District Consumer Disputes Redressal Forum
Dakshin Dinajpur, W. Bengal
(Old Sub-Jail Municipal Market Complex, 2nd Floor, Balurghat Dakshin Dinajpur Pin - 733101)
Telefax: (03522)-270013
Present
Shri Sambhunath Chatterjee - President
Miss. Swapna Saha - Member
Shri Siddhartha Ganguli - Member
Consumer Complaint No. 35/2015
Smt. Tagari Choudhury
W/o Late Shib Sankar Choudhury
Vill.: Madhab Nagar, PO: Makdampur, PS: English Bazar
Dist. Malda, W.B. …………………Complainant(s)
V-E-R-S-U-S
1. The Divisional Manager,
Life Insurance Corporation of India, Divisional Office
Jalpaiguri Divisional, ‘Jeevan Deep Building,
Shantipara, PO & PS : Jalpaiguri
Dist.: Jalpaiguri
2. The Branch Manager,
Life Insurance Corporation of India, Balurghat Branch
PO & PS: Balurghat
Dist.: Dakshin Dinajpur – 733101 ……………Opposite Parties
Ld. Advocate(s):
For complainant …………… - Shri Sumit Kr. Mohanta
For OP Nos. 1 & 2 …………… - Shri Dibakar Bhattacharya
Date of Filing : 30.07.2015
Date of Disposal : 22.12.2015
Contd…P/2
Judgment & Order dt. 22.12.2015
The case of the complainant is that the complainant’s husband obtained a Life Insurance Policy- Jeevan Saral as per the Table & Terms 165/10 in his name from Balurghat Branch on 6.1.2010 and the date of maturity was fixed on 6.1.2020. It was stated that the payment was to be made to the tune of Rs.3.062/- quarterly and sum assured of policy was Rs.2,50,000/-. Husband of the complainant Shri Shib Sankar Choudhury the actual policyholder met with an accident and he was on commuted leave on and from 19.10.2008 to 17.9.2009 after getting his fitness certificate he again joined in his service and promoted to S.I. from A.S.I. Subsequently due to his illness and treatment he was admitted at Tata Memorial Hospital, Mumbai on 24.1.2012 and died on 25.1.2012 due to Metastatic Renal Cell Carcinoma and Cardio Respiratory Arrest. In the said policy no. 456568756, it was agreed with the OPs that if the policyholder died the nominee will get the sum assured amount plus(+) benefit, if any. The complainant’s name was registered as nominee and accordingly after death of policyholder Shib Sankar Choudhury’s widow the complainant submitted the prayer with all the necessary documents claiming the amount. The complainant submitted all the documents but the OPs did not allow the prayer of the complainant praying for the sum which was assured by the OPs in case of death of policyholder. The claim of the complainant was repudiated by the OPs for which the complainant submitted a representation to the OPs for reconsideration of the prayer of the complainant but no response was received by the complainant for which the complainant filed this case praying for claim of Rs.2,50,000/- plus (+) bonus and interest and also payment of Rs.5,000/- for cost.
The OP Nos. 1 & 2 have contested this case by filing a written version whereby the OPs denied all the material allegations made by the complainant in the complaint. The claimant has claimed in the
Contd…P/3
complaint that the life assured i.e. the policyholder was on medical leave from 19.10.2008 to 17.2.2009 while the life assured signed the proposal form for insurance did not disclose the facts and suppressed the vital information while signed the proposal form. Insurance contract is a contract of UTMOST GOOD FAITH each party has to declare all the material information for assessing and accepting risk of insurance and any false information given while signing the proposal form for insurance has to vitiate the contract of insurance and the insurance contract becomes null and void. But in the instant case life assured suppressed his previous ailment. The complainant in the complaint has forgotten to add that the insurance sum assured plus benefit, if any are paid has subject to existence of valid insurance contract between the insured and the insurer.
LICI received all the documents on the basis of these documents namely discharge summary of insured from Apollo Hospital, Chennai, wherein it was stated that the history of H.T.N. for the last 10 years and he has availed commuted leave on medical ground for 122 days and undergone Ortho surgery for treatment of his leg fracture during the period from 19.10.2008 to 17.2.2009 and during that period the policyholder availed of medical leave. From the treatment sheet of the Apollo Hospital, Chennai it is manifestly cleared that Ortho surgery was done in 2008 and in the past history was a disease as mentioned as Hypothyrodism. The insured did not declare his decease mentioned above and did not disclose his surgery of leg fracture done between 14.10.2008 to 17.2.2009, while he signed the policy on 1.6.2010 and in the proposal paper stated that he has not suffered from any disease and never hospitalized and his health was good. From the medical report availed from Apollo Hospital, Chennai, it appears that the policyholder has been suffering from Hypothyrodism for the last 8 years and accordingly the claim of the complainant regarding sum assured of Rs.2,50,000/- to bonus etc.
Contd…P/4
The complainant while made a representation to Zonal Office against the decision of the regional office and whenever the complainant found that no relief was given to her by the regional office she could have preferred an appeal before the insurance Ombudsman but the said intimation was given to the complainant which was sent to the complainant by registered letter and the same was returned with postal remark as ‘not known’.
The insurance company OPs stated that as per section 45, wherein it is stated that if a policy was in force for 2 years or more the insurer can repudiate the claim of suppression of material facts by the insured. In this case the insurer has relevant documents that the policyholder has been suffering for the last 10 years due to Hypothyrodism and since the insured suppressed his disease and accordingly claim was repudiated.
In view of the facts and circumstances of the case the OPs claimed for dismissal of the case.
On the basis of pleadings of respective parties it is to be clarified here in this case regarding the points mentioned herein below:-
- Whether the policyholder had the policy under the OPs?
- Whether the policyholder suppressed his disease in the proposal?
- Whether any misdeed committed by the agent will confer any liability on LIC of India?
- Whether for suppression of any disease the complainant being a legal heir of the deceased will be entitled to get any relief as prayed for?
- Whether the insurance company repudiated the claim of the complainant on the basis of suppression of disease?
- Whether there is any deficiency in service on the part of the OPs?
Contd…P/5
DECISION WITH REASONS
All the points are taken together for avoidance of repetition of facts.
Ld. Lawyer for the complainant submitted that during the life time of the policyholder i.e. Shib Sankar Choudhury he contributed premium towards Jeevan Saral of life insurance policy in Balurghat Branch and paid Rs.3,062/- quarterly commencing on and from 6.1.2010 and date of fixed for maturity on 6.1.2020. The sum assured of the policy was Rs.2,50,000/-. During his lifetime he met with an accident for which he had to take commuted leave on medical ground commencing from 19.10.2088 to 17.2.2009 and after getting fitness certificate he joined in his service and promoted to S.I. and after getting promotion he purchased a policy on 6.1.2010. After he fell in illness he went to Tata Memorial Hospital, Mumbai on 24.1.2012 and died on 25.1.2012 due to Metastatic Renal Cell Carcinoma and Cardio Respiratory Arrest. After death of the policyholder the complainant applied to LICI – OP-1 for releasing fund in her favour on premature death of her husband. The request of the complainant was negated and subsequently an appeal was made to Zonal office whereby observation of the regional office was affirmed and claim of the complainant was repudiated on the ground that the complainant’s husband suppressed his illness while he opened the policy.
Ld. Lawyer for the complainant emphasized that the OP-1 failed to appreciate the fact the policyholder got promotion and after getting promotion he purchased the policy and subsequently because of his illness he went to Tata Memorial Hospital, Mumbai for his treatment where he died. Therefore, the said fact cannot be considered to be ground for negation of the claim of the complainant and for that reason the complainant has suffered mental agony and should be
Contd…P/6
compensated along with death claim benefit of Rs.2,50,000/- plus bonus and other benefits that will be accrued in favour of the complainant. The claim of the complainant was made in accordance with law that there was no suppression of material facts regarding opening of policy at the relevant point of time by the husband of the complainant who was the policyholder. In view of the said fact the Ld. Lawyer has prayed for allowing the prayer as made in the complaint.
Ld. Lawyer for the OPs argued that husband of the complainant was on medical leave from 19.1.2008 to 17.2.2009 and while the life assured signed the proposal for insurance, he did not declare the facts and suppressed the vital information while signed the proposal form. The insurance contract is a contract of UTMOST GOOD FAITH each party has to declare all the material information for assessing and accepting risk of insurance and any false information given while signing the proposal form for insurance has to vitiate the contract of insurance and the insurance contract becomes null and void.
During investigation of the case by the OPs whenever the claim was made by the complainant it revealed that on the basis of the information gathered from Apollo Hospital, Chennai, Ld. Lawyer for the OPs emphasized that the policyholder Shib Sankar Choudhury before his death he was admitted to Apollo Hospital, Chennai with the history of Left Pleural Malignant Effusion, he had been there from 5.1.2012 to 20.1.2012 and he had also an ailment of Hypothyrodism as well as he had been suffering from Hypertension for the last 10 years i.e. at the time of opening of policy he suppressed his previous ailment while signing the proposal for insurance. LICI has received all the documents of the insured who was admitted in the Apollo Hospital, Chennai from the discharge summary it is crystal clear that the history of Hypertension for the last 10 years and he availed commuted leave on
Contd…P/7
medical ground for 122 days and also got Ortho surgery for treatment of his leg during the period from 19.10.2008 to 17.2.2009. The insured did not declare the disease and also did not disclose his physical condition and the policyholder suppressed that he has been suffering from disease before commencing of the policy (DoC 6.1.2010). In view of the said fact that the Ld. Lawyer argued that the insurance company OPs rightly rejected the claim of the claimant and could not prefer an appeal which was communicated to the complainant by registered letter which was returned to the OP-1 with the remarks ‘not known’. But without availing of that opportunity of preferring an appeal but he came to this Forum with the plea that she has suffered mental pain and agony and also claim of damage which is not at all maintainable and accordingly the Ld. Lawyer argued that the case is to be dismissed.
Having regard to the submission of respective parties on perusal of the materials on record that it is admitted fact that late Shib Sankar Choudhury was a policyholder of life insurance and the policy was opened on 6.1.2010 with sum assured of the policy was Rs.2,50,000/-. In the complaint the wife of the policyholder i.e. Smt. Tagari Choudhury stated that her husband late Shib Sankar Choudhury availed commuted leave on and from 19.10.2008 to 17.2.2009 i.e. he availed commuted leave of 122 days, but it is curious enough that what was the ailment for which late Shib Sankar Choudhury availed of commuted leave has not been mentioned. From the said fact that it is clearly established the allegation of the insurance company that the policyholder suppressed the material facts regarding his diseases coupled with the said fact that documents filed by the OPs establishes the fact that late Shib Sankar Choudhury before his death at Tata Memorial Hospital, Mumbai was treated at Apollo Hospital, Chennai, from the documents filed by the OPs, it is crystal clear that said late Shib Sankar Choudhury had been
Contd…P/8
suffering from Left Pleural Malignant Effusion and he had also the ailment of Hypothyrodism and he was admitted to Apollo Hospital, Chennai from 5.1.2012 to 22.1.2012 and in the discharge summary of the said hospital it was specifically stated that late Shib Sankar Choudhury that the history of suffering from Hypertension for the last 10 years.
From the materials on record and also the claim made by the complainant that policy was opened on 6.1.2010 and at the time of filling of form of opening policy late Shib Sankar Choudhury did not disclose the abovementioned diseases. Though, he was fully aware that he underwent operation of leg fracture and he availed of commuted leave on and from 19.10.2008 to 17.2.2009 while taking policy on 6.1.2010 and in the proposal papers said late Shib Sankar Choudhury disclosed that he was never suffering from any disease and he was never hospitalized and his health was ‘good’ vide answer to the proposal Question No. 11(a) to 11(i) whereas all (a) to (i) declaration regarding his health were false, he was suffering from Hypertension and Hypothyrodism since 8 years prior to issuance of the said policy and he was hospitalized for operation for fracture of his leg prior to date of commencement of the policy.
Ld. Lawyer for the complainant though argued that at the time of considering the suppression of fact, we should look into the fact that where due to the said impact of the disease the policyholder died and here in this case the death had taken place 2 years after the said accident. Therefore, it cannot be considered that there was any suppression of material facts and for that ground only repudiation the claim of the complainant cannot be made. Ld. Lawyer in support of his contention cited several rulings as reported in CPR Vol.X 342, CPR Vol.II 2012.
Contd…P/9
On perusal of the materials on record it is admitted fact that the policyholder had suffered injury and he enjoyed commuted leave during the period 2008 – 2009 and the policy was obtained in the 2010, but at the time of filling of the proposal form the fact of his admission in the hospital for undergoing operation was not mentioned. In this respect, we can also rely on a decision (LICI v Kusum Patro) [RP No.1585 of 2011 dt. 19.3.2012] where it was held that even if there was on nexus with the case of death, non-disclosure of material information about the medical condition should result in the non- payment of the claim.
Considering all these aspects and on perusal of materials on record coupled with the medical reports submitted by the OPs, we are of the opinion that the OPs rightly repudiated of claim of the complainant since the policyholder suppressed the material facts regarding the disease he had at the time of opening of the policy and for suppression of the said fact itself will deny the claim of the complainant to get back assured sum. Further we like to add that since the complainant lost her husband and death was premature one, therefore, the OPs are directed to return the amount paid by the policyholder during his life time with all benefits that will be accrued in favour of the complainant.
Thus, all the points are disposed of accordingly.
Hence it is,
O R D E R E D
that the instant petition of complaint CC No. 35/2015 is dismissed on contest without any cost.
Contd…P/10
Let a plain copy of this order be furnished to the parties forthwith free of cost.
Dictated & corrected
…………………….…….
(Sambhunath Chatterjee)
President
We concur,
………..…… ………….……..
(S. Saha) (S. Ganguli)
Member Member
- Date when free copy was issued ……………………
- Date of application for certified copy ……………………
- Date when copy was made ready ……………………
- Date of delivery ……………………
FREE COPY [Reg. 18(6)]
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