Tripura

West Tripura

CC/14/76

Smt. Anita Das - Complainant(s)

Versus

The Branch Manager, LICI & Others - Opp.Party(s)

Sri Utaam Kr. Majumdar

10 Jun 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSSAL FORUM
WEST TRIPURA : AGARTALA

 

    CASE NO:  CC- 76 of 2014

 

Smt. Anita Das,
W/o- Late Brajendra Das,
katasheola, Jogendranagar,
Agartala, West Tripura.        ...........Complainant.

         ______VERSUS______

 

1. The Branch Manager,
Life Insurance Corporation of India,
Agartala Branch No.1,
Agartala, West Tripura.

2. The Divisional Manager,
Life Insurance Corporation of India,
Silchar Division Office, 
Silchar-15,

3. The Zonal Manager, 
Life Insurance Corporation of India,
Eastern Zonal Office,
Kolkata- 72,

4. Sri Kajal Biswas,
Development Officer of LICI
Agartala Branch No-1,
Paradise Chowmuhani, 
Agartala, West Tripura.
         

5. Sri Swapan Das,
Agent of LICI, 
Agartala Branch No-1,
Paradise Chowmuhani, 
Agartala, West Tripura.

6. Medical Superintendent,
A.G.M.C. & G.B.P. Hospital,
Agartala, West Tripura.        ......Opposite parties.
    

 

 

                    __________PRESENT__________

 SRI S. C. SAHA
PRESIDENT,
  DISTRICT CONSUMER  DISPUTES REDRESSAL FORUM,
      WEST TRIPURA, AGARTALA. 

SMT. B. BHATTACHARYA,
MEMBER,
  DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, 
  WEST TRIPURA,  AGARTALA.

SHR. B. BHATTACHARYA,
MEMBER,
  DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, 
  WEST TRIPURA,  AGARTALA.

 

C O U N S E L

 

For the Complainant         : Mr. Uttam Kumar Majumdar,
                  Advocate.
                           
For the Opposite party    : Mr. Nepal Majumdar,
                  Advocate.
                    

JUDGMENT  DELIVERED  ON : - 10.06.15

J U D G M E N T     
        This is a complaint U/S 12 of the Consumer Protection Act (herein after referred to as 'the Act') filed by the complainant, Smt. Anita Das, W/O- Lt. Brajendra Das of Katasheola, Jogendranagar, Agartala, West Tripura against the O.Ps, namely The Branch Manager, Life Insurance Corporation of India, Agartala Branch No-1 and 5 others over a consumer dispute alleging negligence and deficiency in service on the part of the O.Ps No. 1, 2 and 3. 

2.        The fact of the case as gathered from the record is that husband of the complainant, Late Brajendra Das, during his life time, had taken a policy of insurance on his own life for a sum assured  Rs.1,25,000/- in pursuance of the proposal No-31457 dated 30.03.10 with quarterly premium of Rs.1531/-. The policy is likely to be matured on 28.03.2025. Having accepted the proposal, the Insurance policy issued by the LIC is No-492711713. The life assured died of Hepatic Encephalopathy at GBP hospital, Agartala on 29.03.11. The complainant, who is that nominee u/s 39 of the Insurance Act, preferred claim under the said policy with the LIC. By a letter dated 28.03.13, the LIC repudiated the liability under the policy on account of the deceased life assured having fraudulently suppressed the material fact in the proposal form regarding his pre-existed ailment. According to the complainant, the O.Ps No. 1, 2 and 3 are guilty of negligence and deficiency in rendering service. Hence, this complaint.

3.        The complaint was contested by the O.P Insurance company stating, interalia, that as the insurance contracts based on the principle of 'utmost good faith', responsibility casts on the insured to give full and accurate information to the question contained in the proposal  form. As the life assured, in the proposal form, withheld material information and gave wrong answers as to his previous medical history, the claim was repudiated. Further that, at the time taking the policy the life assured was suffering from serious disease of Hepatic Encephalopathy but he suppressed the fact of his preexisted ailment and give false declaration in the proposal form with an intent to commit fraud upon the LIC. According to the O.P. Insurance company, they rightly repudiated the claim of the complainant for violation of the provisions of Indian Contract Act. It is denied that they were negligent and deficient in rendering service to the complainant.

4.        In support of the claim, the complainant, Smt. Anita Das, has examined herself as P.W. 1 and another Smt. Sabita Das as P.W. 2 and has proved and exhibited the following documents :
    Exhibit 1 Series: letters dated 28.03.13, 16.08.13 and 02.06.14,
    Exhibit 2 Series: money receipts,
    Exhibit 3: copy of ration card.

5.        On the other hand, one Sri Niranjan Bal, Administrative officer of the LICI, Agartala Branch No-1, has examined himself as O.P.W.1 as a witness of the O.P. Insurance company and has proved and exhibited 21 sheets of document filed by them with firisti on 02.03.15 as Exhibit: A series.

Findings:
6.        The points that would arise for consideration in this case are:
        (i) Whether the deceased life assured suppressed material fact in the proposal form regarding his preexisted ailment at the time of taking the policy;
        (ii) Whether the O.P. Insurance Company rightly repudiated the claim of the complainant;
        (iii) Whether the O.P. Insurance Company is guilty of negligence in rendering service.

7.        We have already heard arguments advanced by the learned counsel appearing for the parties. Also perused the pleadings, documents on record and the evidence adduced by the parties meticulously.

8.        It appears that the O.P. Insurance company by a letter dated 28.03.13 repudiated the claim of the complainant mainly on the ground of deliberate misstatement and withholding of material information in the proposal form furnished by the deceased life assured at the time of taking the policy.

9.        The deceased life assured while taking the policy has answered the  question No- 11 in the proposal form in the following manner; 
 
Sl. No.    Questions    Answers       
11(viii)    Do you use or have you ever used alcoholicdrink, narcotics, any other drugs tobacco in any form?    No       
11(ix)    What has been your usual state of health?    Good     

10.        Indisputedly, the deceased life assured was admitted to AGMC and GBP hospital, Agartala on 25.03.11 and died in the said hospital on 29.03.11. During the course of treatment his disease  was diagnosed as Hepatic Encephalopathy. On perusal  of the Medical Attendant's Certificate (Form B)  and the Certificate of Hospital Treatment(Form BI) it is found that the primary cause of death of the deceased was Hepatic Encephalopathy. The bed head ticket of the hospital shows that the patient was suffering from alcohol withdrawal symptom for a life time.
        As per medical dictionary, acute hepatic encephalopathy develops because of serious liver disease which may cause by exposure to alcohol, chemicals, drugs or supplements etc.

11.        The O.P. Insurance company in their pleading clearly stated that the claim of the complainant was repudiated on 28.03.13 on the sole ground that the deceased life assured withheld material information regarding his health and habit at the time of effecting the assurance of insurance policy.

        Now, let us examine whether the repudiation of the claim of the complainant by the O.P. Insurance company is sustainable on the basis of the materials available  on record.
            
12.        As it appears, The O.P. Insurance Company repudiated the claim of the complainant strongly placing reliance upon the medical documents, particularly the Medical Attendant's Certificate(Form 'B') and the Certificate of Hospital Treatment (Form 'B1') issued by attending physician on record.

13.        In the Medical Attendant's certificate, the exact cause of death of the deceased life assured was stated to be Hepatic Encephalopathy. The relevant column of Medical Attendant's Certificate reads as follows:
 
Sl. No.    Question    Answer       
4(C)    How long had he been suffering from this disease before death?         Not known        
4(d)    What were the symptoms of the illness?    (i) Unconscious followed by abnormal movement of whole body X 1 day
(ii) vomiting X 1 day           
4(e)    When were they first observed by the deceased?    Not known       
4(f)    What was the date of which you were first consulted during the illness?    25.03.11       
4(g)    Did you attend him during the whole of its course? If not, state during what period?    Yes     
     
        In the Certificate of Hospital Treatment (Form B1), the medical officer concerned of the hospital has answered to the questions No. 5 (a) (b) and (C) in the following manner:        
 
Sl. No.    Question    Answer       
5(a)    What was the exact history reported by the patient at the time of admission?(dates, durations of the ailments, the symptoms narrated etc. to be given)      Patient was unconscious.       
5(b)    Was the history reported by the patient himself or by someone else?    By patient party.       
5(c)    If history was not reported by the patient himself the name and relationship of the person who reported. Was the patient present at that time and was he conscious?    Not known     

14.        From the Medical Attendant's Certificate and Certificate of History of Treatment issued by the attending physician of GBP hospital, Agartala, it clearly indicates that the attending physician came to know about the nature of ailment of the deceased life assured for the first time on 25.03.2011 when the patient was brought to hospital for treatment. They had no prior knowledge or information as to the pre-existed ailment of the patient. If so, it is not understandable to us on what basis it was mentioned in the bedhead  ticket that the patient had been suffering from alcoholic syndrome for the last 20 years. As per Certificate of Hospital Treatment, if the medical history of the patient is given by any person other than the patient himself, his name and relationship with the patient is to be recorded. But in the present case, nothing of this sort was done. The O.P. Insurance company did not produce the medical officer concerned, who issued the medical certificates to controvert the plea of the complainant that the deceased life assured was not a chronic alcohol consumer. Had the medical attendant, who treated the patient and issued medical certificates appeared at the witness box to face cross examination by the adversary, it would have been made clear under what circumstances he arrived at the conclusion that the deceased life assured was a chronic alcohol consumer for the last 20 years. There is not a scrap of paper on record to support the plea of the O.P. Insurance Company that the deceased life assured previously got treated in the said hospital. So, the conclusion arrived at by the attending medical physician that the life assured had been a patient of alcohol syndrome for the last 20 years has remained unproved by clear, cogent and tangible evidence.

15.        We have already indicated that in the Medical Attendant's Certificate the name of person from whom the attending physician came to know about the medical history of the patient has not been mentioned though it is mandatory. In this backdrop, there is no scope to ascertain the genuineness of the statement made by the attending physician in the Medical Attendant's Certificate as to the preexisted ailment of the patient when it had been clearly stated in column No. 4(f) of the certificate that the attending physician was first consulted during the illness of the patient on 25.03.2011.  

16.        There is no manner of dispute on the fact that the deceased life assured got admitted to the hospital after one year of taking the policy for alcoholic syndrome. If he remained hospitalized before taking the policy, then the question of withholding of material facts as to his previous ailment could have been arisen. It is true that the life assured died in the hospital after one year of taking policy of Hepatic Encephalopathy which may occur for various causes including exposure to alcohol. This disease may develop even after taking of the policy. The O.P. Insurance company has failed to lead clear, cogent and credible evidence that the deceased life assured was attacked by Hepatic Encephalopathy even before taking the policy. The O.P. Insurance company has failed to controvert the evidence adduced by the complainant corroborated by another witness(P.W.2) to the effect that the deceased life assured had been suffering from alcoholic syndrome long before taking of the policy of insurance.

17.        It is well established that a contract of insurance is made in ''utmost good faith'' and suppression of any material fact by the insuree  would entitle the insurance company to repudiate the claim.
        We have already pointed out that the O.P. insurance company has miserably failed to establish that the deceased life assured had been suffering from alcoholic syndrome before taking of the policy which resulted into his death. That being so, it can not be said that the deceased life assured had suppressed material facts regarding his preexisted disease which eventually led to his death. 

18.         For all the foregoing reasons, we hold that the O.P. Insurance company repudiated the claim of the complainant without any justifiable cause. It is needless to say that repudiation of claim without sufficient cause constitutes negligence and deficiency in service.

19.        In the result, therefore, the complaint U/S 12 of the Act, filed by the complainant is allowed on contest. The O.P., Life Insurance Corporation of India, is directed to pay to the complainant the sum assured Rs.1,25,000/- (Rupees One lakh twenty five thousand) with interest @9% P.A. from the date of repudiation of the claim on 28.03.13 till the payment is made. The O.P. Insurance company is further directed to pay Rs.5,000/- (Rupees Five thousand) to the complainant as compensation for mental agony and harassment together with Rs.2000/-(Rupees Two thousand) as costs of litigation. 

20.                  A N N O U N C E D

SRI S. C. SAHA
PRESIDENT,
DISTRICT CONSUMER  DISPUTES 
REDRESSAL FORUM,
WEST TRIPURA,  AGARTALA.

 
SMT. B. BHATTACHARYA,
MEMBER,
  DISTRICT CONSUMER DISPUTES 
REDRESSAL FORUM, 
  AGARTALA, WEST TRIPURA.    SHRI. B. BHATTACHARYA,
MEMBER,
  DISTRICT CONSUMER DISPUTES 
REDRESSAL FORUM, 
  AGARTALA, WEST TRIPURA.