Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 667
Instituted on : 28.11.2019
Decided on : 16.02.2024
Saroj age 44 years w/o Late Sh. Ajmer, R/o Vill. Bakherta District Rohtak.
……….………….Complainant.
Vs.
- Life Insurance Corporation of India, through its Branch Manager of branch office, Gohana District Sonepat(through its Branch Manager).
- Life Insurance Corporation of India, through its Divisional office, Rohtak, 3,4,5, SCO, Sector-1, Rohtak(through its Divisional Manager).
...........……Respondents/opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR. VIJENDER SINGH, MEMBER
Present: Sh.Shakti Singh, Advocate for the complainant.
Sh.V.K.Groha, Advocate for the opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case as per the complainant are that her husband namely Ajmer had taken a policy bearing no.504753136 from the opposite parties and sum assured under this policy was Rs.8,00,000/- with date of commencement 31.01.2017. Complainant was appointed as nominee of the policyholder. The husband of the complainant named Ajmer hadexpiredon 20.02.2018. After the death of policyholder, complainant duly intimated to the respondent about the death of her husband and has applied for disbursement of claim within time to the office of opposite parties. Complainant also deposited all the documents as required by respondents. Complainant visited to the respondents repeatedly to get the claim amount but the respondents have not paid the claim amountand sent a letter dated 11.02.2019 submitting therein that the respondents have decided to repudiate all liability under the policy on account of the deceased having suppressed material information regarding his health at the time of effecting the assurance with the opposite party. It is further submitted that Ajmer was hale and hearty at the time of issuing the insurance policy and opposite party had issued the insurance policy after medically examined the policy holder prior to issuing the policy. The policy holder had fallen ill all of a sudden in the month of January 2018 and thereafter he was admitted in PGIMS Rohtak and prior to January 2018 there was no problem in the health condition of the policy holder.The act and conduct of the respondents of not disbursing the amount ofclaim is illegal and there is deficiency in service on the part of the respondents. Hence this complaint and it is prayed that respondents/opposite parties may kindly be directed to pay claim amount of Rs.800000/- alongwith bonus interest and other benefits and also to pay Rs.50000/- as compensation on account of deficiency in service and litigation expenses along with interest @ 18% р.а. from the date of its due till its actual disbursement to the complainant.
2. After registration of complaint, notices were issued to the opposite parties. Opposite parties in their reply has submitted that the policy in question was run for one year only. The death claim was early claim and was examined/investigated under the provisions laid down u/s 45 of the Insurance Act, 1938. It is denied that policy holder Sh. Ajmer was hale and heaty at the time of taking the insurance i.e. 31.01.2017 and was having a good health condition. The competent authority has repudiated the liability under the above said policy on genuine grounds. The deceased policy holder had given false answers to the questions of proposal form. As per Form no.3784 dated 20.02.2018, Form no.3816 dated 08.11.2018 issued from PGIMS Rohtak, deceased life assured was admitted in hospital on 20.02.2018 with complaint of blood in vomiting. Deceased life assured was k/c/o Alcoholic Liver Disease with history of Haemotemisis and complications of ALD. The deceased life assured had not disclosed the facts about his Alcoholic Liver Disease and deliberately made incorrect statements and withheld correct information in his personal declaration from the respondent Corporation regarding his health. Hence the claim of the complainant has been rightly repudiated after considering all the relevant facts on genuine grounds. An amount of Rs.12232/- was paid to the complainant towards the full and final settlement of claim. Hence, it is submitted that respondents are not liable to any payments under the above mentioned policy. All the other contents of the complaint were stated to be wrong and denied and opposite party prayed for dismissal of complaint with costs.
3. Ld. counsel for complainant in his evidence has tendered affidavit Ex.PW1/A, documents Ex.P1 to Ex.P5 and closed his evidence on dated 08.03.2022. Ld. Counsel for opposite parties has tendered affidavit Ex.RW1/A, document Ex.R1 to Ex. R6 and closed his evidence on dated 06.09.2022.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. In the present case, insurance and death of husband of the complainant is not disputed. After the death of life assured, complainant filed the claim with the opposite parties but the same has been repudiated by the opposite parties vide their letter Ex.R3 dated 11.02.2019 on the ground thatdeceased life assured was k/c/o Alcoholic Liver Disease with history of Haemotemisis and complications of ALD. The deceased life assured had not disclosed the facts about his Alcoholic Liver Disease and deliberately made incorrect statements and withheld correct information in his personal declaration from the respondent corporation regarding his health. However, opposite parties have refunded the premiums paid under the policy towards full and final settlement of claim. We have perused the documents placed on record by both the parties. As per the medical literature placed on record as ‘Annexure-JNA’, there are three histologic stages of alcoholic liver disease
1.Alcoholic Fatty Liver or Steatosis-At this stage, fat accumulates in the liver parenchyma.,
2. Alcoholic Hepatitis-Inflammation of liver cells takes place at this stage and the outcome depends on the severity of the damage. Alcohol abstinence, nutritional support, treatment of infection and prednisolone therapy in severe cases can help in the treatment of alcoholic hepatitis, but more severe cases lead to liver failure.,
3. Alcoholic Cirrhosis-Liver damage at this stage is irreversible and leads to complications of cirrhosis and portal hypertension.
Moreover in this document under the term Etiology, it is submitted that : “Different factors, such as metabolic, genetic, environmental and immunological collectively play a role in alcoholic liver disease”.
Meaning thereby the consumption of alcohol is not sole reason of alcoholic liver disease and different factors play role in alcoholic liver disease. We have also perused the documents Ex.R4 and Ex.R5 placed on record by the opposite parties. Both the documents have been issued by the doctors of department of medicine PGIMS, Rohtak. As per Ex.R4 the main cause of death was hypovolemic shock upper GI Bleed.
As per this document, under the question no.4 it is mentioned that :
a) What was the main reason of death?and the answer is Hypovolemic
b) Whether the disease was diagnosed by testing after death or the disease was observed during life time? and the answer is: Patient was diagnosed with Alcoholic liver disease when alive.
c)For how much time, the deceased was suffering from the alleged disease? And the answer is : Record not available.
e) When was the patient firstly contacted you during his disease: The answer is : Record not available.
Hence this document shows that neither past history of patient nor any record of previous ailment was available with the PGIMS, Rohtak. There is an apprehension that the deceased was a chronic alcoholic at the time of commencement of policy and he concealed the material fact. No previous record was available with PGIMS. No treatment record placed on record by the respondent that he was suffering from alcoholic disease. We have also observed the document Ex.R5 Certificate of Hospital Treatment andunder question no.4 it is submitted that what, at the time of admission was
b) the duration of the complaint as reported by him? and the answer is : One day. Hence the opposite party has not placed on record any previous history of treatment record of deceased for Alcoholic Liver Disease. We have also perused the copyof judgement relied upon by ld. Counsel for the opposite parties in 2020(2)CPJ 429 titled as T.Manjulatha&Anr. Vs. Birla Sun Life Insurance Co. Ltd. &Ors., III(2020)CPJ 204(NC) titled as Vinita Sethi Vs. ICICI Prudential Life Insurance Co. &Anr. And 2021(1)CPJ(NC)287 titled as Sunita&Anr. Vs. HDFC Standard LIC Ltd. But the same are not applicable on the facts and circumstances of the case as in the present case opposite parties have failed to place on record any document or previous hospital record of deceased life assured to prove the fact that deceased life assured was suffering from Alcoholic liver disease prior to commencement of policy. Hence the repudiation of claim on this ground is illegal and amounts to deficiency in service. As such opposite parties are liable to pay the sum assured to the complainant. We have also observed that the 2nd instalment was due and the policy was in grace period. Hence the amount of 2nd instalment will be deducted from the sum assured. We have also observed that as per Ex.R2 parentsof the deceased are alive and deceased have also two children. Hence there are 5 legal heirs of deceased i.e. mother, father, spouse and two children. So the amount of claim will be distributed in equal share to the L.Rs of deceased. As per the policy Ex.R1, the sum assured under the policy is Rs.800000/- and the amount of premium is Rs.5616/-.Hence the opposite parties are liable to pay the sum assured Rs.800000/- less amount of premium due i.e. Rs.5616/- less amount of Rs.12232/- already paid by the opposite parties i.e. to pay Rs.782152/-.
In view of the facts and circumstances of the case we hereby allow the complaint and direct the opposite parties to pay the amount of Rs.782152/-(Rupees seven lac eighty two thousand one hundred and fifty two only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e28.11.2019 till its realization, also to pay Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the L.Rs of deceased within one month from the date of decision. However complainant is directed to submit the list of legal heirs within 15 days to the insurance company.
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:
16.02.2024
........................................................
Nagender Singh Kadian, President
..........................................
TriptiPannu, Member.
……………………………….
Vijender Singh, Member
