DATE OF DISPOSAL: 27.08.2024.
PER: SRI SATISH KUMAR PANIGRAHI, PRESIDENT
The factual matrix of the case is that the complainant has filed this consumer complaint Under Section 12 of the Consumer Protection Act, 1986, alleging deficiency in service against the Opposite Parties (in short the O.Ps.) and for redressal of his grievance before this Commission.
2. This complainant is the son of the deceased mother late Sabiha Begum was aged 40 years by the time she died on dated 18.12.2017 and has a LIC policy No. 574045079 on her life under name and style “New Jevan Anand” (with profits) with date of commencement of risk w.e.f. dated 31.03.2015 and the date of maturity is 28.03.2036 for sum assured Rs.10,00.000/-. She had duly paid her premium till her death on dated 18.12.2017 at AMRI HOSPITAL Bhubaneswar. The complainant is the nominee in this policy. Her mother was suffering from fever and dry cough as usual and had outdoor treatment by Dr. Amulya Kumar Mishra on dated 31.10.2017 and 1.11.2017 at Berhampur and subsequently admitted on dated 13.12.2017 at AMRI HOSPITAL Bhubaneswar for further treatment under Dr. Ritesh Kumar Agrawala. During the treatment her diseases was diagnosis as Bronchopneumonia, septic shock, MODS, T2DM. The doctor told that this fever and cold became aggravated due to weakened immune system that brings mucus and shortness of breath also infection in lung and alveoli. This disease of her mother “Bronchopneumonia” and other were never diagnosis earlier at any Hospital or any symptoms or breath sounds diagnosis by earlier by any doctor. This disease was developed aggravated within two months and increased the risk of her life. This disease “Bronchopneumonia” etc. were not pre-existing diseases at time of fill-up the proposal form on dated 31.03.2015 for policy. However, she was examined by LIC doctor on the dated 31.03.2015 while filling up her proposal form and doctor of LIC’s had certified her to take the policy since she was fit and sound health. Moreover, medical records/certificates issued by the doctors of AMRI Hospital, Bhubaneswar was filled up by them only. This deceased put her signature in that records in ill health unsound mind condition and she was also semi-illiterate. Under the law the Insurance Regulatory and Development Authority (Protection of policy Holders interests) Regulation 2002 it is duty of insurer or person undertaking the insurance to explain all pros and cons etc. that while insured she put her signature in this case its contains were not read or explained by the LKIC agents or doctor in either in proposal form or in Medical records. There are 3 conditions for application of section 45 of the Insurance Act.
(a) The statement must be on material matter or must suppress facts which material to disclose.
(b) The suppression musts be fraudulent made by the policy holder.
(c) The policy holder must have known at the time of making statement that it was false or that it suppressed facts which it was material to disclose.
In this case the policy holder not faulty under above condition, hence section 45 of the Insurance Act is not applicable in this case. This policy holder died due to the natural complication of the disease and the follow up the procedure of the Hospital suspected to be in variance of the medical practices and procedure in vogue. Also the information took from the doctor by the O.Ps is not of fool proof as such they have knowledge about the medical sciences in vogue. Consequent upon the reasons stated above the mother of the complainant was declared died by AMRI hospital on 18.12.2017 for known reasons of aggravated/ serious conditions of the pulmonary decease which squarely fall for the claim in case of the ordinary causes of death that may be of any disease unlike the Medi-claim policies which is covered under the category-9 of the Medi-claim policy is nothing to do with in any manner. So making the repudiation is sheer illegality is a perpetrated crime. The complainant has filed his claim papers on 14.04.2018 before the O.P.No.1 for which it has repudiated the claim on dated 01.01.2019 stating that the mother of the complainant has suppressed the material facts is not at all true rather the O.P.No.1 & 2 has influenced the doctors of the AMRI hospital to suit the technical need of the LIC is nothing but misfeasance and malfeasance perpetrated on the part of the public officers who created evidence to get repudiation of the claim also attracts criminal procedure for filing criminal cases for creating the false evidence to cause wrongful loss to the complainant. For the reasons stated above for the deficiency of service and doing unfair trade practice to the complainant. Alleging deficiency in service on the part of the O.Ps the complainant prayed to direct the O.Ps to pay Rs.10,00,000/- assured policy amount with 24% interest per annum from the date of death, Rs.1,00,000/- compensation and Rs.10,000/- for litigation cost in the best interests of justice.
3. The Commission admitted the case and issued notice to the Opposite Parties.
4. The Opposite Parties filed written version through his advocate. It is stated that all the averments made in the petition arte all not true and correct and the petitioner is put to strict proof of such of the allegation, which is not specifically admitted herein. In Para-1 regarding the policy particulars name of the policy holder, date of death etc. are based on records and the complainant is put to strict proof of the same. As per policy documents and records Syed Murtzza, who was the son of the policy holder, was the nominee. Subsequently, an affidavit has been submitted stating therein that both Syed Murtaza and Sayad Mohammed Murtaza is one and same person. In Para-2 & 3 regarding the health condition of the deceased life assured and further explanation given therein are not all true and to the knowledge of these opposite parties and the complainant is put to strict proof of the same. Admittedly the policy was taken by the life assured. At the time of taking the policies the deceased life assured has given the proposal form stating her health condition as good and she has not been suffering from any diseases. The deceased life assured had also clearly stated “no” to all the questions mentioned vide clause No. 11 (I to viii) and stated “good” to the question mentioned in 11(ix). Moreover, in the declaration given the policy proposal form, the life assured has stated that, the facts stated in the proposal form and answers given by her to the doctor are all true. Both the doctor and policy holder have also certified and declared that, all the answers to the question No. 10 onwards of the form has been correctly recorded. The medical report given by the doctor at the time of proposing for insurance is based on clinical observation and not on pathological testing. It is the responsibility and duty of the policy holder to tell the truth regarding to her health condition to the doctor. Being an early claim (claim arising within three years from the date of commencement of the policy), on verification of the records of Amri Hospital, Bhubaneswar produced by the nominee, it was found that the deceased life assured was admitted on 13.12.2017 vide IP No. 10360249. The deceased life assured was suffering from Type 2 DM for more than 8 years and was on insulin for 7 years. From the above it is quite clear that Deceased life assured was suffering from type 2 DM prior to taking the policy but she suppressed the same in the proposal though she has the knowledge of her suffering which is a material fact which have a bearing on the granting of risk and was clearly done with the intent to mislead the corporation. She had disclosed the fact of her suffering from such diseases in the proposal from dated 31.12.2015 LIC would not have granted/accepted the said policy or the same would have dealt otherwise. Hence the claim was repudiated on 01.01.2019 due to suppression of material facts. So it is clear that, the deceased life assured by suppressing material facts regarding her illness and treatment, has taken the aforesaid policy. So these O.Ps have repudiated the death claim arising out of the policies and intimated the same to the nominee vide its letter dated 01.01.2019. So nothing is payable under this policy. The contract of insurance is a contract of UBERRIMA FIDES, i.e. contracts of utmost good faith. In these cases the policy holder has by deliberately suppressing her health condition taken this policy and these Opposite Parties on detection of the same has rightly repudiated the claim. No medical examination was required to be conducted, since the coverage of insurance is granted on the basis of self declaration of good health only. The health condition of a policy holder is a material condition in the contract of insurances and as the material condition was suppressed, these Opposite Parties have rightly repudiated the claim. Hence the O.Ps prayed to dismiss the case with exemplary cost in the interests of justice.
5. On the date of hearing advocate for the complainant and advocate for O.Ps are found present. The Commission perused the complaint petition, written version, evidence on affidavit, written argument and documents available in the case record.
On evaluation of the evidence adduced by both the parties, it is revealed that the Opposite Parties have not filed any corroborative documents regarding the insured has been suffering from T2DM and on insulin prior to obtaining the policy from other medical and pathological institution.
It is further apparent from the proposal form submitted by parties that, the LIC Medical practitioner has declared the insured as medically fit for the said specific insurance policy. It is manifest from the “Guidelines to the Diagnostic centre for LIC pre-insurance Medical check Up” brought to the record by the complainant and it is a directive to carry out the pathological test apart from Medical Test while certify by the LIC Medical practitioner. In the instant case the O.P. has issued policy on the basis of Medical Examination Report (MER). It deems that the MER consist of both the reports i.e. Medical and Pathology report. The O.P. has pressed on suppression of Material information while obtaining the policy by the insured stating that, the past illness mentioned in the prescription can never be wrong thing or casual noting, as it is either based on the relevant treatment papers produced before them or revealed by the patient’s declaration on declaration by patients kith and kin. In the present case, the O.P. has not confirmed who stated such information or from where it brought by the doctor. Law is well settled in Neelam Chopra v. Life Insurance Corporation of India, the National Consumer Disputes Redressal Commission (NCDRC) on 08th Oct., 2018 in R.P.No.: 4461 of 2012 ruled that common lifestyle diseases, such as type 2 diabetes mellitus (T2DM), cannot be grounds for outright denial of insurance claims. The O.P. also not able to brought any documents regarding suffering from such diseases prior to obtaining of the policy to the case record. In absence of such documents, the O.P. has repudiated the claim of the complainant. More the less, certificate of Hospital treatment and medical attendants certificate of LIC of India speaks different from the basis grounds of repudiation of claim. The doctor of AMRI hospital in the said report specifically stated in certificate of Hospital treatment – LIC of India claim form B-1, dated 26.03.2018 also disclosed same information at Sl.No. 4(a)/(c) i.e., the time period since November 2017. These two vital documents proved the time period of suffering from T2DM since November 2017 and both the certificates upon which the O.P. relied upon and does not disclose that the insured has been suffering from T2DM and on insulin prior to obtained the insurance policy. The O.P. measurably failed to substantiate that the insured has suppressed the material facts while submitting proposal form and the O.P. repudiated the claim of the complainant in a mechanical and routine manner and not taken extreme care and caution. Hence there is no suppression of material fact in non-disclosure of information regarding health condition while obtaining the present policy by the complainant.
In considering the ratio decidendi in Mahakali Sujatha v. The Branch Manager, Future Generali India Life Insurance Company Limited & Another disposed of on April 10, 2024 in the Court of Hon’ble Supreme Court of India in Civil Appeal No.:3821 of 2024, AIR 2001 SC 549 and AIR 2017 Orissa 54 can be equated with the ratio of the present case.
Relying upon the above decision of law, the Commission allowed the complaint of the complainant against the Opposite Parties on contest. The Opposite Parties who are jointly and severally liable to release the death sum assured policy benefit of Rs.10,00,000/- with simple interest @ 6% p.a from the date of death of the insured i.e. 18.12.2017 to the complaint together with litigation costs of Rs.5000/- within 45 days from the date of receipt of the order. In the event of non-compliance of the above order by the opposite parties, the entire dues shall carry interest @ 9%p.a from the date of filling of the case i.e., Dated: 21.12.2019 till the actual date of realization is made by the opposite parties and the complainant is at liberty to realize said entire dues with interest as above from the opposite parties in accordance to the Consumer Protection Act, 2019.
This case is disposed of accordingly.
The Judgment be uploaded on the www.confonet.nic.in for the perusal of the parties.
A certified copy of this Judgment be provided to all the parties free of cost as mandated by the Consumer Protection Act, 2019.
The file is to be consigned to the record room along with a copy of this Judgment.
