum while allowing the complaint, passed the following order:- “In view of the facts and circumstances of the case it observed that opposite party shall pay the sum assured under the policy No.179831310 amounting to Rs.3,00,000/-(Rupees three lacs only) alongwith interest @ 9% p.a from the date of filing the present complaint 06.10.2015 till its actual realization; other benefits under the policy, if any, and shall also pay an amount of Rs.5000/-(Rupees five thousand only) litigation expenses to the complainant maximum within one month from date of decision failing which the awarded amount shall carry further interest @12% p.a. from the date of decision. Complaint is allowed accordingly.” 5. Aggrieved by the said Order dated 06.01.2017 of District Forum, the Respondent (OP/Insurance Company) appealed in State Commission and the State Commission vide order dated 21.03.2018 in FA No.201 of 2017 has accepted the Appeal and passed the following order:- “11. On the aforesaid facts and law enunciated, it stands established to the hilt that the person insured was suffering from chronic kidney disease, prior to the purchase of the insurance policy and he suppressed this fact, Thus, the District Forum fell in error in allowing the complaint and as such the impugned order cannot be allowed to sustain. The appeal is accepted, the impugned order is set aside and the complaint is dismissed.” 6. Petitioner has challenged the said Order dated 21.03.2018 of the State Commission mainly on following grounds: - There is no record of previous treatment that the deceased/insured was suffering from any ailment. The Petitioner has also relied upon the judgment in New India Assurance Co. Ltd. Vs. Rakesh Kumar III 2014 CPJ 340 (NC), wherein the National Commission held that O.P. did not produce any evidence to prove that which medicine and for how long the complainant was taking for diabetes/hypertension. The OP (insurance company) cannot apply hard and fast rule to presume that complainant was suffering for long duration i.e. before taking the policy. People can live for months even years, without knowing they have the disease and it’s often discovered accidently after routine medical check ups concealment not established repudiation not justified.
- The deceased/insured has not concealed any ailment at the time of purchasing policy and he was not suffering from any disease at the time of purchasing the policy and there is no documentary proof also. The insured/deceased has not suppressed any material fact. The question for insured/deceased that he suppressed any material fact does not apply in this case because the Appellant/OP failed to lead any direct evidence to prove that the insured was suffering from any prior ailment and the OP/insurance company has not examined the doctor. It has become a fashion that hardly in any case the insurance company pay the insured amount without litigation.
7. Heard counsels of both sides. Contentions/pleas of the parties, on various issues raised in the RP, Written Arguments, and Oral Arguments advanced during the hearing, are summed up below. 7.1 In addition to the grounds for Revision Petition, it is contended by the Petitioner that the State Commission has committed material irregularity in its order which is based on the document which was certified by medical officer of PGIMS, Rohtak, there is no document proof that the husband of the petitioner was suffering from Chronic Kidney disease and hypertensive (HTN) Nephropathy. The insurance company is putting false and fabricated grounds for not paying the amount according to policy purchased by her husband. 7.2 On the other hand it is contended by the OP/Insurance Company that the deceased/insured has given false and fraudulent answers with respect to questions pertaining to Personal Medical History of the Insured. The insured has hood-winked and mislead the insurer LIC by fraudulently concealing material facts for the purpose of applying for LIC’s Jeevan Anand Policy. The deceased was suffering from Chronic Kidney disease as well as Hypertensive Nephropathy (HTN) and was taking treatment from PGIMS Rohtak but did not disclose this fact in his Personal History in the proposal form at the time of obtaining the insurance policy. These facts were only brought to light when the doctor treating the deceased submitted the certificate of hospital treatment under Claim Form. The Petitioner has falsely claimed by way of Affidavit of Evidence that the insured passed away in ordinary course of nature at his native Village Ballam (Garhi). This averment of the Petitioner is devoid of any merit, the Petitioner is attempting to mislead the Commission with this submission. It is a matter of record that the deceased was admitted in PGIMS, Rohtak on 25.05.2023 and passed away on 26.05.2023 due to Chronic Kidney disease as well as Hypertensive Nephropathy (HTN). In support of its contentions, the Insurance Company has relied upon the judgments passed by the Hon’ble Supreme Court in Life Insurance Corporation of India V. Asha Goel (2001) 2 SCC 160; PC Chacko Vs. Chairman, Life Insurance Corporation of India; Satwant Kaur Sandhu Vs. New India Assurance Co. Ltd. (2009) 8 SCC 316; Branch Manager, Bajaj Allianz Life Insurance Company Vs. Dalbir Kaur, Civil Appeal No. 3397 of 2020 (SC) and Reliance Life Insurance Co. Ltd. Vs. Rekhaben Nareshbhai Rathod, (2019) 6 SCC 175. 8. We have carefully gone through the order of the State Commission, order of the District Forum, repudiation letter dated 08.04.2015 of OP/insurance company and all other relevant records. The claim has been repudiated by the OP/insurance company on the grounds that the deceased/insured has concealed the fact of pre-existing ailments at the time of taking the policy. In their repudiation letter dated 08.04.2015, the OP/insurance company has stated that the deceased/insured had given false answers to the following questions:- During the last five years, did you consult a medical practitioner for any ailment requiring treatment for more than a week. | NO | Have you ever been admitted to any hospital or nursing home for general check-up, observation, treatment or operation. | NO | Have you remained absent from place of work on grounds of health during last five years. | NO | Are you suffering from or have ever suffered from diabetes, Tuberculosis, High BP, Low BP, cancer, epilepsy, hernia, leprosy, or any other disease. | NO | Are you suffering from or have ever suffered from ailment for pertaining to liver, stomach, Heart, Lungs, Kidney, Brain or nervous system. | NO |
9. The only document in support of their case which OP/insurance company has filed is Claim Form No. 3816, which is signed by a doctor of PGIMS, Rohtak. As per this claim/report, date of admission was 25.05.2014 and death of death was 26.05.2014. In this regard response to certain questions contained in this form are reproduced below:- “3. Under whose treatment was the patient before he was admitted into the Hospital? If the patient had brought a letter or a note from any doctor at the time of admission, kindly furnish us with a certified copy thereof. | No Records Available | 4. What, at the time of admission was? a) the nature of his complaint | Chest pain, Abdominal pain, Myalgia | b) The duration of the complaint as reported by him? | x 3 days | 5 a)What was the exact history reported by the patient at the time of admission? (Full history including the dates, duration of the ailments, the symptoms narrated etc. to be given). | a)Chest pain, Abdominal Pain, Myalgia x 3 days | b) Was the history reported by the patient himself or by someone else. | b) Patient himself | c) If the history was not reported by the patient himself, the name and relationship of the person who reported the history. Was the patient present at that time and was he conscious? | c)Not available in Records. | d) To whom was the history reported and by whom was it recorded? | d) Doctor on duty (Dr. Shakti) | e) is the Doctor, to whom the history was reported/who has recorded the history, still with the Hospital and if not, what is his present Address? | e) Yes | 6. What was the diagnosis arrived at the hospital? | Case of chronic kidney disease (HTN Nephropathy) on Maintenance Hemodialysis with subarachnoid hage | 7.Was there any other disease illness which preceded or co-existed with the ailment at the time of the patient’s admission into the Hospital? If so, Please give details. | Patient was a known case of Hypertension | 8. a) What was it | a)Hypertension | b) Date when first observed by the patient | b) two months before | c)By whom treated? | c) On Treatment from Medicine (PGIMS)as a Nephrology clinic card. | d) By whom history was reported? (If not by the patient himself. Please indicated if it was recorded in his presence and was in his knowledge) | d) Not available in Records | e) By whom the history was noted and recorded? (If the doctor is not with the hospital at present please give his present address) | e) Not available in Records. | 8. What was the date of his discharge from hospital? | Patient died on 26.05.2014. | 9. What was his condition when he was discharged? | Patient died on 26.05.2015. | 10. Was he treated in the hospital on any previous occasion either as an inpatient or as an outpatient? | No records available | 11. History of illness as per records | Patient Surender S/o Raghbir Singh admitted in Ward 28 (Nephrology) with CR No. 246557. He was a known case of Hypertension with Hypertensive Nephropathy with chronic kidney disease on Maintenance Hemodialysis. Patient Managed with Best Medical efforts but he died on 26.05.2014. 8:00 am. |
10. From the above, it is clear that even as per this document, there were no records available about the deceased’s earlier treatment before he was admitted in PGIMS, Rohtak on 25.05.2014. The nature of complaints recorded above are shown for last three days only from the date of admission by the patient himself. The mention about chronic kidney disease in the above report is as per the diagnosis arrived at the hospital i.e. on or after the date of admission i.e. 25.05.2014. The hypertension is also recorded for last two months only. As per this report, the patient died on 26.05.2014 in PGIMS, Rohtak but there is no death certificate issued by PGIMS Rohtak clearly stating the details of his treatment since admission and cause of death. The document in question is not PGIMS, Rohtak’s medical record but Claim Form got filled and signed by the Insurance Company from the PGIMS, Rohtak. The complainant has contended that the insured had died due to heart-attack. The insurance company has not produced any record of treatment taken by the deceased/insured from any medical practitioner during the last five years for any ailment requiring treatment for more than a week, any record relating to admission in any hospital/nursing home or any record showing the deceased was suffering from any of the disease mentioned in the repudiation letter, especially the chronic kidney disease etc. Hence, it cannot be established that the deceased/insured had suppressed any pre-existing ailments or given false answers to the above stated five questions mentioned in the repudiation letter. It is possible that the deceased/insured himself may not have been aware of any of his ailments. Hence, the allegation of false answers does not stand. Hence, we are of the view that the District Forum was right in holding from the documents produced by the OP that it has not proved that the deceased was suffering from any disease prior to taking the policy and observing that repudiation was illegal and unjustified and complainant is entitled to the claim amount as per policy. We find that State Commission went wrong in appreciating the evidence on record as to whether the insured was suffering from pre-existing disease prior to purchase of the insurance policy and that he suppressed this fact. Hence, we find a material irregularity in the order of the State Commission. Accordingly, the same is set aside and order of the District Forum is restored. Revision Petition is disposed of accordingly. 11. The pending IAs in the case, if any, also stand disposed off. |
