Presented by Miss R. Pattnayak, President .
Alleging deficiency in service against the Opposite Parties, the present complaint is filed claiming the insured amount of Rs.2,50,000/-(Rupees two lakh fifty thousand)only towards policy along with compensation and litigation expenses to the extent of Rs.1,00,000/-(Rupees one lakh)only with 18%(eighteen percent) interest from the date of death of insured Urmila Devi Agrawal till actual payment.
(1) Brief facts of the case of the Complainant is that, his mother Late Urmila Devi Agrawal had obtained one insurance policy under the name and style “Wealth Plus” bearing No.593855735 for a sum of Rs. 2,50,000/-(Rupees two lakh fifty thousand)only valid from Dt.31/03/2010 to Dt.31/03/2018 from the Opposite Party insurance company and the Complainant was the nominee in the said policy. During subsistence of the said policy the insured died on Dt.14/12/2010. So, the Complainant being the Nominee lodged a claim against this policy with the Opposite parties along with the relevant documents as per requirement but the said claim was repudiated by the Opposite Party Insurance Company on Dt.20/03/2012 on the ground that the deceased had made deliberate mis-statement and suppression of material facts regarding her health while availing insurance policy. As according to the Complainant, since there was no material suppression of facts on the part of the life assured while taking the policy, such repudiation was illegal and contrary to the insurance contract, the same amount to deficiency of service, as such filed this complaint claiming the amount under the policy and compensation etc.
(2) The Complainant in support of his case had filed affidavit of Sri Rudra Kumar Debta, his co-villager, Affidavit of Dayanidhi Patel, Ex-Sarpanch of Ghesh Grampanchayat and Affidavit of Sri Alekh Bihari Luha, his co-villager and placed reliance upon a number of following documents.
Status Report of policy bearing No.593855735 issued by Opposite Party No.1(one) indicating the policy number, the sum assured, date of commencement of policy and amount of premium paid.
Claimant's statement of Ram Chandra Agrawal (Claim form-'A').
Letter of Opposite Party No.1(one) to the Complainant on Dt.14/01/2011 to provide necessary documents as per list.
Certificate of Dr. Gopal Agrawal Dt.26/01/2011, indicating the ailment of the insured Urmila Devi Agrawal and the facts regarding discharge from Catholic Mission Hospital, Bargarh on Dt.14/11/2010.
Letter Dt.05/08/2011 of Opposite Party (L.I.C.) to Dr. K.C. Dash to provide Form B2 in respect of policy of Urmila Devi Agrawal.
Report of Dr. K.C. Dash in Form-B (Medical Attendant's Certificate of Urmila Devi Agrawal).
Report of Dr. K.C.Dash in Form- B1 (Certificate of Hospital treatment of Urmila Devi Agrawal).
Medical attendant's certificate issued by Dr. Gopal Agrawal in Form-B of Urmila Devi Agrawal.
Certificate of Hospital treatment at Form- B1 issued by Dr. Gopal Agrawal.
Death Certificate of Urmila Devi Agrawal.
Letter of Opposite Party No.1(one) to the son of the Complainant namely Rama Chandra Agrawal on Dt.24/11/2011 to provide certain documents.
Reply in response to letter Dt.24/11/2011 of Opposite Party No.1(one) Complainant on Dt.03/01/2012.
Repudiation letter Dt.20/03/2012 of the Opposite Party No.2 to Complainant.
True copy of letter of Bajaj Allianz insurance company Dt.08/02/2011 addressed to Lok ram Agrawal for Acknowledgment of cheque No.146915 for Rs.2,50,000/-(Rupees two lakh fifty thousand)only towards death claim of late Urmila Devi Agrawal.
True copy of First Premium receipt Dt.09/03/2009 issued by Bajaj Allianz Insurance Company in respect of policy No.0153962223 of Urmila Devi Agrawal.
True Copy of Cheque No. 146915 Dt.01/02/2011 of Bajaj Allianz Insurance Co. Ltd drawn on Axis Bank in favour of Lok ram Agrawal towards the full and final settlement of insurance claim arising out of policy No. 0153962223 of Urmila Devi on Dt.09/03/2010.
The Complainant also filed written argument along with the decision of Hon'ble State Consumer Disputes Redressal Commissions, and National Consumer Disputes Redressal Commission, New Delhi which are attached to the case record.
(3) Notices were duly served on the Opposite Parties and after Notice being served the Opposite Parties entered their appearance and filed their written statement jointly rebutting the allegations made in the complaint on the ground that, since the deceased Urmil Devi Agrawal, the policy holder was suffering from various diseases at the time of taking the proposal and as such obtained the insurance policy fraudulently after suppression of material facts about hes death. As such the policy were void-ab-initio and the claim had rightly been repudiated by the Opposite Parties and there is no deficiency of service on the part of the Opposite Parties in the present case.
The Opposite Parties further submitted that, since in this case there was violation of most sacred principle of uberima-fide or utmost good faith on account of suppression of material health in formation by the insured. Such case against the Complainant needs to be dismissed as the Complainant is not entitled to get any relief as sought for.
The Opposite Parties filed the following documents in support of his case.
Status report of policy No.593861373.
Copy of Policy No. 593861373.
Proposal form.
Agent's Confidential Report.
Medical examiner's Confidential Report.
Status Report of Policy No.593634095.
Copy of Policy No. 593634095.
Proposal form.
Agents Confidential Report.
Medical Examiner's Confidential Report.
Medical attendant's certificate.
Correspondences with the Complainant.
Repudiation Letter.
Correspondences of Ram Chandra Agrawal and statements of the witnesses.
We have heard the submission of learned counsels for both the Parties and have gone through the evidence on record and from the pleadings of the Parties, the points that arise for consideration are:-
Whether the Life Insurance Corporation was Justified in repudiating the claim on the basis of suppression of Material facts ?
Whether there is any deficiency in service on the part of the Opposite Parties ? If so whether they are liable to pay the insurance amount and the compensation as prayed for ?
To what relief ?
Point No.1(one), No.2(two) and No.3(three):-
There is no dispute with regard to the policy taken by the deceased mother of Complainant and also her death cause during the validity period of the policy is also not in dispute but the only dispute is that the Opposite Party/Insurance corporation repudiated the insurance claim vide letter dated 20/03/2012 addressed to the Complainant is that the insured Urmila Devi Agrawal had not disclosed her pre-existing disease in the proposal form at the time of taking the insurance policy and has answered the question No “(a) to (J) of proposal from as “(No)” which amounts to suppression of material facts regarding her health.
There are 3(three) conditions for the application of the second part of Section-45 of the Insurance Act-1938.
(a) The statement must be on a material matter or must suppress facts which it was material to disclose.
(b) The suppression must be fraudulently made by the policy holder and
© The policy holder must have known at the time of making the statement that it was false or that it suppressed fact which was material to disclose.
But after perusal of the record, we found that none of the 3(three) conditions are present in the case and the ground for repudiation was not well based. As per the Medical Examiner's Confidential Report, the authorized doctor of the L.I.C. had examined the assured before she was given the insurance policy and the doctor has given certificate of good health and the doctor also did not notice anything wrong with the assured. If the person is suffering from any pre-existing disease, certainly, the doctor of the L.I.C., who examined the assured before taking the insurance policy would have noticed that the assured is suffering from any disease. Even if the proposer was suffering from any disease, the doctor of the L.I.C. who examined her before the insurance would have certainly found it out.
We also perused the E.C.G. Report Dt.31/03/2010 of Urmila Devi Agrawal, where we found that Dr. Fakir Mohan Patel, M.D.(Pathology) has given report that he E.C.G. is normal and blood pressure is 120/80 and there is normal heart sounds. We also perused the blood sugar Tolerance Report where the doctor has given report that there is normal blood glucose. We also perused the Routine Urine Analysis Report which is also normal. After perusal of the Haemogram Report, the heamogram is 12gm%. In the Lipidogram Report, there is also normal cholesterol, HDL, LDL, S. Triglycerides. From the perusal of the record it is clear that before obtaining the policies, the assured had well examined by the doctor and the doctor examining the assured given his report. Since the L.I.C. has not been able to prove with evidence that the policy was obtained by suppressing information relevant in column No.11(eleven) dealing with personal history of the proposer in the proposal form for insurance on own life. Before issuing a policy to the insured, the L.I.C.'s authorized doctor medically examined her and affirmed that she answered all the questions of the proposal from correctly. So here onus lies on the insurance corporation to prove that there was material concealment of any disease which proved fatal lies on the insurance company. In the present case detailed medical examination of insured was carried out by penal doctor of L.I.C.. Since life assured medically examined by the penal doctor authorized by L.I.C. before issuance of policy and since presence of any disease not found at that point of time. So, now the allegation of suppression of material facts by the Opposite Parties is unjustified.
It has been time and again held by several courts and various State Commission that the onus is heavy on the insurer to prove that the insured deliberately suppressed the fact-relating to the health condition.
The Opposite Party in his version submitted that since the contract of Insurance is based on principles of utmost good faith, it is the responsibility of the policy holder to disclose all informations regarding her health and habits.
On this point we rely on the decision reported in III (2008) C.P.J page No.389 at 393 in New India Assurance Company Limited Vrs Dinesh Kumar Mittal and another decision, M/s Modern Insulators Ltd Vrs Oriental Insurance Company reported in AIR-2000 S.C. 1014, where it was held that it is the fundamental principle of insurance law, that utmost good faith must be observed by the contracting parties and good faith forbids either party from non-discloser of the facts which the parties knew. The insured has a duty to disclose and similarly it is the duty of the insurance company and its agent to disclose all material facts in their knowledge since obligation of good faith applies to both equally.
The Opposite Party also submitted that the insured had pre-existing disease of which she had prior knowledge and before taking the proposal the DLA was treated at NIMHANS, Bangalore, APPOLO, Raipur, APPOLO, Bhubaneswar, APPLO Vishakapatnam and by suppressing that fact opened the policy.
After perusing the record it is clear that, the the policy opened on Dt.31/03/2010. On Dt.08/11/2010 she felt headache with mild fever, discomfort and uneasiness for which she consulted Dr. K.C. Dash and Dr. Gopal Agrawal from Dt.10/11/2010 to Dt.14/12/2010. After perusing the Medical Attendant's certificate of Late Urmila Devi, Certificate of treatment issued by Dr. K.C. Dash, Certificate of Hospital treatment and Medical Attendant's Certificate issued by Dr. Gopal Agrawal reveals that the insured had not any pre-existing disease. The medical attendance certificate issued by Dr. K.C.Dash only reveals that the primary cause of death is Hypertension (Blood pressure ), but the First Hazard Report, like medical Examination confidential report, Electrocardiogram, Blood Sugar Tolerance Report, Routine Urine Analysis Report, Hemogram Report, Lipidogram Report conducted by the Opposite Party at their end by their enpanel doctor and pathologist as relied by the Opposite Party reveals that, the blood pressure before acceptance of proposal was 120/80 (normal) and the heath of insured was absolutely normal in all respect.
It is also medically established that fever, headache are temporary medical condition and it is quite common ailment in our country and are easily treated and thus curable. Similarly, hypertension is more of a life style problem and it is not unnatural that a person whose hypertension is normal at a particular point of time will not fluctuate. In the instant case, the Opposite Party has neither adduce a single piece of evidence to establish that the insured had any ailment at any point of time nor the Opposite Party has proved through any oral/document any evidence that the insured was ever taking any treatment in any of the hospital. The Opposite Party has also failed to prove any nexus of treatment taken by the insured long back in the year 1990 at NIMHANS, Bangalore with the death. Not only that, no record also in the nature of prescription of any doctor or hospital has produced indicating that she took any treatment in any hospital. We are not convinced from these documents that the cause of death of the deceased is pre-existing. In our opinion the suppression of the material or the wrong answer must have same direct bearing or nexus with the ultimate cause of death which in this case is not proved. It is also not proved by the Opposite Party that the deceased had previously admitted in the different hospitals and it is also not proved that the death was due to pre-existing disease.
On this point the Complainant relied on the decision of Rajastan State Consumer Disputes Redressal Commission, Jaipur reported in 2012 (1) CPR 1996 Life Insurance Corporation of India Vrs Gopal Singh Rathore, where it was held that, “non mentioning of diseases cured long ago does not amount to suppression of material facts.” Another decision reported in 2001 (1) C.P.R. 475 Chandigarh, L.I.C. of India Vrs Smt. Kavita Vinayak, where Hon'ble Court held “In absence of any nexus between cause of death and disease which insured was alleged to have concealed, repudiation of claim under life insurance policy is deficiency in service.”
In the instant case there is also no evidence adduced by the Opposite Party to prove that insured suffered from any disease or received treatment before obtaining policy. Therefore allegation of concealment of treatment before taking the proposal is not acceptable in absence of any evidence. The Opposite Parties have failed to prove what has been alleged in the letter of repudiation. The proposal form gave negative answers to the questions put. Therefore, L.I.C. should have led directed evidence to prove what it was asserted in the repudiation letter that the deceased had the previous ill-health while submitting proposal form. The Life Insurance Corporation has not done so. No expert evidence in the line of medical profession has not been produced. There is also no documents filed by the Opposite Parties, so no presumption can be done in the absence of opinion of medical expert. So the Opposite Parties only tried to make allegation but the same is not tendered in evidence. Besides that Complainant had filed the treating doctor's opinion showing that there was no pre-existing disease. Repudiation of claim therefore unjustified. The onus Probandi in cases of fraudulent suppression of material facts rests heavily on party alleging fraud namely the insurer. On this point we rely on the decision of Hon'ble Supreme Court reported in III (1996) C.P.J. 8(SC) Life Insurance Corporation Vrs Smt. G.M. Channa basemma, where it was held that “the burden of proving that the insured had made false representation and suppressed material facts is undoubtedly on the Life Insurance Corporation of India”.
We also rely on another decision of Hon'ble National Consumer Disputes Redressal Commission, New Delhi reported in II (2005) C.P.J 12 (NC) National Insurance Co. Ltd Vrs Bipul Kunda, where it was held that for repudiating a claim of an insured, it is for the insurer to show that a statement on a fact, which was material for the policy had been suppressed by the insured and that statement was fraudulently made by her with the knowledge of the falsify of that statement. In the instant case, the Opposite Party miserably failed to establish that the insured fraudulently suppressed the material facts regarding her health condition before obtaining the policies. The Opposite Parties failed to produce any cogent and convincing evidence either oral or documentary to prove contrary. Only the Opposite Party filed statement of witnesses but the same persons again filed affidavits given contradictory statements. We also perused all documents and the cheque No.146915 Dt.01/02/2011 of Bajaj Allianz Insurance Co. Ltd drawn on Axis Bank in favour of the Complainant's father Lokram Agrawal, who have already settled the claim amount in other policy bearing No.0153962223 of Urmila Devi. So the Opposite Parties were not justified in refusing the claim on the ground that the deceased had suppressed the material facts relating to her health condition.
Admittedly, the deceased had paid premiums in this policy and as such and as per the terms of the policy the Opposite Parties are bound to pay the insured amount. Refusal to make the payment, amounts to deficiency in service. Since the Opposite Parties without proper verification and with out any valid ground refused the claim and as such they are also liable to pay the compensation for causing mental agony to the Complainant.
-O R D E R -
In the result, the Complaint is allowed, the Opposite Parties are directed to pay insurance amount of Rs. 2,50,000/-(Rupees two lakh fifty thousand)only to the Complainant in respect of the policy No.593855735 with interest @9%(nine percent) per annum from the date of repudiation i.e. Dt.20/03/2012 to till the date of Order i.e. Dt.12/06/2013, along with compensation of Rs.5,000/-(Rupees five thousand)only for causing mental agony, loss and harassment within one month from the date of Order, failing which the awarded amount shall carry 18%(eighteen percent) interest per annum till the date of realization of amount.
The Complaint allowed and disposed off accordingly.
Typed to my dictation
and corrected by me.
I agree, I agree, I agree,
(Miss Rajlaxmi Pattnayak) (Smt. Anjali Behera) ( Sri Pradeep Kumar Dash)
P r e s i d e n t. M e m b e r. M e m b e r.
