Pronounced on 2nd August, 2011 ORDER PER VINEETA RAI, MEMBER The present revision petition has been filed by the Life Insurance Corporation of India and another (hereinafter referred to as the ‘Petitioner’) being aggrieved by the order of the State Consumer Disputes Redressal Commission, Himachal Pradesh (hereinafter referred to as the ‘State Commission’). Smt.Vimla Verma who was the original complainant before the District Form is the Respondent herein. The facts of the case according to the Respondent are that her son, Munish Kumar Verma had taken a life insurance policy from the Petitioner on 10.02.2002 for a sum of Rs.1 lakh for a period of 20 years. Respondent was the nominee under the said policy in case of accidental or natural death of the policyholder. During the subsistence of the policy for which the premium was fully paid, the insuree died on 20.05.2002 following a short illness for which he was admitted in P.G.I. Chandigarh. Respondent, therefore, lodged a claim with the Petitioner/Insurance Corporation seeking payment of Rs.1 lakh and bonus for three years amounting to Rs.25,000/-. Respondent also supplied the required documents to the Petitioner/Insurance Corporation to enable early settlement of the claim. However, Petitioner refused to settle the claim on one pretext or the other and finally repudiated the same in August, 2003. Aggrieved by this, Respondent filed a complaint before the District Forum on grounds of deficiency in service and requested that the Petitioner be directed to settle her claim by paying Rs.1 lakh insurance amount, Rs.25,000/- as bonus, Rs.3,000/- on account of litigation cost and Rs.10,000/- as compensation for harassment, inconvenience etc. along with interest @ 12% per annum from the date of death of the policyholder till the date of payment. Petitioner refuted the above contentions and stated that the claim was rightly repudiated because in violation of the terms and conditions of the insurance policy which is a contract made in utmost good faith, insuree suppressed material information that he had suffered from Enteric Fever & “LGI Bleed” in the year 1998 for which he had undergone treatment at P.G.I., Chandigarh. This fact was certified in a document signed by the Assistant Professor, Department of Gastroentology, P.G.I. Chandigarh. Further, in the year 2002, when the insuree was admitted for the illness because of which he expired, insuree himself had given facts about his earlier illness which was duly recorded in the medical history sheet of the hospital. However, in the Proposal Form of the insurance policy, he had specifically stated “No” in respect of the columns pertaining to previous illness, hospitalization and treatment undergone by him. The District Forum after hearing both parties dismissed the complaint by recording as follows: “In the instant case there is ample evidence on record that the insured Shri Munish Kumar Verma signed the insurance form and had categorically answered ‘No’ to any physical ailment in the columns of his previous health and has alleged that he was possessing good health. This fact is evident from Annexure R-1. Sh.Munish Kumar died at PGI Chandigarh and his certificate of treatment, which was obtained by the OP-LIC is at Annexure R-4 and suggests that he was suffering from enteric fever and was having rectal bleed since 8 PM on 14.05.2k2 and for similar ailment four years back, he was discharged on 3.6.98. The certificate of hospital treatment of Munish Kumar dated 3.6.98 was also obtained which suggests that Munish Kumar remained admitted in the hospital as he had been suffering from fever for three weeks and had been bleeding. The genuineness of these certificates has been disputed by the learned counsel for the complainant on the ground that in Annexure R-4 the date of admissions has been shown as 25.08.98 and date of discharge as 3.6.98 whereas in Annexure R-III the date of admission as well as date of discharge has been shown as 3.6.98. The perusal of the record suggest that though there are discrepancies in these documents, yet this fact cannot be denied that both these documents are the original document procured from PGI and have been signed by Assistant Professor of the Gastroenterology Department. Moreover, the complainant has not denied the admission of Munish Kumar in PGI Chandigarh in the year 1998. The District Forum, therefore, concluded that by suppressing these material facts in his insurance proposal form, insuree had breached the conditions of the insurance policy. Aggrieved by this, Respondent filed an appeal before the State Commission which accepted the appeal by stating that the District Forum erred in placing reliance on Annexures R.III and R.IV which were the statements signed by the Asstt.Professor of Medicine in 1998 and the Sr.Resident of the same Hospital in 2002 regarding the two illnesses suffered by the insuree. In this connection, The State Commission observed as follows: “In case, Annexure-R.III and R.IV are excluded from consideration, there is no material on the record to suggest that the deceased was suffering from any such disease which resulted in his death. Therefore, in order to take advantage of both these Form Nos.3816, i.e. Annexures R.III & R.IV, it was incumbent upon the respondent (LIC of India) to have at least filed the affidavit(s) of the doctor(s) who has treated the deceased in the year 1998 and thereafter in the year 2002 when he died. We may clarify in this behalf that in case of failure after having made an attempt to obtain the affidavit(s) from the doctor(s) concerned, nothing prevented the respondent to have got such doctor(s) summoned through process of law and under Section 13 of the Consumer Protection Act, 1986. No explanation could be put forth by Shri Chauhan on behalf of the respondent for either not filing the affidavit(s) and/or having not summoned the doctor(s) for examination/cross examination.” Aggrieved by this order, the present revision petition has been filed. Learned Counsel for both parties made oral submissions. Learned Counsel for Petitioner stated that the State Commission erred in concluding that no reliance could be placed on Annexures R.III & R.IV, relied upon by the Petitioner in support of its case. In fact, these Annexures were provided to the Petitioner/Insurance Corporation by the Respondent herself following the death of her son. In this connection, our attention was drawn to the affidavit filed in evidence by Shri K.P.S. Rawat, who was the Manager with the Petitioner/Insurance Corporation. In that affidavit, it has been stated that Annexure R.III and R.IV being certificates of the hospital treatment, were submitted by the Respondent herself in connection with the claim filed by her following the death of the insuree and it was only thereafter that the claim was repudiated on grounds of suppressing of material information by the insuree regarding earlier illness, hospitalization etc. The Respondent, therefore, now cannot take the plea that these were unreliable documents produced by the Petitioner/Insurance Corporation to repudiate her genuine claim. Counsel for Respondent reiterated that since Annexures R.III and R.IV have not been supported by affidavits nor have the doctors concerned been examined, these documents, as rightly concluded by the State Commission, have little evidentiary value. Further, the death of the insuree occurred two years after the policy and in such cases unless it is a suppression of a material fact, it cannot now be called into question that the statement made in the proposal form was incorrect or false. In the instance case, no material facts were suppressed since the insuree was not suffering from any disease prior to 2002 which had a nexus with his death. The State Commission correctly appreciating these facts accepted Respondent’s appeal and the present revision petition, therefore, deserves to be dismissed. We have heard learned counsel for both parties at length and have gone through the evidence on record. As discussed earlier, the main reason for the State Commission in accepting the appeal of the Respondent was that the two documents (Annexures R.III & R.IV) produced in evidence by the the Petitioner could not be relied upon since these were not backed by the affidavits of the concerned doctors nor were those doctors who reportedly treated the insuree examined by the District Forum. However, we note that the State Commission failed to take into account the affidavit of Sh.K.P.S. Rawat, Manager of the Petitioner/Insurance Corporation stating that these two documents had been given to the Petitioner/Insurance Corporation by the Respondent herself when she filed her insurance claim as the nominee of the insuree. Under these circumstances, there was no need to obtain affidavits of the concerned doctors. To a pointed query by us to Counsel for the Respondent, whether it was a fact that the Respondent, as stated in the affidavit of Sh.Rawat, had filed these documents, Counsel for Respondent could not deny the same. In view of these facts, Respondent now cannot take a plea that Annexures R.III & R.IV were not reliable and were based on wrong facts at the instance of the Petitioner/Insurance Corporation. On the other hand, a perusal of these documents makes it amply clear that the insuree had in fact been hospitalized in P.G.I. Chandigarh in 1998 for enteric fever, rectal bleeding, bronchial asthma etc. for which he was given radical medical treatment. In 2002, he was again admitted in the same hospital for somewhat similar medical conditions because of which he expired. In Columns 4 and 5 of Annexure R.IV, it is clearly stated that his previous medical history was given by the patient himself. It is also not in dispute that the Respondent’s son (insuree) did not state these facts of which he was fully aware in his insurance policy proposal form. In view of all the above facts, there can be no doubt regarding the authenticity of the two documents relied upon by the Petitioner and which were supplied by the Respondent herself. Respondent has also not been able to produce any specific or credible evidence to counter these facts or the affidavit of Shri K.P.S.Rawat as being incorrect. Not giving information of a prior hospitalization undoubtedly was a material suppression of facts and it is settled law that a contract of insurance between the insuree and the insurance company is based on the principle ubberima fides i.e. a contract entered into ‘utmost good faith’ and suppression of any material information by the insuree would amount to breach of contract which would justify repudiation of the claim by the insurance company. The instant case is squarely covered by the above principles. In view of these facts, we are unable to uphold the order of the State Commission which is set aside. The revision petition is accepted with no order as to costs. |
