DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,<br /> BATHINDA (PUNJAB)<br /> <br /> CC No. 200 of 18-07-2007<br /> Decided on :26-11-2007<br /> <br /> Rekha Rani aged about 34 years widow of Shri Sunil Dutt S/o Sh. Dharamveer R/o House No. 1948, Kanwal Cinema Wali Gali, Santpura Road, Bathinda.<br /> .... Complainant<br /> <br /> Versus<br /> <br /> 1.Life Insurance Corporation of India, Divisional Office, Urban Estate,. Phase-I, Dugri, Ludhiana through its Senior Divisional Manager.<br /> 2.Life Insurance Corporation , Branch Office, Jeevan Jyoti Building , Bibiwala Road, Bathinda, through its Branch Manager.<br /> ...Opposite parties<br /> <br /> Complaint under Section 12 of the Consumer Protection<br /> Act, 1986.<br /> <br /> QUORUM :<br /> Sh. Lakhbir Singh, President<br /> Sh. Hira Lal Kumar, Member <br /> Dr. Phulinder Preet, Member<br /> <br /> For the Complainant : Sh. Balwant.Singh Maan, Advocate.<br /> For the Opposite parties : Sh. Sandeep Baghla,Advocate.<br /> <br /> O R D E R <br /> <br /> LAKHBIR SINGH, PRESIDENT<br /> 1. Sh. Sunil Dutt was the husband of the complainant. On 28.4.06, he had purchased Life Insurance Policy No. 300526099 from opposite party No. 2. Premium was paid. According to it, he was assured for a sum of Rs. 2.00 Lacs. This policy was effective from 28.3.06 and its date of maturity was 28.3.2022. Unfortunately, he expired on 28.8.06 due to Cardiac arrest (Heart attack) in Adesh Institute of Medical Sciences & Research Centre, Barnala Road, Bathinda. After his death, complainant lodged claim with opposite party No. 2 well in time. It has been repudiated by the opposite parties vide letter No. Claims/Repdt/5158 dated 19.2.07 on the grounds that deceased had withheld the correct information regarding his health at the time of effecting the insurance. They further allege that deceased remained admitted in C.M.C. Ludhiana from 1.9.2001 to 28.9.2001 for having lower limbs problem and did not disclose this fact in his proposal form/personal statement. Instead, he gave false answers. On 20.3.07, a representation was made by her stating that admission of her husband at previous stage in C.M.C. Ludhiana could not be the basis for the issuance of the policy or repudiation of the claim. Opposite parties appeared in the complaint filed by her before the Insurance Ombudsman, Chandigarh. Claim was contested by them. Ultimately, it was dismissed on 14.5.07. She assails that repudiation of the claim under the policy is illegal, arbitrary and against contractual obligations. Her husband was enjoying good health at the time of taking the policy. He had no alarming pre-existing disease at that time. She, being his wife and nominee under under the policy, is entitled to receive the payment. No proper enquiry or valid investigation regarding the previous illness of her husband has been made by the opposite parties or their Investigator in any manner. Due to act and conduct of the opposite parties in repudiating her claim, she has undergone mental tension, harassment and botheration. In these circumstances, instant complaint under Section 12 of the Consumer Protection Act, 1986 (Here-in-after referred to as `Act') has been preferred seeking direction from this Forum to the opposite parties to pay insurance claim amount of Rs. 2.00 Lacs to her alongwith accrued bonus and interest @12% P.A. from the date of death of her husband till payment besides cost of the complaint<br /> 2. Opposite parties filed their version taking legal objections that complaint is not maintainable in the present form; intricate and contentious questions of facts and law are involved and as such, complaint cannot be decided in summary procedure by this Forum; this Forum has got no jurisdiction to entertain and try the complaint as claim has already been dismissed by Insurance Ombudsman; complainant is estopped from filing the complaint by her act and conduct and complaint is false and frivolous. On merits, they do not deny the purchase of the Insurance policy by her deceased husband and the fact that complainant was appointed as nominee. As per record submitted by the complainant, her husband had expired on 28.8.06. He had paid the insurance premium concerning the policy in question. Complainant had lodged the claim concerning the policy informing about death of the life assured. They admit the repudiation of the claim vide letter dated 19.2.07. They deny that claim has been illegally repudiated. Inter-alia their plea is that there is material concealment of material facts with respect to the state of health by life assured at the time of taking the policy. He was suffering from problem of lower limbs i.e. Left femoral artery thromboembolism. He remained admitted in C.M.C. Hospital, Ludhiana from 1.9.2001 to 28.9.2001. He was treated for this disease. This material fact was not disclosed by him at the time of seeking the insurance. Had the complainant disclosed true or material facts, he would not have been issued the insurance policy. It was obtained by mis-representation and concealment of correct facts. Claim has been rightly repudiated. As per Section 5 of the Insurance Act and terms of the policy, complainant is not entitled to claim the amount. They deny that life assured has died on account of Cardiac arrest. They do not admit the remaining averments in the complaint.<br /> 3. In support of her averments contained in the complaint, complainant has produced in evidence her affidavit (Ex. C-1), photocopy of policy (Ex. C-2), photocopy of letter dated 19.2.07 (Ex. C-3), photocopy of death form (Ex. C-4), photocopy of death certificate (Ex. C-5) and photocopy of order dated 14.5.07 (Ex. C-6).<br /> 4. In rebuttal, on behalf of the opposite parties affidavit of Sh. J.P. Arya, Manager (Ex. R-1), photocopy of Insurance Policy (Ex. R-2), photocopy of letter dated 19.2.07 (Ex. R-3), photocopy of letter dated 17.1.07 (Ex. R-4) and photocopy of Claim Form (Ex. R-5 & Ex. R-6) have been tendered in evidence.<br /> 5. We have heard learned counsel for the parties. Besides this, we have gone through the record and written briefs of arguments submitted on behalf of the parties.<br /> 6. First objection taken by the opposite parties is that complainant had approached the Insurance Ombudsman, Chandigarh and her claim has been dismissed vide order dated 14.5.07 and as such, this Forum has got no jurisdiction to entertain and try the complaint. This argument is devoid of merits in view of the observations of the Hon'ble National Commission in the case of Kamleshwari Parshad Singh Vs. National Insurance Company Limited 2005 CTJ 747 in which it has been held that the “Role of Ombudsman is to investigate individual's complaints against the maladministration, especially that of public authorities. He does not discharge any judicial or quasi-judicial functions. Complainant may not accept his decision. He can take the rejection of his claim by the insurer as in the present case before a Consumer Forum, if he so likes.” Similar view has been held in the case of Brij Kishore Aggarwal Vs. The New India Assurance Company Limited & Others 2006(1) CPC 733 in which Honb'e State Commission, Punjab has held that “ If claim is rejected by ombudsman complainant can approach the District Forum.”<br /> 7. Arguments pressed into service by the learned counsel for the complainant is that the husband of the complainant has since died on 28.8.06 due to Cardiac arrest (Heart attack) in Adesh Institute of Medical Sciences & Research Centre, Bathinda. Claim lodged with the opposite parties has been illegally repudiated vide repudiation letter copy of which is Ex. C-3. Repudiation is illegal and it is liable to be set aside.<br /> 8. Mr. Baghla, learned counsel for the opposite parties argued that life assured i.e. Sunil Dutt, husband of the complainant had intentionally concealed material facts regarding the sufference of disease while seeking the policy. As per terms and conditions of the policy, copy of which is Ex. R-2, claim is not payable. Life assured has died within four months from the date of policy. Even certificate given by the Doctor of Adesh Institute of Medical Sciences & Research Centre, the death of the life assured was due to the disease for which he was suffering and got treatment from C.M.C. Hospital, Ludhiana regarding which copy of certificate is Ex. R-5. Complainant has also admitted sufference of the disease in para No. 5 & 6 of the complaint and also in her affidavit Ex. C-1. In support of it, reliance is placed by the opposite parties on the authorities Sr. Divisional Manager, L.I.C. of India Vs. Smt. Gangama & Anr. 2002(3) CPR 24 (NC) and Life Insurance Corporation of India Vs. Smt. Lily Rani Roy I(1997) CPJ 46 (NC).<br /> 9. We have given our thoughtful consideration to these rival arguments.<br /> 10. Claim has been repudiated vide letter dated 19.2.07, copies of which are Ex. C-3 & Ex. R-3. Substantive para of this letter is reproduced as under :<br /> “In this connection we have to inform you that in the Proposal for Assurance dated 28.3.06 & Personal Statement signed by the deceased Assured on 28.3.2006, he had answered the following questions as under :-<br /> QUESTION ANSWER<br /> 11.(d) Are you suffering from or have you ever suffered from No<br /> ailments pertaining to liver, stomach, Heart, Lungs, Kidney, <br /> Brain or Nervous System ?<br /> <br /> (e) Are you suffering from or have you ever suffered from No<br /> Diabetes, Tuberculosis, High Blood Pressure, Low <br /> Blood Pressure, Cancer, Epilepsy, Hernia, Hydrocele,<br /> Leprosy or any other disease ? <br /> (i) What has been your usual state of Health Good<br /> <br /> We may, however, state that all these answers were false as we hold indisputable proof to show that about in Sept., 2001 he remained admitted in CMC(H), Ludhiana from 1.9.2001 to 28.9.2001 from having lower limbs problem. He did not, however, disclose these facts in his Proposal/Personal Statement. Instead he gave false answers therein as stated above.<br /> It is, therefore, evident that he had made incorrect statement and with-held correct information from us regarding his health at the time of effecting the assurance and hence in terms of the Policy Contract and the Declaration contained in the forms of Proposal for Assurance and Personal Statement, 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.”<br /> 11. No doubt, life assured has died on 28.8.06 and policy was issued on 28.4.06. In other words, he died within four months after issuance of the policy. Material question for determination is as to whether husband of the complainant intentionally concealed material facts while seeking the policy and that the facts concealed has any nexus with the disease due to which he has expired. According to the certificate of Hospital treatment given by Christian Medical College, Ludhiana, Sunil Dutt was suffering from Femoral Artery Thromboembolism. He was admitted in the hospital on 1.9.01 and was discharged on 28.9.01. He had history of severe pain of left thigh and leg. He had weakness of left lower limb. Opposite parties have not proved that after he was discharged from C.M.C Hospital Ludhiana, he was suffering from this disease for which he was admitted in this hospital till the day he purchased the Life Insurance Policy. No medical certificate to this effect is on the record. If a person temporarily suffers from some disease, it cannot be presumed that he continues suffering from it for all times to come. Concealment should be regarding material particulars. When the evidence is lacking to the effect that complainant was suffering from Femoral Artery Thromboembolism till the date he purchased the policy, it cannot be concluded that he has concealed material facts from the opposite parties while submitting proposal for insurance. No doubt, in the certificate issued by Doctor of Adesh Institute of Medical Sciences & Research Centre, Bathinda, life assured has been shown to have been suffering from Hypertension and protein S- deficiency yet it cannot be held that there is nexus between cardiac arrest and the disease from which he was suffering while he was admitted in C.M.C. Hospital, Ludhiana. Moreover, matter stands clinched with the document Ex. R-4 upon which opposite parties are themselves relying. Doctor R K Gupta, M.D. (Medicines) , Consultant Physician and Heart Specialist D.M.R. (Life Insurance Corporation of India) has opined that life assured (Sunil Dutt) has died of Cerebro Vascular Accident Cerebral Thrombosis. He has further made it clear that this disease has no direct relation with illness from which he was suffering in September, 2001. Hence, there is no material concealment on the part of the life assured while seeking the Life Insurance Policy. When it is so, repudiation of the claim by the opposite parties is certainly illegal and arbitrary. In this view of the matter, we get support from the authorities Life Insurance Corporation of India Vs. Darshana Dhingra 2005 (2) CPC 283, L.I.C.of India and Another Vs. T. Suguna 2005 (2) CPC 150, Life Insurance Corporation of India Vs. Smt. Kulwant Kumari 2006(2) CPC 495 and Life Insurance Corporation of India Vs. Smt. Veena Puri 2006(2) CPC 465. With utmost regard and humility to the authorities relied upon by the opposite parties, they are distinguishable on facts. In the case of Sr. Divisional Manager, L.I.C. of India Vs. Smt. Gangama & Anr (Supra) Deceased had malignancy which had been detected in late 1988 for which he had obtained treatment in the form of radio/chemotherapy. This was within his knowledge which he concealed/suppressed at the time of giving replies in the proposal form. Similarly in the case of Life Insurance Corporation of India Vs. Smt. Lily Rani Roy (supra) Deceased intentionally and fraudulently concealed the fact of the illness requiring treatment over a week as indoor patient in G.B. Hospital, Agartala and thus had knowledge that he was suffering from papillary carcinoma.<br /> 12. In view of our aforesaid discussion, repudiation of the claim made by the opposite parties regarding death of Sunil Dutt, is set aside leading to deficiency in service on their part. Question that now arises is as to what relief should be accorded to the complainant under the circumstances. No specific date has been given by the complainant in the complaint on which date she lodged claim with opposite party No. 2. Claim has been repudiated vide letter dated 19.2.07. Since repudiation of the claim stands set aside, it is a case for direction to the opposite parties to pay the due amount i.e. Rs. 2.00 Lacs to the complainant on account of death claim of her husband alongwith interest @ 9% P.A. w.e.f. 19.2.07 till realisation.<br /> 13. No other point was urged before us at the time of arguments.<br /> 14. In the result, complaint is accepted against the opposite parties with cost of Rs. 1,000/-. Opposite parties are directed to do as under :-<br /> i) Pay Rs. 2.00 Lacs to the complainant alongwith interest @ 9% P.A. from 19.2.07 till realisation.<br /> Compliance of this order be made within 30 days from the date of its receipt. Copy of this order be sent to the parties concerned free of cost and file be consigned to record room.<br /> Pronounced :<br /> 26-11--2007 (Lakhbir Singh )<br /> President <br /> (Hira Lal Kumar ) (Dr. Phulinder Preet)<br /> Member Member