BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.139 of 2014

Date of Instt. 29.04.2014

Date of Decision :13.03.2015

Mamta wife of late Shri.Ramesh Kumar, R/o House No.154, BA Bazaar, Lal Kurti, Jalandhar Cantt.

..........Complainant

Versus

Life Insurance Corporation of India, Divisional Office, Model Town Road, Jalandhar through its Senior Divisional Manager.

.........Opposite party

Complaint Under Section 12 of Consumer Protection Act,1986.

Before: S. Jaspal Singh Bhatia (President)

Ms. Jyotsna Thatai (Member)

Sh.Parminder Sharma (Member)

Present: Sh.KC Malhotra Adv., counsel for complainant.

Sh.MS Sachdeva Adv., counsel for opposite party.

Order

J.S Bhatia (President)

1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act, 1986, against the opposite party on the averments that Ramesh Kumar (since deceased) husband of the unfortunate complainant whilst alive got his life insured vide policy bearing No.132465880 for sum assured Rs.2 Lacs with opposite party from its branch office Unit No.4, Jalandhar through its authorized agent. The policy was with profits under plan No.179 for terms 16 years. The proposal dated 2.6.2011 was accepted at ordinary rate of premium as standard life. The risk of the policy commenced from 2.6.2011. The mode of payment of installment of premium was monthly under salary saving scheme. The signature of the life assured on printed proposal form No.300 dated 2.6.2011 were taken in routine and mechanically on dotted lines on the proposal form filled in English by securing agent of opposite party. The educational qualification of the life assured was 7th class and as such he was semi-literate not conversant with English language. Opposite party obtained reports on the requisite forms from securing agent, Development Officer and Moral Hazard Report etc on the eve of proposing for insurance and carefully and thoroughly scrutinized and verified before acceptance of proposal. All of them in their respective report recommenced his life for insurance as would be clear from their reports with opposite party pertaining to policy subject matter of complaint. Ramesh Kumar, life assured employed as Safai Karamchari in Station Headquarters, Jalandhar Cantt. He worked on tedious and strenuous job of safai karamchari without any trace of any ailment or sickness throughout his life. He was hale and hearty and kept good health with temperate and sober habits at the time of taking insurance on his life. He was insurance minded and was insured under policy No.1324456420 in the year 2007. The life assured had healthy existence and normal physical conditions during his life and was not harbouring and labouring under any disease or sickness when he sought insurance on his life under the policy subject matter of the complaint. The life assured fell ill suddenly and unfortunately died on 20.6.2011 due to heart attack at the age of 40 years. It was God's Will. The policy was alive on the date of death of the life assured. Subsequent to death of life assured, the complainant lodged death claim with opposite party through its policy servicing branch office for payment of sum assured with accrued bonus and other benefit flowing from the policy subject matter of complaint. The complainant completed and complied with all requirements and submitted requisite claim forms whichever the complainant was obliged to complete for quick settlement of claim. Claim so made covered by the policy has been repudiated vide letter Ref.:Claim/Death/Repd/13G/43 dated 30.4.2012 by registered A.D.Post by opposite party. This letter of repudiation was sent by mentioning wrong and incomplete address to the complainant which was not delivered to the complainant due to wrong and incomplete address. The correct address of the complainant was House No.154, B.A.Bazaar, Lal Kurti, Jalandhar Cantt but in the letter of repudiation it was wrongly mentioned B.I.Bazaar instead of B.A.Bazaar. The complainant obtained copy of repudiation letter through RTI application dated 21.5.2013 from opposite party through its Manager (CRM) CPIO vide letter dated 19.6.2013. Refusal to pay just, rightful and genuine claim is wrongful, arbitrary, malafide, capricious and palpable on untenable and unsustainable allegations based on non existing and spurious reasons without any valid justification whatsoever. Letter of repudiation of liability of death claim was not made on germane facts rather on conjectures. The cause of death of the life assured was heart attack. There was no nexus between the cause of death and abdominal pain and the alleged misstatement of sick leave taken on different date for short duration on 30.3.2010 for three day, from 2.4.2010 to 10.4.2010 for nine days and 11.4.2010 to 20.4.2010 for 10 days (total 22 days), as mentioned in letter of repudiation but reason for leave was not consciously mentioned by opposite party. It is not unknown that the employees get leave by producing medical certificate feigning illness although they may not have been actually sick. The leave taken by the employees on medical grounds can not be a proof of actual illness. On such like averments, the complainant has prayed for directing the opposite parties to pay sum assured i.e Rs.2 Lacs alongwith bonus to her alongwith interest. She has also claimed compensation and litigation expenses.

2. Upon notice opposite party appeared and filed a written reply raising preliminary objections regarding want of cause of action, locus-standi etc. It further pleaded that the insured Ramesh Kumar did not disclose the proper facts to the replying opposite party in his proposal form. Rather, he had given false answers and thus, the provisions of section 45 of the Life Insurance Act are applicable to the facts of the present case and the present complaint, being not maintainable, is liable to be dismissed with costs. The brief facts of the case, which would facilitate this Forum to dismiss the present complaint, are that Ramesh Kumar (now deceased) got himself insured with Life Insurance Corporation of India under policy No.132465880 with date of commencement 2.6.2011 for the sum assured of Rs.2 Lacs under the Table-Term 179-16 and the installment premium was Rs.1166/- with monthly mode of payment. The age of said Ramesh Kumar at the time of entering into proposal form was 45 years and nominee was Smt.Mamta being wife, as claimed by the deceased while filling proposal form. He has now been reported to have expired due to heart attack on 20.6.2011 and the duration of the policy at the time of death of Ramesh Kumar was 18 days and the said insurance policy was in force. It has come to the knowledge of the opposite party that Ramesh Kumar had availed various sick leaves on health grounds from his office and the longest period of sick leave from 30.3.2010 to 1.4.2010 and 2.4.2010 to 10.4.2010 and 11.4.2010 to 20.4.2010 rather he gave false answers in the proposal form while procuring the insurance policy as stated above to the questions and on the basis of documentary evidence, the competent authority had repudiated the liability of the opposite party in the policy in question with judicious mind and as per the law, so on this score alone, this complaint is liable to be dismissed with costs. Ramesh Kumar had not disclosed the facts of illness in his proposal form. This history of illness and thereafter medical treatment was relevant for accepting of the risk on his life and he should have disclosed the same in the proposal papers. Ramesh Kumar had intentionally and willfully concealed the factum of his illness before the date of risk and thus, as per the provisions of section 45 of the ibid Act, the present complaint is not maintainable and the competent authority had every right to repudiate the death claim and thus, in view of the law and as per the terms and conditions of the policy, this claim has been rightly repudiated. It denied other material averments of the complainant.

3. In support of her complaint, learned counsel for the complainant has tendered affidavits Ex.CA to Ex.CC alongwith copies of documents Ex.C1 to Ex.C3 and closed evidence.

4. On the other hand, learned counsel for opposite party has tendered affidavit Ex.OPA alongwith copies of documents Ex.OP1 to Ex.OP46 and closed evidence.

5. We have carefully gone through the record and also heard the learned counsels for the parties.

6. The facts involved in the present case are not much disputed. It is not disputed that Ramesh Kumar husband of the complainant obtained insurance policy from the opposite party and sum assured was Rs.2 Lacs. The risk under the policy commenced w.e.f. 2.6.2011 and unfortunately the insured died on 20.6.2011 due to heart attack. The complainant lodged claim with opposite party but opposite party repudiated her claim vide letter dated 30.4.2012 Ex.C1 on the ground that while filling the proposal form the life assured gave wrong answers to the questions relating to his health. In the abovesaid letter, it was further observed that the opposite party has reasons to believe that deceased had availed various sick leave on health ground, for long period from 30.3.2010 to 1.4.2010 (3 days), from 2.4.2010 to 10.4.2010 (9 days) and from 11.4.2010 to 20.4.2010 (10days), (total 22 days) which were not disclosed in the proposal form while taking the insurance policy. So the opposite party has come to the conclusion that the DLA gave wrong answers relating to his health as he has availed various sick leaves on health ground as mentioned above. The opposite party has produced medical certificates Ex.OP28 to Ex.OP33 and Ex.OP37 to Ex.OP40 submitted by deceased at the time of taking medical leaves. Now question which falls for determination is, whether the opposite party was justified in repudiating the claim of the complainant on the above said ground? Counsel for the opposite party contended that the deceased has intentionally gave wrong answers relating to his health while filling the proposal form and as such opposite party has rightly repudiated the claim of the complainant due to non disclosure of status of health by life insured in his proposal form. In support of this contention, he has relied upon Bhanwari Devi Vs. Bharatiya Jeevan Bima Nigan & Anr, IV(2011) CPJ 71 (NC), Life Insurance Corporation of India Vs. Francis Antony D'souza, IV (2011) CPJ 603(NC), Satwant Kaur Sandhu Vs. New India Assurance Company Ltd, IV (2009) CPJ 8 (SC). We have carefully considered the above contentions advanced by learned counsel for the opposite party. The above cited authorities are on its own facts. Medical certificate Ex.OP28 is dated 13.2.2008 and the doctor issuing the certificate has mentioned that Mr.Ramesh Kumar was under his treatment for fever since 11 Feb. Similarly medical certificate dated 16.10.2008 Ex.OP29 is on the ground of fever. Same is position regarding medical certificate dated 8.8.2008 Ex.OP30, it is also on the ground of fever. Medical certificate dated 11.4.2014 Ex.OP31 is on the ground that Ramesh Kumar is suffering from abdomen pain and he is advised rest from 11.4.2010 to 20.4.2010. Similarly medical certificate dated 30.3.2010 Ex.OP32 is on the ground of Ramesh Kumar suffering from abdomen pain. Medical certificate dated 2.4.2010 Ex.OP33 is also on the ground of abdomen pain. Medical certificate dated 11.5.2009 Ex.OP37 is on the ground of cold and fever. Medical certificate dated 16.10.2008 Ex.OP38 is also on the ground of fever. Similarly medical certificate Ex.OP39 and Ex.OP40 are on the ground of Ramesh Kumar having fever. So the deceased took medical leave on the ground of fever, cold or abdomen pain. He is stated to have died due to heart attack. The fever, cold or abdomen pain has no direct nexus with heart attack. So the insured was having minor ailments for which he took leave. It can not be treated as suppression of material facts and opposite party was not justified in repudiating the claim of the complainant on the ground of suppression of deceased or ailment which was not material. In Life Insurance Corporation of India Vs. Sajida Begum, 2007(3) CLT, it has been held by Hon'ble National Commission as under:-

"The State Commission returned the finding that Dr.Vijay Kumar's medical certificates given for getting leave from the employer, as an unreliable evidence. On the very face of it this repeated stereotype medical certificates are being given by the same doctor in similar fashion for number of years without any record of treatment for the same do not inspire us to believe in the same. There is no affidavit of Dr.Vijay Kumar and no other evidence is produced by the petitioner in order to reaffirm their contention".

7. In Santosh Kanwar Vs. Life Insurance Corporation of India, 2008(3) CLT 599, the Hon'ble National Commission while interpreting the provision of section 45 of the Insurance Act ultimately held as under:-

"Keeping the aforesaid law in mind, the controversy is required to be decided. In the present case, the insured deceased was not suffering from any serious disease at the time of filling up the proposal form for obtaining the insurance policy. There was no material suppression on his part".

8. In the present case, the deceased has not taken medical leave on the ground of any serious disease. As already observed above, he took medical leaves on the ground of cold, fever or abdomen pain. It is matter of common knowledge that employees some times for getting leave submit false medical certificates to the employers. In the present case, the opposite party has not led any evidence to show that deceased has taken treatment of any serious disease before taking the policy in question. Further affidavits of doctors issuing the above said certificates have not been filed by opposite party. In our opinion, opposite party was not justified in repudiating the claim of the complainant simply on the ground that the DLA has taken medical leave on various occasions on the ground of fever, cold or abdomen pain which has no nexus with cause of death. The deceased was not supposed to disclose the above mentioned minor ailments while taking the policy, it can not be treated as suppression of material facts.

9. In view of above discussion, the present complaint is accepted and opposite party is directed to pay Rs.2 Lacs to the complainant being the sum assured and other benefits, if any alongwith 9% interest from the date of repudiation of claim till the date of payment. It is clarified that interest amount is being granted by way of compensation. The complainant is further awarded Rs.3000/- on account of litigation expenses. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.

Dated Parminder Sharma Jyotsna Thatai Jaspal Singh Bhatia

13.03.2015 Member Member President