Orissa

Debagarh

CC/27/2015

Monoja Manjari Padhi, aged about 50 years, W/o-Lt. Prafulla Kumar Padhi - Complainant(s)

Versus

Sr. Divisional Manager, LIC of India , Divisional Officer - Opp.Party(s)

Abhijit Mishra, S. Soren, S.Dash, K.K. Rout.

01 Dec 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, DEOGARH.

Shri P.Ch. Mahapatra, Member & Smt. Jayanti Pradhan, Member

 

Manoja Manjari Padhi,

aged about 50 Years,

W/O - Late Prafulla Kumar Padhi,

At – Matha Sahi, Ward No.3,

P.O/P.S/ Dist - Deogarh.                                                  ....                    Complainant.                                      

               Versus

 

1. Sr. Divisional Manager,

Life Insurance Corporation of India,

Divisional Office, Jeevan Prakash,

Ainthapali, Sambalpur,

768004.

2. Manager (Claim),

Life Insurance Corporation of India,

Divisional Office, Jeevan Prakash,

Ainthapali, Sambalpur,

768004.

3. Manager,

Life Insurance Corporation of India,

Sambalpur Branch - II,

Sambalpur.                                                                  ...                     Opp.Parties.

 

C.D.Case No.25/2015.

DATE OF HEARING : 10.11.2016         DATE OF ORDER : 01.12.2016.

 

For the Complainant   :           Shri Abhijit Mishra, Advocate,

                                                Shri S.Soren, Advocate,

                                                Shri S.Dash, Advocate,

                                                Shri K.K. Rout, Advocate.

                        For the Opp.Party       :           Shri Sachi Kanta Dashr, Advocate.

                                                                       

 

SHRI PRATAP CHANDRA MAHAPATRA, MEMBER : - The genus of the case germane in the fact that consequent upon death of Shri Prafulla Kumar Padhi, the Complainant, a permanent resident of Matha Sahi, of Ward No.3 of Deogarh Municipality P.O/PS/Dist – Deogarh being the wife & Nominee of deceased Shri Prafulla Kumar Padhi (hereinafter referred as DLA), claimed the death benefit under LIC Policy No.592225525 to OPs, who are officials of Life Insurance Corporation of India Ltd. Complainant’s Death Benefit Claim was repudiated by the OPs and hence the Complaint.

            Brief facts of the case is that being persuaded by one Agent of the OPs named Shri Biranchi Narayan Behera, DLA decided to go for a policy “Jeevan Saral ( with profits)” and the agent after making him sign all the documents and forms , took the premium and handed over a policy certificate bearing Policy No.592225525 after few days with the date of commencement of the policy as 28.03.2010 and the date of commencement of risk as 31.03.2010. It was further mentioned in the said certificate that maturity sum assured in the said policy was Rs.2,94,500/- , Death benefit sum assured under main plan was Rs.5,00,000/- , and total instalment premium is Rs.2042/- .Copy of the policy certificate has been annexed as ANNEXURE-1. Unluckily DLA died out of renal failure on 28.02.2013 at his home at Matha Sahi, Deogarh leaving behind the complainant, the widow and two unmarried daughters. The complainant being the nominee of the said policy, claimed the benefits of the policy to the Opp.Parties No.3 by submitting all relevant documents and filling up all forms which were needed to be done at the time of filling application for such claims. Copy of all such documents and forms filled up by the complainant annexed herewith as ANNEXURE-2 series. It has been averred that after receipt of the claim documents, the O.P.No.2 sent a letter to the complainant mentioning therein, as per discharge summery report issued by Apollo Hospital, Bhubaneswar, that the DLA was admitted from 11.02.2013 to 27.02.2013 for treatment of T2Dm, HTN, CKD-V on MHD and requested the complainant to send all treatment particulars for the above stated period to enable them to process the claim without further delay.( Copy of the letter dated 05.05.2014 is annexed herewith ass ANNEXURE-3.) and ultimately repudiated  the claim of the complainant on the ground that DLA was suffering from Diabetes Mellitus and Hypertension since 10 to 15 years and was on medical leave from 01.08.2009 to 25.08.2009;which fact was not disclosed at the time of effecting the policy. Copy of the letter dated 18.11.2014 is annexed herewith as ANNEXURE-4.

            Further, it has been averred that challenging the  said letter of the O.Ps under annexure-4 , the complainant filed one complaint case before the Hon’ble State Consumer Disputes Redressal Commission, Odisha, Cuttack vide C.C.No.5/2015, which was dismissed on dated 12.3.2015 on the observation that the case has been directly filed in State Commission praying for compensation of Rs.21 lakhs to avoid the appropriate District Forum. It is submitted that as no liberty was granted to the complainant to file the case before the District Forum, the complainant approached the Hon’ble National Consumer Disputes Redressal Commission, New Delhi vide First Appeal No. 316 of 2015. The Hon’ble National Commission vide its order dated 29.04.2015 disposed off the appeal as withdrawn giving liberty to the complaint to approach this Hon’ble Forum. Copy of the order dated 12.03.2015 passed in C.C.No.316/2015 and copy of the order dated 29.04.2015 passed in First Appeal No.316/2015 are annexed herewith as ANNEXURE-5 & 6  respectively.

            Hence the present complaint.

2.         In the above noted case , the answering O.Ps/L.I.C of India challenging the instant case not being maintainable in the eyes of law as well as on fact and having no valid cause of action against the O.Ps, while admitting Paras 1 & 2 submitted in response to Para -3 of the complaint petition that Policy No.592225525 was issued  on the life of late Prafulla Kumar Padhi by Sambalpur Branch Office-II of the Corporation with date of commencement as 28.03.2010 under Plan-165-15,Sum Assured Rs.5,00,000/- with date of maturity 28.03.2025. Policy was under Salary Saving Scheme with instalment premium of Rs.2,042/-per month. As per the policy condition maturity benefit of the policy is Rs.2,94,500/- as mentioned on the policy bond and the death benefit is death sum assured along with all premium paid excluding premium for first year and extra premium provided the policy is in force on the date of death. While admitting the fact that complainant being Nominee of the DLA claimed the benefits of the policy and since the duration of the Policy ( from the date of commencement of the policy till the date of death) is less than 3 years the claim, as per rules in force, is treated as an early one and O.Ps in routine process investigated the genuineness of the claim by requiring the claimant to furnish previous treatment particulars. During such enquiry treatment particulars received from Apollo Hospital , Bhubaneswar revealed that the DLA had H/O Diabetes Mellitus and Hypertension, which he was suffering from the said diseases for the last 10 to 15 years and was under medication. Also, from leave particulars made available from Employer of DLA it was found that the DLA had availed leave on medical ground during the period 01.08.2009 to 25.08.2009 i.e. prior to the commencement of the policy. but suppressed this fact by not mentioning the same in the proposal form during inception of the policy.

            OPs have further contended that unlike contracts of ordinary forms coming under purview of the Indian Contract Act,1872, the contract of Insurance is based on the principles of "Uberrima Fide" i.e. "Utmost good faith". Here the contract is based on the information provided by one party to the contract i.e. the proposer/Life Assured. Based on the information provided by him/her in the proposal form, the Corporation undertakes to underwrite the risk based solely and solely on the information furnished by the proposer. By considering this information the corporation decides to accept or decline the proposal or at times even an alternative plan is suggested, taking in to account the overall information. This is done in a scientific manner and this practice is adopted by the insurer all over the world. But DLA in the instant case did not disclose the facts in his proposal that he was suffering from Diabetes Mellitus and Hypertension since last 10 to 15 years and was under treatment for the ailment at Apollo Hospital, Bhubaneswar on dtd.04.02.2013. and had availed medical leave from 01.08.2009 to 25.08.2009. DLA answered falsely to the questions in the proposal form. Had he disclosed the suppressed facts matter would have been different? Since, the insurance is a contract of utmost Good Faith, the DLA breached the spirit of contract by suppressing the actual state of health in the proposals . Hence, the death claim of the policy was repudiated on the basis of valid ground. After all, it is the duty of LIC to protect the policy holders money by discouraging the fraudulent claim.

            Hence deficiency of services cannot be attributed to OPs and the petition is liable to be dismissed.

3.         Heard both the sides. Learned advocate for the OPs submitted that complainant had suppressed material fact regarding suffering from Diabetic Melitus and Hypertension prior to making proposal for the impugned contract of Insurance. He was aware of this fact since Case Record of Apollo Hospital, Bhubaneswar categorically reveals the fact that Complainant was suffering from Diabetes Melitus & Hypertension since 10 – 15 Years. [Exhbt. – D/8-2 under Heading PAST HISTORY]. In spite, he had answered to the questions under serial 11 of the Proposal Form [Exhbt. – D/1-3] as reproduced below:

11	Personal History		Answer Yes or No.	If Yes, please give details.
	(i)	During the last five years did you consult a Medical Practitioner for any ailment for treatment for more than a week.	No
	(ii)	Have you ever been admitted to any hospital or Nursing Home for general check up, observation, treatment or operation.	No
	(iii)	Have you remained absent from place of work on grounds of health during the last five years ?	No
	(iv)	Are you suffering from or have you suffered from ailments pertaining to liver, stomach, Heart, Lunga, Kidney, Brain or Nervous system ?	No
	(v)	Are you suffering from or have you suffered from Diabetics, High Blood Pressure, Low Blood Pressure, Cancer, Leprosy or any other Disease ?	No
	(vi)	Do you have any bodily defect or deformity ?	No
	(vii)	Do you ever have any accident or injury ?	No
	(viii)	Do you use or have ever used Alcoholic drinks, Narcotics, any other drugs, tobacco in any form ?	No
	(ix)	What has been your usual state of health ?	Good
	(x)	Have you ever received or at present availing, under going medical advice, treatment or tests in connection with Hepatitis-B or an AIDS related condition ?	No

 

Answers given to questions 11(iii) & (v) very clearly evinces that material facts have not been disclosed, they have been suppressed by the DLA.

Further, DLA died of  (i) Primary Cause being  HTM   1HD    CRF and  Secondary cause CRF (Chronic Renal Failure) as evinced from MEDICAL ATTENDANT’S CERTIFICATE [Exbt. – D/7-1]. Thus it is well construed that suppressed fact i.e. the DLA had been suffering from Diabetic Malitus & Hypertension is the cause of death and hence it is material fact.Also it reveals from Exhbt. – D/ 5 & Exhbt. – D/ 4  that DLA had availed 25 days of Leave commencing from the period from 01.08.2009 to 25.08.09 on Medical ground Exhbt. – D/ 5 being the Leave Application Form  & Exhbt. – D/ 4 Leave Sanction Order. This also amounts to suppression of facts.

            Besides, learned Advocate cited cases LIC of India Vrs. Mansa Devi [ II (2003) 135(NC)); LIC of India & Ors Vrs, Smt. Shashi Bala [ IV 2003 CPJ 91 (NC)]; LIC of India Vrs. Krishan Chander Sharma [II (2007) CPJ 51 (NC)]; LIC of India Vrs. Ayesha [R.P.No.3362/2004 NCDRC]; P.C.Chacko & Anr Vrs. Chairman, LIC & Ors [2007 (13) SCALE 329 (SC)] and  R.P.No.1061/2011 NCDRC.

            Learned advocate for complainant assailed contention of OPs in regards to Exhbt. – D/8-2  that the date of Proposal for issuance a Policy is 27^th.February 2010 and diagnosis of ailment suffered by complainant in Apollo Hospital, Bhubaneswar is 11^th February 2013. Hence complainant cannot be alleged to have suppressed any material fact. Also  it is objected by the learned counsel that availing of leave for 25 days by the complainant on Medical ground does not establishes the fact that such leave was availed for self-treatment. Leave availed was for treatment of family member. It is submitted Medical Attendant’s Certificate ( Exhbt. – D/7-1) is a document prepared by OPs themselves and far away from truth. Vehemently Counsel for complainant submitted that Repudiation of just Claims of the Complainant is illegal and the grounds on which repudiation made are fictitious, frivolous and devoid of application of judicial mind.

            Cases of both the sides are concluded thus.

4.         Before setting forth any further the question raised by the OPs that the instant case is not maintainable in the eyes of law as well as on fact and having no valid cause of action against the O.Ps,, needs to be looked in to at the outset. We quote here the definition of “Consumer” & “Service” as provided under Sec.2(1)d & Sec.2(1)

 

Sec.2(1)(d) - "consumer" means any person who-

(i) buys any goods for a consideration which has been paid or promised or partly paid and partly promised, or under any system of deferred payment and includes any user of such goods other than the person who buys such goods for consideration paid or promised or partly paid or partly promised, or under any system of deferred payment when such use is made with the approval of such person, but does not include a person who obtains such goods for resale or for any commercial purpose; or

(ii) 4[hires or avails of] any services for a consideration which has been paid or promised or partly paid and partly promised, or under any system of deferred payment and includes any beneficiary of such services other than the person who hires or avails of the services for consideration paid or promised, or partly paid and partly promised, or under any system of deferred payment when such services are availed of with the approval of the first mentioned person; (but does not include a person who avails of such services of any commercial purpose;)

Explanation.-For the purposes of sub-clause (i), "commercial purpose" does not include use by a consumer of goods bought and used by him exclusively for the purpose of earning his livelihood, by means of self-employment;

 

Sec.2(1)(o) - "service" means service of any description which is made available to potential users and includes the provision of facilities in connection with banking, financing insurance, transport, processing, supply of electrical or other energy, board or lodging or both, housing construction or entertainment, amusement or the purveying of news or other information, but does not include the rendering of any service free of charge or under a contract of personal service;

            On conjoint reading of the above cited definitions it is beyond doubt that complaint is maintainable under law and fact and repudiation of claim being the setting stone of the bunch of events, there exists cause of action. Having heard and on perusal of documents adduced by both the sides we find as follows :

1.     Beyond doubt it is established that there was an insurance contract between DLA, husband of the complainant, and Life Insurance Corporation of India of whose, OPs are officials, in shape of a JEEVAN SARAL (WITH PROFIT) under Table/Term – 165/15 bearing Policy No.592225525 [Exhbt. – P/1] . Overview of the policy are :

Date of Commencement : 28.03.2010; Date of commencement of risk : 31.03.2010; Maturity Sum Assured : Rs.2,94,500/-; Death Benefit Sum Assured under main plan : Rs.5,00,000/-; Accident Benefit Sum Assured : Rs.5,00,000/-; Total Instalment Premium : Rs,2042/-; Due Date of Premium : 28^th; Mode of Payment of Premium : Monthly.

2.     DLA died at his residence at Matha Sahi, Ward No.3 of Deogarh Municipality on 28.02.2013 [Exhbt.- P/3], the immediate cause of death as stated by the Complainant in CLAIMANT’S STATEMENT [Exhbt. – P/4] is Renal Failure and in the MEDICAL ATTENDANT’S CERTIFICATE [Exhbt. – D/7] it has been stated - Primary cause of death is HTM & IHD & CRF while Secondary cause of death is CRF (Chronic Renal Failure)
3.     Complainant, wife of DLA and Nominee under the Policy, raised the claim of  Death Benefit Sum Assured as her husband, the insured, died while the assured policy is in full force before the OPs and her claim was repudiated by  OP Company [Exhbt.- D/11] on the ground that DLA while making the proposal had withheld material information. Relevant portion of the speaking repudiation letter is produced below:

“ xxxxxxxxxxxxxxxxxxxxxx. In this connection, we have to inform you that in the proposal signed by him, he had answered the questions as under:

Question No                                                                                    Answer

11      (i)        During the last five years did you consult                                                      a medical Practitioner for any ailment                                                                                                requiring treatment for more than one week ?                                                    No              (iii)       Have you remained absent from place of                                                                                            your work on grounds of health during the                                                                                          last 5 years ?        No                                                                                               (iv)  Are you suffering from or have you ever suffered                                                                                                        from ailments pertaining to liver, stomach,                                                                                 heart, lungs, Kidney, Brain or Nervous system ?                                           No              (v)        Are you suffering from or have you ever suffered                                                                             from Diabetes, Tuberculosis, high or low Blood                                                                         Pressure, Cancer, Epilepsy, Hernia, Hydrocele,                                                                                Leprosy or any other disease ?                                                                              No

          (ix)       What has been your usual state of health ?                     Good

We however state that we have evidence and reasons to believe that before he proposed for the above policy he was suffering from Diabetes Melitus and Hypertension since 10 to 15 years. This is evident from the case record of Apollo Hospital, Bhubaneswar, date 04.02.2013. The Deceased Life Assured was also on medical leave from 01.08.2009 to 25.08.2009, which is established from the leave application of the deceased and Leave Sanction letter issued by D.I.P.R.O., Deogarh. He did not however disclose this fact in his proposal form and gave false answers therein as stated above inducing us to issue the policy on the basis of the false statement.

        It is therefore evident that he had made deliberate misstatements and withheld material information from us regarding his health at the time of taking the policy and hence terms of the policy contract and the declaration 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 policy and all money that have been paid in consequence thereof stands forfeited. xxxxxxxxxxxxxxxxxxx”

4.     OPs in repudiating the claim of the Complainant have relied and have put emphasis upon the Case Record of Apollo Hospital, Bhubaneswar, date 04.02.2013 wherein under the Heading PAST HISTORY  it has been written  H/o Diabetes Melitus – 10-15 years; H/o Hypertension – 10 – 15 years. This has been written on 04.02.2013 and if we go back to 15 years, it comes to 04.02.1998 and 10 years it is 04.02.2003. Apollo Hospital, Bhubaneswar was inaugurated on 5^th of March 2010 as it is observed from the Web-portal of Apollo Hospital, Bhubaneswar. Hence it is very clear that  Apollo Hospital, Bhubaneswar did not exist prior to 5^th of March 2010 or Apollo Hospital, Bhubaneswar had not provided any treatment to the DLA for Diabetes Melitus & Hypertension itself prior to 05.03.2010, so that the past history stated is outcome of their own record. In that case the information must have been collected and recorded on the Case Record [Exhbt.- D/8]. Out of many possibilities of collecting the past history most probable one is verifying old papers related to treatment of DM & HTN at some other Hospital / Nursing Home at some other time produced before them. Another possibility, Patient himself or his Attendant might have narrated symptoms leading to the conclusion of suffering from DM & HTN since 10-15 years. In the former possibility in absence of any such document of treatment of DM & HTN prior to 04.02.2013 to conclude was suffering from DM & HTN since last 10-15 years, is just an apprehension, not a fact. Also in the later possibility it is not a first-hand information. In a recent decision, the Supreme Court in Kalyan Kumar Gogoi vs Ashutosh Agnihotri & Anr., has examined and explained the law relating to the appreciation of 'hearsay' evidence. Honourable Justice J.M. Panchal, speaking for the bench has observed as under;

“18.The word `evidence' is used in common parlance in three different senses : (a) as equivalent to relevant (b) as equivalent to proof and (c) as equivalent to the material, on the basis of which courts come to a conclusion about the existence or non-existence of disputed facts. xxxxxxxxxxxxx   The idea of best evidence is implicit in the Evidence Act. Evidence under the Act, consists of statements made by a witness or contained in a document. If it is a case of oral evidence, the Act requires that only that person who has actually perceived something by that sense, by which it is capable of perception, should make the statement about it and no one else. If it is documentary evidence, the Evidence Act requires that ordinarily the original should be produced, because a copy may contain omissions or mistakes of a deliberate or accidental nature. These principles are expressed in Sections 60 and 64 of the Evidence Act.

19.The term `hearsay' is used with reference to what is done or written as well as to what is spoken and in its legal sense, it denotes that kind of evidence which does not derive its value solely from the credit given to the witness himself, but which rests also, in part, on the veracity and competence of some other person. The word `hearsay' is used in various senses. Sometimes it means whatever a person is heard to say. Sometimes it means whatever a person declares on information given by someone else and sometimes it is treated as nearly synonymous with irrelevant. The sayings and doings of third person are, as a rule, irrelevant, so that no proof of them can be admitted. Every act done or spoken which is relevant on any ground must be proved by someone who saw it with his own eyes and heard it with his own ears.

21.xxxxxxxxxxxxxxxx It is a fundamental rule of evidence under the Indian Law that hearsay evidence is inadmissible. A statement, oral or written, made otherwise than a witness in giving evidence and a statement contained or recorded in any book, document or record whatever, proof of which is not admitted on other grounds, are deemed to be irrelevant for the purpose of proving the truth of the matter stated. xxxxxxxxxxxx”

         In our considered opinion, OPs have failed to establish that DLA was suffering from Diabetes Melitus & Hypertension and was aware of the fact that he was suffering from DM & HTN earlier than 04.02.2013.

5.     The speaking letter of repudiation also speaks “The Deceased Life Assured was also on medical leave from 01.08.2009 to 25.08.2009, which is established from the leave application of the deceased and Leave Sanction letter issued by D.I.P.R.O., Deogarh”- which has been assailed by learned advocate for the complainant by submitting that  sick leave about which the OPs have averred in the written statement does not have any relation to the cause of death and the said leave was not taken for the disease out of which he died and finally non-disclosure of the sick leave cannot be a ground for repudiating the claim of the complainant which has been clarified by Hon’ble Supreme Court in number of cases and has cited the case of Life Insurance Corporation of India Ltd Vrs. Asha Goel & Anr in Appeal (Civil) No.4186-87 of 1988 while Learned Advocate for OPs have also cited a number of cases, viz. LIC of India Vrs. Mansa Devi [ II (2003) 135(NC)); LIC of India & Ors Vrs, Smt. Shashi Bala [ IV 2003 CPJ 91 (NC)]; LIC of India Vrs. Krishan Chander Sharma [II (2007) CPJ 51 (NC)]; LIC of India Vrs. Ayesha [R.P.No.3362/2004 NCDRC]; P.C.Chacko & Anr Vrs. Chairman, LIC & Ors [2007 (13) SCALE 329 (SC)] and  R.P.No.1061/2011 NCDRC to justify the act of repudiation on the ground of  making deliberate misstatements and withholding material information regarding his health at the time of taking the policy and thereby violating terms of the policy contract and the declaration in the forms of proposal for assurance.
6.     Learned counsel for complainant has raised objection to Exhbt.-D/7, MEDICAL ATTENDANT’S CERTIFICATE & has submitted that the said document has been prepared by OPs themselves, which is far away from truth. Objection raised is not maintainable as because Medical Attendant’s Certificate is a document with relevancy to Claim Form. It is not prepared by LIC, it is prepared in the insistence of the claimant while filing the claim form to LIC.
7.     (i) In the case of LIC of India Vrs. Mansa Devi [ II (2003) 135(NC)] respondent’s answers were false to the questions and on enquiry it was found that he was on medical leave for 150 days from 26.3.1992 to 22.08.1992 and remained in the hospital due to a thorn prick at his foot for which his left leg was amputated. Also there was evidence that DLA had been getting treatment from P.G.Hospital for the last eight years. Hence ratio of the case does not fit to the instant case.

        LIC of India Vrs. Krishan Chander Sharma [II (2007) CPJ 51 (NC)] is a case of revision before Hon’ble National Consumer Disputes Redressal Commission directed against the order dated 30.03.1999 of State Consumer Disputes Redressal Commission, Haryana, Chandigarh. Out of four policies viz. Policy for Sum Assured – Rs.30,000/- on 28.03.1982, Policy for Suma Assured – Rs.50,000/- on 20.12.1985, Policy for Suma Assured – Rs.1,00,000/- on 25.10.1990 and Policy for Suma Assured – Rs.2,00,000/- on 20.09.1993 obtained by deceased wife of the respondent only the last policy i.e. Policy for Suma Assured – Rs.2,00,000/- was repudiated on the ground of withholding information regarding her health status. Ratio of this case does not fit to the case in hand in as much as the fact that two years had not been completed from the date of commencement till the date she died i.e. 20.02.1994 and as such Section 45 of Insurance Act would not be attracted whereas in the case in hand decease Prafulla Kumar died on 28.02.2013 and Date of Commencement is 28.03.2010. Clearly the policy had run for two years and eleven months.

        It is seen in all the rest cases cited by learned counsel for the OPs namely LIC of India & Ors Vrs, Smt. Shashi Bala [ IV 2003 CPJ 91 (NC)]; LIC of India Vrs. Ayesha [R.P.No.3362/2004 NCDRC]; P.C.Chacko & Anr Vrs. Chairman, LIC & Ors [2007 (13) SCALE 329 (SC)] and  R.P.No.1061/2011 NCDRC,  claims have been repudiated by LIC of India on the ground of suppression of material facts and death of the insured in all of them have occurred within two years, the limiting period as provided under section 45 of the Insurance Act. We therefore decline shelving ratios of these cases in the instant case where the limiting period has already crossed and the DLA deserves being awarded the benefit of Section 45 of the Insurance Act.

8.     Before dwelling upon the citation brought to our notice, we would like to discourse the fact of availing of sick leave by DLA. CERTIFICATE BY EMPLOYER [Exhbt.- D/6], LEAVE APPLICATION FORM SUBMITTED FOR SANCTION OF E.L. [Exhbt.- D/5] and SANCTION ORDER ISSUED BY DIPRO, DEOGARH [Exhbt.- D/4] reveal that DLA had availed  25 days of E.L. for the period from 01.08.09 to 25.08.09 on medical ground and 19 days of E.L. for the period from 10.02.2013 to 28.02.2013 also on Medical ground. 19 days E.L. for the period from 10.02.2013 to 28.02.2013 is after commencement of the policy and risk period under the policy and hence cannot be shelved under the category of misstatement in the light of questionary under serial 11 of the Proposal Form. 25 days of E.L. availed from 01.08.2009 to 25.08.2009 is definitely prior to proposal for effecting an insurance and there too availed on Medical ground has been labelled material against the question – 11(iii). Nowhere, Employer, District Information & Public Relations Officer, Deogarh has stated the said leave was availed by DLA for his own treatment. OPs have also adduced no document as to the impugned leave on medical ground was availed for own treatment by the DLA. As per provision of Rule-140, 141 of Orissa Leave Rules, 1966 a government servant availing leave on medical ground for self treatment is required to furnish medical fitness certificate at the time of joining in duty after leave. In the instant case no such medical fitness certificate has either been furnished by the DLA or DIPRO, Deogarh has required him to produce. This evinces the fact that the impugned leave on medical ground was not availed for self treatment

        Now we focus our attention to the citation brought to our notice by learned advocate for complainant  i.e. Life Insurance Corporation of India Ltd Vrs. Asha Goel & Anr in Appeal (Civil) No.4186-87 of 1988, where the claim was repudiated for non-disclosure about sick leave in the proposal form and the insured had died after two years of its commencement, while disposing up the Appeal Hon’ble Supreme Court have held that non-disclosure of sick leave details cannot be a ground to repudiate the claim by the insurer.

            We are of the considered view that OPs have failed to establish the grounds upon which the genuine claim of the complainant has been repudiated and hence they thereby have committed deficiency in service. We feel it worthy here to quote one observation of Hon’ble Natinal Consumer Disputes RedressaL Commission -  in the case of Abdul Latheef & Others. Vrs. The Life insurance Corporation of India & Others., [2014(3)CLT 386(NC)]

“ It will be unfortunate, if the Insurance Companies try to repudiate genuine death claims on such technical and flimsy grounds. Most of the innocent insured will be victims and the beneficiaries will be deprived of the fruits of life insurance. xxxxxxxx It is unfortunate that on one hand the LIC raises the voice of “Utmost goodfaith” but, in contrast, the faith will be lost while not settling the genuine claims for some or other reasons xxxxxxxx It is the exploitation of the policy holders xxxxxxxxxx The consumers are literally under fear or dilemma that, whether, after death, the beneficiaries ever certainly get any fruit from the LIC xxxxxxxx(Para-10)”

            As such I order as under:

 

ORDER

 

The complaint is allowed. O.Ps jointly and severally are directed to pay the Death Benefit Sum Assured i.e. Rs. 5,00,000/- (Rupees five lakhs) and interest @ 9% from 01.03.2013 till date the amount is paid and Rs.10,000/- (Rupees ten thousand) towards cost of litigation to the Complainant  within 45 ( Forty five) days of receipt of this order failing which the O.P. shall have to pay in addition, an interest of 9% per annum till actually the amount is paid in course of Law.

            Office is directed to supply the free copies of the order to the parties free of costs receiving acknowledgement of the delivery thereof.

Order is pronounced in the open court today i.e. on 1^st  Day of December 2016 under my hand and seal of this forum.

             

                              I agree                              

 

                        (Jayanti Pradhan)                                                        (P.C. Mahapatra)

                          MEMBER (W)                                                                MEMBER

 

            Dictated and Corrected by me.

 

 

                              MEMBER