IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION

 Date of Institution: 14.08.2018

Date of Reserving the order: 15.02.2022

Date of Decision: 29.04.2022

FIRST APPEAL NO.-370/2018

IN THE MATTER OF

Mrs Anju Gupta

W/o Late MrSatish Gupta,

R/o 1/3487, Ashok Marg,

Ram Nagar Extn. Delhi

(Through: Mr.Vijay Waghey, Advocate)                                                                                                                                                                        …Appellant

VERSUS

Life Insurance Corporation of India,

Delhi Divisional Office-II,

9^th Floor, SCOPE MINAR,

Laxmi Nagar, Delhi-110092

Through its Branch Manager

                                       (Through: Ms. Rita Rani Jain, Advocate)

                                                                                       …Respondent

HON’BLE MS. PINKI, MEMBER(JUDICIAL)

HON’BLE MS. BIMLA KUMARI, MEMBER (FEMALE)

1. Whether reporters of local newspaper be allowed to see the judgment?        Yes
2. To be referred to the reporter or not?                                                  Yes

Present:       Mr Vijay Waghey advocate learned counsel for the appellant

Ms Rita Rani Jain, advocate learned counsel for the respondent

PINKI, MEMBER (JUDICIAL)

ORDER

1.           The present appeal has been filed on 14.8.2018 impugning the judgement dated 04.05.2018 passed by the District Consumer Disputes Redressal Forum (East) in Complaint Case No. 253/14.
2.           We have heardMr.Vijay Waghey, Advocate, Learned Counsel for the appellant/complainant &Ms Rita Rani Jain, Advocate, Learned Counsel for the respondent/opposite party. We have also carefully perused the record as well as copy of record of the District Forum as filed by parties. We have also given considerable thought to the submissions put forth on behalf of the parties.
3.           It is pertinent to mention that an Application under section 5 of the Limitation Act read with Section 151 of the Code of Civil Procedure for condonation of delay in fling of the accompanying appeal against the order dated 04.05.2018 passed by the District Consumer Dispute Redressal Forum, East District, Delhi in C.C. NO. 253/14 has been decided vide order dated 25.04.2019 passed by Mr O.P. Gupta the then Member (Judicial) vide which delay was condoned.
4.           The short question in controversy is whether the District Consumer Disputes Redressal Forum has rightly dismissed the complaint?
5.           Briefly stating the facts required for deciding this appeal are as under:
6.           The appellant/complainant is wife of the deceased who had got himself insured vide Policy No.125362757 dated 13.09.2009and Policy No.126009560 dated 23.08.2011 for a sum of Rs.5 lakhs each. In the morning of 17.11.2012 the Deceased Life Assured(DLA)was admitted in Pushpanjali Medical Centre,VikasMarg Extension, Delhi with the complaint of stomach ache but was got discharged the same day and thereafter he was admitted in St. Stephen’s Hospital, Tis Hazari, Delhi where he expired on 20.11.2012. In St. Stephen’s Hospital he was being treated for Upper Gastrointestinal Bleed, Chronic Liver Disease etc.
7.           As per the record, claim was filed with the respondent/opposite party for both the policies, where claim pertaining to Policy No. 125362757 dated 13.09.2009 was paid. However, claim qua Policy No. 126009560 dated 23.08.2011 was repudiated vide letter dated 03.12.2013, on the ground that the DLA was suffering from “Gastrointestinal Disease” at the time of proposal and he had withheld the material information.
8.           The appellant/complainant has submitted that despite several visits to office of the respondent/opposite party the claim was not settled qua the second policy i.e. Policy No. 126009560 dated 23.08.2011. The appellant had sought directions to the respondent to pay insured amount of Rs. 5 lakhs along with interest @ 24% p.a., Rs.1 lakh as compensation on account of mental agony, harassment and cost of litigation. The appellant had filed number of documents before the District Forum including premium receipt dated 06.10.2012 and 22.08.2012,copies of medical documents of Pushpanjali Medical Centre, photocopies of medical documents of St. Stephen’s Hospital, Death Certificate, photocopy of Surviving Member Certificate and photocopy of letter dated 03.12.2013 issued by the respondent.
9.           The respondent/opposite party had contested the complaint inter alia on the grounds that complaint was not properly filed; the DLA has suppressed the true and material facts qua his health as he was already suffering from CLD-Hepatic EncephlopathyGrade II,Dyslectrlytemia, Severe Anemia&Hpetorenal Syndrome;he hadpast history of Alcoholic and Ansareafour years prior to his death which were not disclosed in the Proposal Form.
10. The case of respondent is that the claim of appellant/complainant had been repudiated after taking into consideration all the facts; the policy in dispute was an early death claim, therefore, afterthorough investigation it was repudiated; there is no deficiency in service which can be attributed to the respondent. The District Consumer Disputes Redressal Forum (East) after dealing with the record and submissions rightly dismissed the complaint in the instant case.
11. Learned counsel for the appellant has submitted that the District Forum has failed to appreciate the Death Summary dated 20.11.2012 of DLA issued by the St. Stephen’s Hospital which clearly shows that DLA was non-alcoholic. He has also submitted that the appellant/complainant in para 3 of the complaint has herself stated that the doctors of Pushpanjali Medical Centre were negligent, as they had put wrong information on the medical papers without asking anything from DLA as well as his attendant. Moreover the respondent has failed to prove that the DLA was suffering from “Chronic Liver Disease” as on 13.10.2011. No reason has been mentioned as to how the learned District Forum has believed one medical document and rejected the other medical document.
12. Per contra learned counsel for the respondent has submitted that the learned District Forum has rightly dismissed the complaint and has further submitted that it is well settled principle of law that in contract of insurance, the policy holder is under obligation to disclose all the information correctly at the time of taking the policy. However, in the present case DLA has concealed true and material facts regarding his health at the time of taking policy. There was no deficiency of service on the part of respondent/Life Insurance Corporation.

13. It has also been argued on behalf of the respondent that there was no complaint by the appellant, neither to the hospital authorities nor to police authorities or any other law enforcing agency regarding the fact that the doctors of Pushpanjali Medical Centre were negligent as they had put wrong information on the medical papers without asking anything from the DLA as well as his attendant as alleged in para 3 of the complaint. It has further been submitted that the claim of the second policy i.e. Policy No. 126009560 dated 23.08.2011 was repudiated on the ground of withholding the true and material facts by the policy holder regarding his health at the time of taking the policy which was duly informed to the appellant by the respondent vide its letter dated 03.12.2013.
14. From the perusal of the impugned judgement it is clear that the District Forum has referred to Discharge Summary of PushpanjaliMedical Centredated 17.11.2012 Ex CW-1/C which bears “Past History” wherein it is mentioned as under:
15. Past History:
16.  

H/o Anasarea 4 years back”

The District Forum has also referred to Death Summary of St. Stephen’s Hospital dated 20.11.2012 Ex CW-1/D wherein it has been mentioned as under:

•      DIAGNOSIS:

UPPER GASTROINTESTINAL BLEED

CHRONIC LIVER DISEASE

HEPATIC ENCEPHALOPATHY

B/L LOWER ZONE PNEUMONIA

AK1?HEPATORENAL SYNDROME

SEVERE HYPONATREMIA

COMPLAINT & HISTORY:

C/O ABDOMINAL DISTENSION SINCE – 5 DAYS

C/O ALTERED SENSORIUM – 1 DAYS

HAEMATEMESIS AFTER COMING TO HOSPITAL

H/O SIMILAR EPISODE-3 DAYS BACK

NON ALCOHOLIC”

15. The District Forum has also referred to the other details mentioned in the Death Summary of St. Stephen’s Hospital and opined that it reflects diagnosis as Upper Gastrointestinal Bleed, Chronic Liver Disease, Hepatic Encephalopalthy; and has opined that the DLA was suffering from Liver Disease but had concealed the same while filing the Proposal Form dated 12.10.2011. After observing the same it has relied on theprinciple of law that the contract of insurance isbased on the principle “Uberrimaefidel” where the insured is expected to disclose all the information correctly. It has been rightly observed by the District Forum that in the instant case the DLA had concealed the same. It further held that the respondent had rightly rejected the claim of the complainant.
16. The Death Summary dated 20.11.2012which is at page 39 of the appeal, St. Stephen’s Hospital mentioned Upper Gastrointestinal Bleed, Chronic Liver Disease, Hepatic Encephalopalthy.The document at page 43 & 44 as well as page 63 & 64 has been filed by the appellant/Complainant which is dated 03.12.2013. This is a letter from the Senior Divisional Manager addressed to the appellant/Complainant regarding death claim of Policy No. 126009560 dated 23.08.2011 which is Ex CW-1/G. This letter is also in order to apprise the appellant/Complainant about the decision to repudiate all liability under this policy on account of the deceased having withheld material information regarding his health at the time of effecting the assurance with the respondent. It has also been informed in this letter about the Proposal for Assurance dated 12.10.2011 and the personal statement therein signed by the deceased assured on 12.10.2011. At the time of taking the policy he had answered the following questions as under:

17. Thereafter it was further informed to the appellant/complainant that these answers were false asthe DLA was suffering from Gastrointestinal Disease before he proposed for the policy for which he consulted a doctor and taken treatment from the hospital. He did not, however, disclose these facts in his Proposal Form/personal statement though he had personal knowledge of the same.Instead he gave false answers. It was also informed to the appellant that the DLA had made incorrect statement and withheld correct information from the Life Insurance Corporation regarding his health at the time of affecting the assurance. Thereafter in terms of the policy contract and declarations contained in the Proposal Form for Assurance, Life Insurance Corporationhad repudiated the claim and has also informed that they were not liable for any payment in this Policy No. 126009560 dated 23.08.2011 and all money that has been paid in consequence thereof belong to Life Insurance Corporation. It has further been mentioned in this letter that :
    • In case you disagree with our decision and feel that we have not considered any particular facts and circumstances in support of your claims, you may send your representation within three months for reconsideration of your claim to our Zonal Office at the following address:

The Zonal Manager,

L.I.C. of India,

Northern Zonal Office,

Connaught Circus,

New Delhi-110001.”

18. It is pertinent to mention that admittedly despite letter dated 03.12.2013 from the Life Insurance Corporation addressed to Ms.Anju Gupta the appellant, wherein she could have sent her representation within three months for reconsideration of her claim to the Zonal Office of Life Insurance Corporation, however, instead of filing any such representation for reconsideration of her claim, she has filed the Complaint No. 253/14 having date of institution as 12.03.2014i.e the case decided from which the present appeal arise.
19. It has been argued on behalf of the appellant that there were two policies. First policy which was taken in the year 2009 i.e. Policy No.125362757 dated 13.09.2009. In that policy the claim has been paid, however, for the reasons best known to Life Insurance Corporation the claim in the second policy, i.e.Policy No.126009560 dated 23.08.2011, the claim has been repudiated. Learned counsel for the respondent has submitted that it is so. However, he has duly explained for the same. He has rightly submitted that with regard to first policy i.e. dated 13.09.2009, the claim was not the early claim, therefore, the matter was processed at Branch level and the claim was paid. However, with respect to the second policy i.e. Policy No. 126009560 dated 23.08.2011, the claim was a case of early claim and it was duly investigated and at that time it was found that the DLA has withheld the material information with respect of his health. The detailed letter dated 03.12.2013 also supports the same. No reason has been explained for not filing any representation, if the appellant/Complainant was not satisfied with the reasons explained in letter dated 03.12.2013, vide which she was informed about the repudiation of claim under the policy on account of disease having withheld the material information regarding his health at the time of affecting the assurance with the Life Insurance Corporation.
20. It is pertinent to mention that the Proposal Form wherein the deceased had furnished information is dated 12.10.2011 and the deceased passed away on 20.11.2012 i.e. within thirteen months of thepolicy. The deceased had not even mentioned in this Proposal Form about consumption of alcohol. He had not mentioned about any ailment pertaining to his stomach or liver.
21. A perusal of the record further shows that regarding non-alcoholic status, the appellant is relying on Death Summary of St.Stephen’s Hospital that, thathas been rightly mentioned but regarding Pushpanjali Hospital Discharge Summary dated 17.11.2012,it has been submitted that the ‘Past History’ mentioned as ‘alcoholic and history of Anasarea 4 years back’ has been wrongly mentioned. It is worthwhile to note that the appellant/Complainant has not taken any steps neither with the hospital authority nor with any other Government authority with respect to wrong information. No cogent reason has been explained for the same despite the fact that the respondent/opposite party had taken such objection in its written statement before the District Consumer Disputes Redressal Forum also.

22. It is noteworthy that the ‘Past History’ mentioned in Discharge Summary of Pushpanjali Hospital dated 17.11.2012 mention “Alcoholic, H/o Ansarea 4 years back.” This Discharge Summary reflects that the DLA was admitted on 17.11.2012 and discharged the same day. Thereafter, he was admitted in St. Stephen’s Hospital on 17.11.2012 at 13:41:29 i.e. in the afternoon of 17.11.2021.

23. The Death Summary of St. Stephen’s Hospital dated 20.11.2012 mention ‘DIAGNOSIS’ as mentioned in parasupra Upper Gastrointestinal Bleed, shock, Chronic Liver Disease etc. ‘COMPLAINT & HISTORY’ also mention Non-alcoholic. The argument put forth on behalf of the appellant is that Pushpanjali Medical Centre has mentioned ‘alcoholic’ and the same day St. Stephen’s Hospital has mentioned Non-alcoholic. It has been submitted that Pushpanjali Medical Centre has wrongly mentioned alcoholic in ‘Past History’. The appellant has relied on Death Summary of St. Stephen’s Hospital. Appellant kept silent about ‘Chronic Liver Disease’ mentioned in ‘Diagnosis’. Appellant harped upon‘non-alcoholic’ and brushed aside diagnosis of ‘Chronic Liver Disease’.

24.           It is also worthwhile to note that the patient was admitted on 17.11.2012 i.e.just in thirteen months of taking the second policy. It reflects that the non-declaration in Proposal Form (12.10.2011)qua the ailment amounts to material suppression of information with regard to health of the DLA.

25.                     It has also been argued on behalf of the appellant/Complainant that at the time of taking the second Policy i.e. Policy No. 126009560 dated 23.08.2011 DLA was not suffering from any Liver Disease but no such document in this respect has been placed on recordas to when the appellant/Complainant or her husband (DLA) had come to know about the ‘Chronic Liver Disease’. It also reflects that intentionally the material fact qua health of the DLA has not been disclosed by the DLA in the Proposal Form. Keeping in view the early claim case the Life Insurance Corporation/respondent had investigated the matter as per their rules/procedure and had arrived at the right conclusion that:

•          We may, however state that the above answers were false as deceased life assured was suffering from Gastro Intestine Disease before he proposed for the above policy for which he consulted a doctor and taken treatment from hospital. He did not however disclose these facts in his proposal form/personal statement though he had personal knowledge of the same. Instead he gave false answers therein as stated above.

It is therefore evident that he had made incorrect statements and withheld correct information from us regarding his health at the time of affecting the assurance. Hence in terms of the policy contract and declarations contained in the form of proposal for assurance, we hereby repudiate the claim and accordingly we are not liable for any payment under the above policy and all moneys that have been paid in consequence thereof belong to us.”

26. It has also been argued on behalf of the respondent that the first policy i.e. Policy No. 125362757 dated 13.09.2009 was not an early claim and no investigation was required in that case and Section 45 of Insurance Act of 1938 was not applicable/operative in that case as well as the claim of the first policy was settled at Branch level without referring the matter to Divisional Office.However, the second policy i.e. Policy bearing No.126009560 dated 23.08.2011 (the policy in question) is an early claim in which as per rules, thorough investigation regarding the health,habit and occupation of the life assured/policy holder, the deceased, was required to know the exact cause of death and duration of disease etc. The Life Assured, nowdeceased (DLA) withheld all the material information regarding his health in the Proposal Form at the time of taking the policy when he was suffering from CLD-Hepatic Encephlopathy Grade-II Dyslectrlytemia, Severe Anemia and Hepatorenal Syndrome. The DLA had past history of Alcoholic and H/o Ansareafour years back.  He did not, however, disclose these facts in his Proposal Form,rather he gave false information having malafide intention on his part. His claim was repudiated vide letter dated 03.12.2013 after considering and scrutinising all the aspects of the case. It has been rightly submitted on behalf of the respondent that the claim was repudiated on documentary proofs that the DLA suffers from history of alcoholic and history of ansareafour years back.

27. We are of the considered view that there is no infirmity in the impugned judgement. We are in agreement with reasons given by the District Consumer Disputes RedressalForum(East). District Consumer Disputes RedressalForum(East) has rightly dismissed the complaint. Appeal is devoid of merits, hence, dismissed. The impugned judgementdated 04.05.2018 is upheld.

28. Application(s) pending, if any, stands disposed of in terms of the aforesaid judgement.

29. Parties shall bear their own cost.

30. A copy of this judgement be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986. The judgement be uploaded forthwith on the website of the Commission for the perusal of the parties.

31. Appeal file be consigned to Record Room alongwith a copy of this judgement.

(PINKI)

Member (Judicial)

(BIMLA KUMARI)

Member (Female)

PRONOUNCED ON

29.04.2022

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