ORDER
(Passed this on 24th March, 2017)
Shri Shekhar P. Muley, President.
01. This is a complaint against Opposite Parties, Reliance Life Insurance Company for not settling the insurance claim of the complainant. The complainant during pendency of the matter died and her legal representative has been brought on record.
02. Anant Deshpande, son of the deceased complainant,
purchased insurance policy of the O.P. for assured sum of Rs. 10 lakh. No medical examination was conducted. The policy was for the period from 22/5/2010 till 22/5/2032. On 28/7/2011 the insured got suddenly ill and had to be admitted to Multi speciality and critical care hospital, Nagpur for treatment. However, he died during treatment on 5/8/2011.
The O.P. was accordingly intimated and claim was submitted to the O.P. The complainant thereafter from
time to time pursued the matter with O.P. but it avoided to settle it on one or other pretext. Alleging this to be deficiency in service, it is prayed to direct the O.P. to pay her claim amount Rs.9,99,000/- with 18% interest along with litigation cost.
03. The O.P. filed its written version and denied the complaint. Bereft the details regarding legal provisions mentioned in the written version, it is stated that the insured Anant Deshpande was suffering from Pulmonary Tuberculosis since 2002 prior to issuing the policy. He had a history of pre existing disease and it was deliberately suppressed at the time of giving proposal for policy. Therefore the claim was repudiated on this ground. The repudiation was intimated to the complainant by letter dated 30/12/2011. Therefore there is no deficiency in its service. It is thus prayed to dismiss the complaint.
04. Heard Ld counsels for the complainant and O.P. Perused documents. Upon consideration of the same, we record our findings and reasons as under.
FINDINGS AND REASONS
- The disputed issue is very small. Whether the
deceased insured had pre existing disease and this fact was suppressed by him while giving proposal for purchasing the policy from the O.P., is the question before us. Since the O.P. repudiated the claim on this ground, burden lies on it to prove this fact. Therefore we will first go by the documents produced by the O.P.
06. The insured Anant died of Pulmonary Kochś with CRA. In simple words, cause of death was Tuberculosis (TB). According to the O.P. he was suffering from this decease since 2002 and was under treatment since 2006. The policy was taken in the year 2010. The O.P. has relied on investigation conducted on behalf of the O.P. The report is placed on record.
07. Perusal of the investigation report reveals the insured was under treatment of Dr. Murkute. This Dr. Murkute appears to be a Homeopath from his clinic name as ¨Yash Homeo Clinic¨. Ld counsel for the complainant has pointed out fallacies of the report on more than one count. First of all, the insured taking homeopathic treatment for TB itself is strange, since TB is a curable disease. Secondly, Dr. Murkute is said to have given a letter disclosing that the insured was suffering from TB since 2002 and was under his treatment since 2006. But no such letter is placed on record nor affidavit of Dr. Murkute is filed in support of the report. The Ld counsel for the complainant by application, Ex.7 sought production of papers relating to investigation and the O.P. was directed to produce the same. But till date no investigation papers are produced. The address of his clinic is also confusing and incorrect.
08. It is also worth to note that as per the investigation,report leave record of the insured was checked. Surprisingly during last three years before his death he did not avail of any kind of leave. He was employed as Supervisor with one company namely, Soni Chemicals on monthly salary of Rs. 4500/-. If he was suffering form TB since long and was under treatment it is really surprising that he did not take any leave during three years. Further, the Investigator inquired with some chemists also to know whether the insured was taking any medicines for TB. But no medicines for TB was purchased by the insured. This investigation gives inference that, possibly, the insured might not have been aware that he was suffering from TB, for, it was not in advanced stage, but he undisputedly died of TB. Suppression fact can only be alleged if the person, despite being aware of the fact, deliberately suppresses it. No affidavit or statement on oath of Dr. Murkute is produced by the O.P. in support of pre existing disease of the insured. Observations made in LIC of India v/s Smt. Priya Sharma Revision Pet. No. 2615/2011 decided on 2/11/2012 (NC) can be considered in this case.
09. Ld counsel for the O.P. in her argument submitted that the insured died soon after taking policy and therefore investigation was undertaken. After investigation it was revealed that the insured was suffering from TB since prior to taking policy and this fact was not disclosed by him in proposal form. This amounts to breach of policy as it a contract of utmost faith and trust and so either party should come clean on material particulars which tend to affect the contract. She further pointed out the certificate issued by City Tuberculosis Control Society, which has certified that the insured was suffering from TB and was receiving anti TB treatment from 2005. In the W.S. some citations are mentioned. However, those are on effect of suppression of pre existing disease on the insurance contract. Therefore those citations will be applicable only if the O.P. can prove its stand on repudiation of the claim.
10. In reply, Ld counsel for the complainant submitted the certificate of the TB Society is filed on record during pendency of the complaint on15/9/2015 and it was not relied on for repudiation of the claim. Besides, it is also stated, age of the insured mentioned in the certificate does not match with his age given in the investigation report and policy. Even if the said certificate is considered, the question is whether the insured was aware of his disease. And importantly, no evidence of treatment is produced by the OP. There is no reference of this certificate in the W.S. For all these reasons, we are unable to attach any importance to this certificate.
11. In the Medical Attendant Certificate given by empaneled doctor of the OP it is disease of the insured was detected recently and he was diagnosed with TB for the first time on 28/7/2011, when he suddenly got ill and was admitted to hospital. That further proves till then he was not aware of his disease. The policy was taken in the year 2010.
12. It is further mentioned in investigation report that on the letter dated 21/9/2011 of Dr. Murkute the insured was referred to Multi Specialty Hospital for further treatment. This alleged letter of reference is the last straw that falsifies the
claim of the O.P. The insured died on 5/8/2011 and so there could not be any remote possibility of referring him for treatment on 21/9/2011. it shows how casually and perhaps carelessly the investigation was conducted and report was made to repudiate the claim.
13. We are thus satisfied with the complainant that her insurance claim has been improperly repudiated and there is certainly deficiency in the service of the O.P. Hence, we allow the complaint and pass the following order.
ORDER
(01) The complaint is partly allowed.
(02) The O.P., Reliance Life Insurance Company is directed to pay a sum of Rs.9,99,000/- (In words Rupees Nine lakh Ninety Nine Thousand only) being death claim of deceased insured Anant Deshpande, with 9% p.a. interest from date of repudiation of the claim to the complainant.
(03) The O.P. shall also pay litigation cost Rs. 5000/- (In words Rupees Five Thousand only) to the complainant.
(04) Order shall be complied by the both Opposite Parties within 30 days from receipt of the order.
(05) Copy of the order shall be given to both the parties, free of cost.
