DATE OF FILING : 15-12-2010.
DATE OF FINAL ORDER : 11-11-2011.
Smt. S. Aruna Kumari,
wife of Late S. Kumar Rao,
Residing at 3, Baje Shibpur Road, P.S. Shibpur,
District Howrah COMPLAINANT.
Versus -
1. Life Insurance Corporation of India,
represented by the Zonal Manager, L.I.C.I.,
Eastern Zonal Office, Hisdustan Building,
4, C.R. Avenue,
Kolkata 72.
2. The Senior Branch Manager,
L.I.C. of India, Howrah City Branch 2,
27/3, G.T. Road ( South ),
P.O. and P.S. Howrah,
Howrah 711 101. OPPOSITE PARTIES.
P R E S E N T
1. Honble President : Shri T.K. Bhattacharya.
2. Honble Member : Smt. Samiksha Bhattacharya.
C O U N S E L
Representatives for the complainant : Shri Manojit Bandyapadhyay,
Shri Anindya Bhadra,
Ld. Advocates.
Representative for the opposite parties : Shri Debasis Chatterjee,
Ld. Advocates.
F I N A L O R D E R
1. This is to consider an application U/S 12 of the C. P. Act, 1986 as amended till date regarding the insurance claim on the ground of deficiency in service.
2. The complainant namely Smt. Aruna Kumari, the wife of Late S Kumar Rao, residing at 3, Baje Shibpur Road, P.S. Shibpur, District – Howrah, filed this case against the o.ps. Life Insurance Corporation of India and others for realization of the claim amount of Rs. 60,000/- against policy no. 437751069 dated 14-03-2007 standing in the name of the policy holder S. Kumar Rao, the husband of the complainant, who expired on 22-06-2008 in Arunima Hospice Kolkata. S. Kumar Rao was the holder of two L.I.C. policies, the other being no. 938226024 dated 12-09-2006 for Rs. 80,000/-. As per claim of the widow of S. Kumar Rao the L.I.C. Authority permitted the complainant to withdraw the amount of Rs. 80,000/- but repudiated the claim of Rs. 60,000/- vide letter dated 05-01-2010 on the ground of suppression of material facts i.e. his illness. Hence the application.
3. The o.p., Life Insurance Corporation of India, contested the case by filing written version contending interalia that this is a case U/S 45 of the Insurance Act, 1938 ; that the claim of the complainant is inaccurate, false, suffers from suppression of facts , that the proposer did not disclose the facts regarding his ill health in his proposal on 12-04-2006 and 14-03-2007 and gave false answers suppressing the material fact of history of illness , that the payment under policy no. 438226024 for Rs. 80,000/- was considered on compassionate ground on ex-gratia basis and the other claim cannot be accepted as there is statutory bar U/S 45 of the Insurance Act, 1938.
4. The two points for determination in this case are – whether there is any deficiency in service on the part of the o.ps. no. 1 and 2, the insurance company and whether the complainant is entitled to an order in terms of Section 14 of the C.P. Act, 1986
DECISION WITH REASONS :
5. Both the points are taken up together for consideration. Admittedly the complainant is the legally married wife of S. Kumar Rao, since deceased, the policy holder of the two policies as above. Admittedly the claim of Rs. 80,000/- was decided by the L.I.C. Authority on compassionate ground and it was reimbursed in favour of the complainant. Admittedly S. Kumar Rao expired on 22-06-2008. Policy in dispute i.e. 437751069 for Rs. 60,000/- was done on 14-03-2007 i.e. prior to one year and three months of his death. Inasmuch as it is the case of the complainant that there was no suppression of fact of illness on the part of the policy holder, the burden of proof of the suppression shifts upon the o.ps., L.I.C. of India to prove that the policy holder was suffering from preexisting disease.
6. Now let us examine if the claim of the o.ps., L.I.C.I., over the suppression of fact of illness has acceptable justification. It is the persistent claim of the o.ps. that this is a case U/S 45 of the Insurance Act, 1938. If the policy holder at the material time of filling up the proforma takes recourse to fraudulent means in suppressing his or her illness and if it is detected at the time of the claim, the claimant has no legs to stand upon. It is bound to be repudiated. The o.ps. claim that S.K. Rao died on 22-06-2008 due to disseminated TB and Meningitis at Arunima Hospice. The first policy commenced on 12-09-2006 and the instant policy in dispute on 14-03-2007. It is their further case that the Life - Assured was suffering from TB long before the stipulated date i.e. 14-03-2007. In respect of their claim they have categorized the dates of the medical treatment of the policy holder. As for example S. K. Rao received medical treatment on 06-10-2006 and 17-10-2006 at School of Tropical Medicine, Kolkata , as OPD patient. On 27-10-2006 it was detected that the patient was suffering from the same disease prior to three months of the said date. He was admitted on 22-06-2007 in the Tropical School of Medicine. Treatment started from 26-06-2007 and ultimately the patient expired at Arunima Hospice on 22-06-2008. Prior to that he received medical treatment in District TB Centre, Howrah, on 06-08-2007.
7. Pinpointing these dates earmarked for his medical treatment, Ld. Lawyer for the o.ps. categorically argued that the policy holder was very much aware of his ailment for Tuberculosis. Knowing fully well that he was a TB patient he suppressed his ailment at the time of initiation of his subsequent policy i.e. the policy dated 14-03-2007. Ld. Lawyer further drew our attention to the questionnaires of the proposal form wherein the policy holder gave his answer in the negative if he consulted any medical practitioner for his ailment during last five years for more than a week or ever admitted in hospital or nursing home for treatment or operation or whether he was suffering from Diabetes, Tuberculosis, Cancer etc. Finally he declared that he was of good health. Ld. Lawyer for the o.ps. vehemently opposed the prayer of the complainant drawing specific reference on the questionnaires and according to him there cannot be better example of suppression of facts of illness than the declaration in the proposal form by the policy holder.
8. Be that as it may, we are aware of the unique gospel that what is sauce for the gander is also sauce for the goose.
9. Thanks to the beneficial temperament of the L.I.C. Authority as good sense prevailed upon them while releasing and disbursing the claim of Rs. 80,000/- to the claimant on ex gratia basis. True it is that this policy was done on 12-09-2006 and according to the o.ps. this date was well beyond the default clause of prolonged illness. But on scrutiny of the dates it appears that this policy was made on 12-09-2006 and the policy holder received treatment as OPD patient just in the next month i.e. 06-10-2006. Had there been proper medical query, it would have been detected that the policy holder was already in the grief of Tuberculosis. Otherwise, only within the elapse of one month he could not have been affected by Tuberculosis. Such disease affects the patient slowly and gradually but not abruptly.
10. If we take up the impugned date i.e. 14-03-2007 as the date of subsequent policy i.e. policy in dispute we come across that the policy holder was admitted at the School of Tropical Medicine, Kolkata , as OPD patient, on 22-06-2007 i.e. after three months of initiation of the policy. Prior to that he was receiving treatment just on the basis of conjecture . There was no specific prescription to conclude that on 06-10-2006 till 14-03-2007 he was definitely attacked with Tuberculosis. Furthermore, Tuberculosis now-a-days is not a fatal disease if treated properly.
11. The photo copy of the prescription dated 27-10-2006 on the OPD patient card contains advice for several tests. The other prescription dated 26-06-2007 confirms that he was affected with Tuberculosis, Meningitis. Now the pertinent question arises if on 14-03-2007 the policy holder had any confirmation in respect to his ailment. The answer is in the negative. This is because on 14-03-2007 on the date of making of the policy the policy holder was totally ignorant of his particular ailment. No document is forthcoming on the part of the o.ps. to justify that the policy holder had definite information that he was suffering from Tuberculosis or that he was guilty for suppression of material facts. We are not in a position to throw aspersion on the policy holder for suppression of fact only on the basis of conjecture and surmise. The o.ps. authority had ample opportunity before initiation of the proposal to thoroughly examine the policy holder medically on 14-03-2007 and as it was not done, the o.p. has no authority to brand the policy holder as a liar. That apart the queries in question in the proposal form are just routine answers as expected from the policy holder. In the instant case the policy holder was not a literate person and not conversant with the English terminology or terms and as such we cannot expect mathematical precision from such a rustic illiterate. In the result we are not in a position to accept the proposition of the ld. Counsel for the o.ps. and we have no other alternative than to jettison the chain of arguments as put forward by him. Accordingly both the points are decided in favour of the complainant.
12. The citation as placed on behalf of the o.ps. does not carry the reference number of the year but we find only the page nos. 71 and 72. The other citation at CPJ decided on 10-10-1994 though legible to some extent, rest one AIR 1938 Mysore page 53 are not legible at all. Be that as it may, the citations deal with the duty and responsibility of the agent and as such cannot have any bearing over our findings.
13. In view of the above the complainant is entitled to get an appropriate order. In the result the application succeeds.
Hence,
O R D E R E D
That the consumer complaint U/S 12 of the C.P. Act, 1986 be allowed on contest against the o.ps. no. 1 and 2 without cost.
That the complainant being the nominee of the deceased policy holder do get an award of Rs. 60,000/- ( Rupees sixty thousand ) on account of assured sum of the policy being no. 437751069 dated 14-03-2007.
That the o.ps. no. 1 and 2, L.I.C.I. are jointly and severally liable to comply with this order and they are directed to pay the aforesaid amount of compensation to the complainant within 30 days hereof, in default, the said amount shall bear further interest at 9 percent per annum from the date of order till the payment.
No order as to costs.
Let certified copies of the order to be supplied to the parties, as per rule.
