Present         (1)    Nisha Nath Ojha,   

                              District & Sessions Judge (Retd.)                                                                                         President

                    (2)     Sri Sheo Shankar Prasad Singh,

                              Member

Date of Order :  08.07.2015

                    Sri Sheo Shankar Prasad Singh

1. In the instant case the Complainant has sought for following reliefs against the Opposite party:-

1. To pay the Insured amount of Rs. 1,00,000/- ( Rs. One Lac only ) with interest @ 18% per annum.
2. To pay Rs. 75,000/- ( Rs. Seventy Five Thousand only ) as compensation.
3. To pay Rs. 25,000/- ( Rs. Twenty Five Thousand only ) as litigation costs.

2. Brief facts of the case which led to the filing of complaint are as follows:-

1. The complainant is widow of the deceased life assured Md. Shameem and nominee under the Life Pay Money Back Policy No. 292398849 taken by her husband for sum assured Rs. 1,00,000/- ( Rs. One Lakh only ) from the opposite parties on 18.01.2007 through their corporate agent AISL at Patna.
2. The husband of the complainant had taken a Life Insurance Policy under Life pay Money Back being Policy No. 292398849 for sum assured of Rs. 1,00,000/- ( Rs. One Lakh only ) from the opposite parties on 18.01.2007 through their corporate agent AISL at Patna and paid a sum of Rs. 4,537/- ( Rs. Four Thousand five Hundred Thirty Seven only )as first half yearly premium. The life assured was hale and hearty and was bearing good health at the time of proposal except a mild complaint of blood pressure about 2 years prior to the date of proposal which was cured within a couple of day. The life assured and his family members had forgotten the incident as it was a very minor problem of health which is a common problem of day to day life of common people and that was not a material fact which needs to be disclosed in the proposal form.
3. The life Assured was leading a healthy life before and after taking the policy till October 2005. Suddenly on 31.10.2008, the life assured felt uneasiness and breathlessness and the life assured approached the Indira Gandhi Institute of Medical Science, Patna for treatment. It is relevant to state that at the time of admission, BP of the life assured was reported as 130/80. The life assured died on 04.01.2009. the complainant being nominee under the policy informed the opposite parties and submitted the claim form on 04.05.2009 with all relevant documents.
4. The opposite parties by their letter dated 30.05.2009, repudiated the claim of the complainant on the sole ground of suppression of material fact regarding health by the life assured at the time of proposal on 18.01.2007. The opposite parties have alleged that answer to question no. 3(ii) have been given as ‘No’. Further it has been alleged that “at the stage of underwriting had the above stated facts been disclosed to us, the captioned policy would not have been revived.”
5. The complainant states repeatedly that at the time of proposal the complainant had no problem of Hypertension or High Blood Pressure and as such it was not relevant to state at that time to disclose that about two years prior to the date of proposal, the life assured had some problem of BP which was cured within a couple of days and thereafter the life assured had never suffered with problem of B.P.
6. The complainant state that the opposite parties in their repudiation letter stated had disclosed about the alleged disease of B.P., the opposite parties would not have revived the policy in question was never revived and as such the repudiation itself is erroneous.
7. The complainant state that the reasons of repudiation are false, baseless, contradictory to the terms of contract of Insurance and has been made with a view to harass the complainant for the reasons best known to them.
8. The complainant state that there is deficiency on the part of the opposite parties is not paying the claim of the complainants; and repudiating the claims of the complainants after a long period. In the circumstances, repudiation of the claims of the complainant is not justified, illegal, arbitrary and is good example of deficiency in service on the part of the opposite parties.
9. The complainant is suffering a lot due to such deficient act of the opposite parties. The complainant is also suffering from mental agony and physical harassment due to deficiency on the part of the opposite parties by repudiating his genuine claims for which the opposite parties are liable to compensate in terms of money.   

3. The Opposite Party no. 1, 2 and 3 in their written statement has asserted the following facts :-

1. The instant complaint is false, malicious, incorrect and malafide and is nothing but an abuse of the process of the law and it is an attempt to waste the precious time of this forum, as the same has been filed by the complainant just to avail undue advantage. It is submitted that as pet the hospital records issued by  Indira Gandhi Institute of medical and Science Hospital, Patna dated 31.10.2008 and submitted along with the death claim intimation, it has been confirmed that the DLI was suffering from hypertension for the past three years, however, the same was not disclosed by the DLI at time of signing the proposal form and therefore the claim was declined validly on the ground of material medical non – disclosure. The complaint is thus liable to be dismissed under Section 26 of the Consumer Protection Act, 1986.
2. The above complaint is neither maintainable in law nor on facts and the same is liable to be dismissed in limine.
3. The complainant has not approached this forum with clean hands. Thus, the present complaint should be dismissed forthwith on the grounds of being malafide, baseless and lacking a banofide cause of action.
4. The opposite parties at the very beginning states that there has been no negligence in service whatsoever, on part of the opposite parties in dealing with the concerned policy, thus, the present complaint is liable to be dismissed by this learned forum on this ground alone.
5. It is most humbly submitted that the instant complaint lacks a cause of action. The complaint is based on mere surmises and conjectures. It is an established principle of law  that the machinery of law cannot be invoked on the basis of mere conjectures. Therefore this complaint is liable to be dismissed on want of the cause of action.
6. The complainant is trying to deceive and mislead the forum by stating wrong facts and statements based on his whims and fancies which in reality does not hold true.
7. In the case of Sapna Arora Vs. Life Insurance Corporation of India & Others., I ( 2009 ) CPJ 588 where the claim was repudiated on the ground of suppression of information on prior existence of Diabetes Mellitus, it has been held by Hon’ble Punjab State Consumer Disputes Redressal Commission that a persons being treated by a Doctor is bound to give correct information. Therefore, documents such as discharge certificate or bed – head ticket have been held to be valid basis for repudiation. Thus, the complaint is liable to be dismissed.
8. Hon’ble Punjab State Consumer Disputes Redressal Commission has observed in Life Insurance Corporation of India vs. Smt. Piari Devi & Others, II (2008)CPJ 156 as follows :

“ The Hon’ble Bombay High Court was pleased to hold in the judgement reported as Padmavati N. Dalya Vs. LIC of India, 1995 (3) Recent Revenue reports 245, that where the information is given to the Doctor by the patient himself that has to be believed. The Hon’ble National Commission has held in the judgement reported as Draupadi Devi S. Chaudhary Vs. United India Insurance Co. Ltd., I (1993)CPJ 94 (NC), that where the history of old disease is given by the insured himself as recorded in the discharge certificate, the said record can be made the basis of repudiation.”

9. On 11.05.2009, the opposite party received a Death Claim intimation – Form A along with hospital records issued by Indira Gandhi Institute of Medical and Science, Patna dated 30.10.2008 from the complainant whereby it was stated that the DLI has passed away on 04.01.2009. it is pertinent to mention here that as per hospital records issued by the Indira Gandhi Institute of Medical and Science, Patna the DLI was a known case of Hypertension for the past 3 years.( Vide Annexure OP-3 )
10. On 12.05.2009, the opposite party duly sent a condolence letter to the complainant and duly acknowledged the receipt of documents provided by the complainant for the evaluation of the claim.( Vide Annexure OP-4)
11. On 30.05.2009, the opposite party repudiated the claim on grounds of suppression of material facts by the DLI while filling up the proposal form based on which the said policy was issued. It is submitted at the time of filling up the proposal form by the DLI i.e. non – disclosure of being a known case of Hypertension for the past 3 years which is much prior to the signing of proposal form and amount to material medical non – disclosure. Had the opposite party known about the DLI’s past medical history at the proposal stage, the policy would not have been issued as proposed.( Vide Annexure OP-5)

Documents available on record have been perused by us and we have also heard the parties in details.

The opposite party has submitted that the claim of the complainant has been rejected on the sole ground that the deceased insured had violated the terms and condition of the policy by furnishing false information about his health condition by concealing about his previous ailment. It has been further submitted that had the complainant provided correct medical history then the Insurance Company would not have issued the policy in his favour.

On the other hand the complainant submits that her husband had filled in a column in the proposal form regarding health condition and usually such forms are approved by Doctors on behalf of the company and the only policy is issued. Had her husband given false information regarding his health condition, then the Doctor of the Insurance Company would not have okeyed the proposal form and it is only after approval of the same by the Doctor this policy was issued. Once the proposal form was accepted by the Insurance Company then they are bound to make payment and now the company cannot take contrary view and repudiate the claim of the complainant. Therefore the Insurance Company is responsible for deficiency in service.

Thus, We find deficiency on the part of opposite parties and accordingly, we direct the Opposite Parties, jointly and severally, to pay to the complainant the insured amount of  Rs. 1,00,000/-  ( Rs. One Lac only ) with interest @ 9% ( nine ) per annum from 30.05.2009, date of repudiation, within a period of two months from the date of receipt of this order failing which the interest rate will be 12% ( twelve ) per annum till its final payment.

Aforesaid opposite parties are further directed to pay Rs. 10,000.00/- ( Rs. Ten Thousand only ) to the complainant as composite charge for compensation and litigation costs within the aforesaid period of two months.

Accordingly, this case stands allowed to the extent indicated above.

Member                                                                             President