BEFORE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
FATEHABAD.
Complaint Case No.: 125 of 2016.
Date of Institution: 27.04.2016
Date of order: 21.04.2017.
Smt.Santro Devi widow of Dharampal son of Diwana resident of village & Post Office Kalwan (Dasha Patti) Tehsil Narwana District Jind.
….. Complainant.
Versus
1.Life Insurance Corporation of India, Divisional Office, Rohtak 3,4,5 SCO Sector-1, Rohtak 124001 through its Divisional Manager.
2.Life Insurance Corporation of India, Ratia Road, Tohana District Fatehabad through its Branch Manager.
….Opposite parties.
Complaint U/s 12 of the Consumer Protection Act
BEFORE: Sh. Raghbir Singh, President.
Sh.R.S.Panghal, Member.
Smt. Ansuya Bishnoi, Member.
Present: Shri Sant Kumar, Advocate for the complainant.
Shri S.K. Dharnia, Advocate for the opposite parties.
ORDER:
The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against the opposite parties (hereinafter to be referred as OPs).
2. Briefly stated the facts of the present complaint are that husband of the complainant namely Dharampal son of Diwana had got himself insured with the OPs vide insurance policy No.179016358 for sum assured of Rs.5,00,000/- having validity from 04.05.2012 to 04.05.2032 and he made the payment of the premium qua the policy in time to the OPs. The complainant is nominee in respect of the said insurance policy. It is further averred that on 20.11.2014 life assured-Dharampal died and after his death, the complainant submitted all the relevant documents to the OPs and also completed all the formalities. She was assured by the OPs that the claim would be settled very soon by releasing all the insurance benefits under the said policy but the OPs instead of settling the claim of the complainant and making payment of insurance benefits wrongly and illegally repudiated the claim of the complainant vide its letter having reference claims/ Rep/2015-2016 dated 01.03.2016 on the ground that life assured did not furnish the correct information and that he furnished the incorrect statements whereas in fact the life assured had furnished the correct information. The repudiation of the claim by the OPs is with a view to cause wrongful loss to the complainant which is clear cut deficiency in service on their part. Thus, the complainant is entitled to compensation of Rs.1,00,000/- from the OPs on account of mental agony and harassment besides the sum assured alongwith interest @ 12% per annum with effect from the date of death of life assured till the date of actual payment. Hence, this complaint.
3. Upon notice, OPs appeared through counsel and resisted the complaint by filing written statement taking preliminary objections regarding cause of action, locus standi, maintainability and suppression of true and material facts. It has been submitted that contract of insurance is totally based on “Utmost Good Faith”, but the policy taken by the deceased is vitiated by fraud committed by him upon the LIC. It is further submitted that the proposer for life insurance was under obligation to disclose all material facts within his knowledge relating to the state of his health at the time of taking of policy but the deceased life assured had withheld correct information regarding his health at the time of taking insurance policy from the OPs. It has been further submitted that in the proposal form for insurance dated 4.5.2012, the deceased had answered the questions as under:-
11(a) During the last five years did you consult a medical practitioner for any ailment requiring treatment for more than a week- No.
(b) Have you ever been admitted to any Hospital or nursing home for general check-up, treatment or operation? No
(c) Have you remained absent from place for work on grounds of health during the last five years- No
(d) Are you suffering from or have you ever suffered from ailment pertaining to Live, Stomach, Heart, Lungs, Kidney, Brain or nervous system? No
(e) Are you suffering from or have you ever suffered from Diabetes, Tuberculosis, high blood pressure, low blood pressure, cancer, epilepsy, Hernia, Hydrocele, Leprosy, or any other disease?
No
- What has been your usual state of health: - Good.
It has been further submitted by the opposite party that all the answers given by the deceased were false, which is clear from the evidence collected by the opposite party which clearly shows that the deceased was suffering from Type II DM * 14 years & Hyptertension with Pulmonary TB on ATT * 1 month as per PGI Chandigarh. It has been further submitted that due to non-payment of premium the policy in question was lapsed from 11.2013 to 05.2014 and thereafter the policy was revived on 10.07.2014 for the full sum assured after making the statement regarding his health by the DLA and the details of the questions duly answered by the DLA are as under:
- Have you suffered from any physical or mental illness, injury or disability and id so, give details? No.
- Have you been required to take medical treatment? If so, give details (such as date of duration of illness Effect of treatment etc. as also name and address of the doctor who treated you) No.
- Are you t present in sound health: Yes.
The policy was revived on 10.07.2014 and the life assured had died on 20.11.2014 which shows that the policy was obtained in order to fetch money from the insurance company. It has been further submitted that the claim of the complainant was correctly repudiated as per the terms and conditions of the policy vide letter dated 01.03.2016. On merits, the pleas taken in the preliminary objections have been reiterated, contents of the complaint have been denied and prayer for dismissal of the complaint has been made.
4. The parties then led their respective evidence by way of affidavits and documents. The complainant has tendered in evidence her affidavit as Ex.CW1/A and documents Annexure C1 to Annexure C5. On the other hand, the OPs have tendered into evidence affidavit of Smt. Gurveen Kaur, Manager (Legal) as Annexure RW1/A and documents as Annexure R1 to R11.
5. We have heard learned counsel for the parties and have perused the case file carefully.
6. The grouse of the complainant is that his claim regarding death of her husband Dharampal who was insured with OPs has been wrongly & illegally rejected by the OPs on the ground that the deceased (life assured) had made incorrect statement and withheld correct information regarding his health at the time of effecting insurance despite the fact that the DLA was not suffering from any ailment and he had not made any concealment. Learned counsel for the complainant during arguments has reiterated the submissions made in the complaint and prayed for acceptance of the complaint.
7. On the other hand the counsel for the OPs rebutted the above said arguments of the counsel for the complainant and argued that the complainant is not entitled for the benefit of Section 45 of Insurance Act because the policy was reinstated on 10.07.2014 as the complainant had defaulted in making the payment of premium due towards the policy in question. It has been further argued that the doctor of PGIMS, Chandigarh had given certificate (Annexure R7) therefore, it established the plea that the patient was having pre-existing disease before taking the policy in question and the certificate given by the government institute need not to be proved/supported with any affidavit. In support of his contention has relied upon the judgments titled as Life Insurance Corporation of India & Ors. Vs. Ramamani Patra & Anr. IV (2015) CPJ (NC), Kajol Vs. LIC of India Revision Petition No.50 of 2011 decided on 04.04.2011 (NC), LIC of India Vs. Smt.Kempamma & Anr Revision Petition No.3848 of 2007 decided on 24.01.2013 (NC), Usha Rani & Anr. Vs. LIC Revision petition No.4875 of 2012 decided on 05.02.2013 (NC), Patel Kirti kumar Prehaladbhay Vs. National Insurance Company Limited 2010 (1) CLT 9 (NC), Life Insurance Corporation of India and others Vs. Murti Devi 2011 (2) CLT 444 (HSCDRC,Panchkula), Rajesh Sharma Vs. Life Insurance Corporation of India 2013 (3) CPJ 650 (NC), LIC of India Vs. Jyothi Sudhir Revision Petition No.1134 of 2016 decided on 20.10.2016 and ICICI Prudential Life Insurance Company Limited Vs. Pushpa Chandran & Others 2014 (4) CLT 272 (NC).
8. We have considered the rival contentions of the parties. It is not disputed that husband of complainant obtained insurance policy dated 16.05.2012 (with date of proposal 04.05.2012) from OPs for a sum assured of Rs.Five lacs (Annexure C1). The complainant being his widow and nominee in the said policy submitted claim to the OPs but they had repudiated the claim of the complainant vide letter dated 01.03.2016 (Annexure C2) on the ground that life assured had made incorrect statements and withheld correct information from them regarding his health at the time of proposal and as per the investigation report he was suffering from Type II DM * 14 years & Hyptertension with Pulmonary TB on ATT * 1 month as per PGI Chandigarh. In support of his contention learned counsel for the OPs has drawn the attention of certificate of hospital treatment issued by Senior Medical Record Officer, Central Registration Department PGIMER, Chandigarh (Annexure R7). It is pertinent to mention here that in column No.7 of Annexure R7 the Senior Medical Record Officer of P.G.I. Chandigarh has reported the history of ailments of DLA on the basis of information furnished by Dalbir Singh, brother of DLA who was his attendant. Otherwise, there is not an iota of evidence of any doctor r any hospital that the ailment was prevalent at the time when the DLA filed up the proposal/revived the policy and had knowledge of the same and had suppressed the same willfully. No record of medical treatment taken by the DLA before revival of the policy has been produced by the OPs. Mere reference in the history is not sufficient to establish that DLA was suffering with the disease before the date of filing of the proposal or revival of the policy. The insurance company is required to prove with credible and cogent evidence to prove that the DLA was suffering from pre-existing disease and had knowingly failed to disclose the same. Moreover, it is well known that hypter-tention is usually a life style disease and easily controlled with conservative medication. There is no evidence that it was so acute or high that it was responsible for death or any other past major illness. It is also quite possible that the DLA despite suffering from Hyper-tension may not be aware of the same. Moreover, the OPs ought to have made thorough inquiry/investigation or necessary medical health check up before issuing/renewal of policy. Without doing so, when they have issued the policy, now they cannot turn around. All the inquiries, investigations and health checkup ought to have been made before issuance of the policy itself. Moreover, the concealment of hypertension has not been taken as suppression of any material information to repudiate the claim. On this point reliance can be taken from case law titled as ICICI Vs. Veena Sharma, 2014 (4) CPJ 580 (NC). It is a matter of common knowledge that in a majority of policies being issued by the Insurance Companies the same are routed through their agents. The agents in their anxiety to get their commission and the insurance companies in order to do more and more business see that the policies are issued the moment they received the premium amount. Even the insurance companies are not aware as to show is the proposer, what is his status or health condition. Here the intention is very clear that first they induce the people to purchase policies and later they start litigation. On this point reliance of case law titled as The Branch Manager, LIC of India & Others Vs. Pasupuleti Bhagya Luxmi & others. 2014 (4) CLT (APSCDRC)
9. The OPs have failed to establish that the life assured had taken treatment prior to obtaining the policy nor could prove the nexus between the disease and cause of death. Perusal of Annexure R8 reveals the immediate cause of death as CARDIAC ARREST/ ACCUTE ON CHRONIC KIDNEY DISEASE; therefore, there is nothing on the file to show that there was any nexus between the disease allegedly stressed by learned counsel for the Ops with the death. When the Ops have failed to prove any link between the so-called disease and death, therefore, we have no hitch to reach at a conclusion that the Ops have wrongly and illegally repudiated the claim of the complainant. Reliance on this point can be taken from case law titled as National Insurance Co. Ltd. & Anr. Vs.Girin R. Shah III (2012) CPJ 322 (NC). There is enough on the file to show that the complainant has been able to prove her case against the OPs and the present complaint deserves acceptance.
10. Thus, as a sequel to our above discussion, we accept the present complaint and direct the OPs to pay the amount of Rs.5,00,000/- (sum assured) to the complainant alongwith interest @ 6% per annum from the date of filing of present complaint till actual realization. This order should be complied within a period of 30 days from the date of this order, failing which the complainant will be entitled to initiate legal proceedings under Section 25/27 of the Act against the opposite party. A copy of this order be supplied to the parties free of costs. File be consigned to the record room after due compliance.
Announced in open Forum.
Dated: 21.04.2017.
(Raghbir Singh)
President
(R.S.Panghal) (Ansuya Bishnoi) Distt.Consumer Disputes
Member Member Redressal Forum, Fatehabad.
