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Since the life assured died within a period of three months five days from the date of revival/commencement of the policy it was treated as a case of an early death claim and hence investigation was carried out by the OPs as provided under Section 45 of the Insurance Act, 1938. During the course of investigation, OPs obtained the Medical Record, own Identity Book of the life assured from his employer and from these documents, they came to know that the life assured was an old patient of pulmonary T.B., but he had suppressed this material fact/information in the proposal forms of all four policies and answered the questions in paragraphs11(a) to (h) of the proposal forms in negative and in para 11(i) stated ‘Good’ about his usual state of health

Life Insurance Corporation of India

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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION

                                 NEW DELHI

REVISION PETITION NO.  2048  OF 2009.

Along with

 

         Application for Condonation of Delay

(From the order dated 03.12.2008   in Appeal No.  406 of 2005 of the   State Consumer Disputes Redressal  Commission, Jharkhand)

 

Smt. Kamoda Devi

W/o Late Muni Dom,

Quarter No. 152/E,

Bhawnathpur Township,

P.O. + P.S. Bhawnathpur,

District Garhwa, Ranchi,

Jharkhand.                                                     ….Petitioner.

Versus.

1.        Branach Manager,

Life Insurance Corporation of India,

Garhwa Branch, Kutchery Road,

Garhwa.

 

2.      Life Insurance Corporation of India Ltd.

Through its Regional Manager,

Eastern Region Office,

4 C. R. Avenue, Kolkata,

West Bengal.

 

                                                                        …….Respondents.

BEFORE:

 

   HON’BLE MR.ANUPAM DASGUPTA, PRESIDING MEMBER

                HON’BLE MR.SURESH CHANDRA, MEMBER

For the Petitioner (s)                                  :                   Mr.  A.K. Yadav,  Advocate. 

 

For the Respondent (s)                                : Mr. Rajat Bhalla, Advocate.

 

Dated :       th  January,  2012.

 

ORDER

 

PER  SURESH CHANDRA, MEMBER

Delay of ninety nine days in filing the present revision petition is condoned for the reasons stated in the application for condonation of delay.

2.     In this case, the complaint was filed by one Kamoda Devi, who is wife of Muni Dom. Muni Dom was an employee in SAIL Hospital at Bhawnathpur in Garhwa District and was working there till his death. During his service period, he had taken four policies bearing nos. 55238727, 552927537, 552959596 and 55391423 from LIC of  India during the period from 28.1.1999 to 28.11.2003. He died on 3.3.2004. After his death, insurance claim was made by the complainant with the opposite parties and relevant documents were submitted along with the claim. The insurance claim was, however, repudiated by the OPs. The complainant, therefore, knocked the door of the Consumer Forum by filing Consumer Complaint No. 11 of 2005 against the OPs for payment of the insurance amount of Rs.5,31,000/- for the four policies plus compensation amounting to Rs. 20,000/- for mental agony and Rs. 5,000/- for economic loss.

3.        According to the complainant, the life assured had been paying premium regularly and all the necessary papers in respect of the claim had been furnished to the OPs but according to her, the Legal Branch Manager of the LIC of India allegedly demanded an amount of Rs. 1,00,000/- to clear the payment of insurance amount but since she refused to fulfill the demand, her claim came to be repudiated.

4.      On the other hand, according to the OPs, policy No. 552938727 for Rs 27,000/- commenced from 28.2.2000, Policy No. 552937537 for Rs. 50,000/- from 15.1.1999, Policy No. 552939596 for Rs. 50,000/-28.1.2002 and Policy No. 553914213 for Rs. 50,000/- from 28.11.2003. Thus, the total amount under the four policies was Rs. 1,77,000/-. It was submitted that the life assured had failed to deposit premium due in January, 2003 within time and hence first three policies lapsed but thereafter on 28.11.2003, three policies were revived and on the same day, 4th Policy bearing No. 553914213 for Rs. 50,000/- was taken. Since the life assured died within a period of three months five days from the date of revival/commencement of the policy it was treated as a case of an early death claim and hence investigation was carried out by the OPs as provided under Section 45 of the Insurance Act, 1938. During the course of investigation, OPs obtained the Medical Record, own  Identity Book of the life assured from his employer and from these documents, they came to know that the life assured was an old patient of pulmonary T.B., but he had suppressed this material fact/information in the proposal forms of all four policies and answered the questions in paragraphs11(a) to (h) of the proposal forms in negative and in para 11(i) stated ‘Good’ about  his usual state of health. The statements made by him regarding his personal history are reproduced below:-

 

Personal History Ans. Yes

or No

If yes, give

details

a) During the last five years did you consult a    Medical Practitioner for any ailment requiring treatment for  more than a week? No  
b) Have you been admitted to any Hospital or nursing home for general check up, observation, treatment or operation ? No  
c)   Have you remain absent from place of work on             grounds of health during the last five years ? No  
d) Are you suffering from or have you ever suffered from ailment pertaining to lever, stomach, heart, lungs, Kidney, Brain or nervous system ? No  
e) Are suffering or have you suffered from diabetes, tuberculosis, high blood pressure, Low blood pressure, Cancer, Epilepsy, Hernia, Hydrocele, Leprosy or any other disease? No  
f)    Do you have any bodily defect or deformity ? No  
g)   Did you ever have any accident or injury? No  
h)  Do you use or have ever used alcoholic drinks, narcotic or any other drugs. Tobacco in any form? No  
i)   What has been your usual state of health? Good  

 

5.        Since the proposer/life assured had made deliberate mis-statements and withheld material information regarding his health at the time of taking the policies, the OPs vide their letter dated 7.10.2004 repudiated the insurance claim under these policies and stated that they were not liable for any payment under the policies in question.

6.     On appraisal of the issues and the evidence adduced by the parties, the District Forum accepted the complaint and vide its order dated 1.10.2005 directed the OPs to pay the entire amount of Rs. 5,31,000/- with compensation of Rs. 5,000/- along with interest @ 8% p.a. on both the amounts.

7.     OPs went in appeal against the order of District Forum before the Jharkhand State Consumer Disputes Redressal Commission, Ranchi (‘State Commission’ for short), which allowed the appeal of the OPs and set aside the aforesaid order of the District Forum and also dismissed the complaint vide its impugned order dated 3.12.2008. The complainant has now challenged this order through the present Revision Petition.

8.     We have heard Mr. A. K. Yadav, Advocate counsel for the petitioner and Mr. Rajat Bhalla, Advocate counsel appearing for the OPs/respondents.

9.     The only contention raised by the learned counsel for the petitioner is that the State Commission has committed a grave error by relying on the OPD record of the treatment  of the life assured, furnished by SAIL authorities to the OPs, because according to learned counsel, the same record has been fabricated. In view of this, conclusion drawn by the State Commission got vitiated and hence the impugned order cannot be sustained in the eye of law.

10.   On the other hand, Mr. Rajat Bhalla, Advocate for the OPs/respondents has submitted that the District Forum ignored the documentary evidence in respect of ailment and treatment taken by the life assured, which clearly established that there was suppression of material facts by the deceased while taking the policies in question. The documents produced before the Fora below have neither been denied nor proved to be false by any counter evidence by the petitioner except raising serious objections over the extracts of the Out Door Patient records obtained by the OPs from the SAIL authorities and produced before the District Forum by alleging them to be forged and fabricated. The State Commission has carefully considered the entire medical record and has rightly come to the conclusion about the suppression of material facts by the life assured and hence allowed the appeal by setting the order of the District Forum.

11.  We have gone through the impugned order. The State Commission while accepting the appeal of the OPs and setting aside the order of the District Forum has made the following observations in its order:-

“8. Admittedly the three policies, which were taken by the life assured earlier had lapsed and were revived on the same day (28.11.2003) on which the fourth policy was taken, fresh statements regarding his personal health and continued insurability in Form no. 680 was made by him. We have to examine whether there was suppression of material facts therein.

 

9.  So far as the indoor medical records of the   life assured received in this Commission from the Mines Hospital, Bhawnathpur is concerned, we find on its perusal that during the period from 13.12.1999 to 09.8.2002 he was admitted for treatment many times i.e. on 13.12.1999, 24.4.2001, 25.5.2001, 28.6.2001, 03.7.2001, 08.8.2001, 01.9.2001, 27.11.2001, 14.3.2002, 19.4.2002, 18.5.2002 and 19.5.2002 for the ailments namely, vomiting loose motion, fever, coma-Hypertension, High Blood Pressure and blood vomiting, severe vomiting, HTN, Deyretion, Bodyache, Fpileptic attack in unconscious state, convulsion etc.

 

10.        Dr. R. R. Dutta, DMO, Mines Hospital, Bhawnathpur, who had sent the indoor medical records had also certified  photocopy of outdoor patient treatment card issued to the life assured  from the said Hospital, on 13.2.2006, wherein on 15.12.1997 it was specifically mentioned that the life assured was an old case of Pulmonary TB. On detailed examination of this document, we are of the view that the District Consumer Forum was wrong in holding the said paper to be forged and fabricated. Even if reliance be not placed on the said entry dated 15.12.1997 in the Medical Book, still the life assured, in our view, had dishonestly suppressed material facts regarding state of his personal health, while answering the question under Clause 11 on 28.11.2003 and therefore the Life Insurance Corporation of India was justified in repudiating the death claim in question.

11.        The life assured was under regular treatment of the Mines Hospital, Bhawnathpur and was an old case of Hypertension and was admitted many times in hospital. Once he was admitted in unconscious condition. He had blood vomitings at times. All those treatments particulars related to the period prior to the date of revival of policies on 28.11.2003. He was a chronic alcoholic, which also stood mentioned in the Medical records.

12.         The District Forum under some misconception passed orders for payment of Rs. 5,31,000.00 while the total sum assured of the four policies was Rs. 1,77,000.00 only. There was no basis for the complainant to claim Rs. 5,31,000.00 as the total insurance amount.

13.         It is well settled that if the deceased life assured knowingly gave incorrect information on personal health in the revival of lapsed policy form and died in a short period claimant would not be entitled to benefit of Section 45 of the Insurance Act, 1938. In this regard reference may be made to a decision of the National Consumer Commission in  LIC of India and another Vs. Naveen Dhingra 2003(1) CPR 54 (NC). Further in LIC of India Vs. Smt. S Vijaya 1 (1995) CPJ 122(NC) the National Consumer Commission held as under:-

“ It is evident that in the personal health statement submitted by the insured just prior to the revival of policy, he had suppressed the material facts concerning his health. As such, repudiation of the policy by the Life Insurance Corporation was fully warranted and there has been no deficiency in service because of such a repudiation. In the result this Revision Petition is allowed, the order of the State Commission is set aside and that of the District Forum is restored. There is no order as to costs”.

 

11.   It is clearly established from the above that the State Commission has allowed the appeal of the OPs and dismissed the complaint by passing a well-reasoned order after considering the documentary evidence in respect of  the claim. In the absence of any proof or documents in support thereof, mere allegations of the documents being forged and fabricated cannot be accepted to ignore the medical records produced by the OPs. In the circumstances, we agree with the view taken by the State Commission while setting aside the order of the District Forum which was apparently based on mis-conception and wrong appreciation of the documentary evidence. No interference is, therefore, called for from us with the impugned order under section 21 (b) of the Consumer Protection Act, 1986.  We, therefore, dismiss the Revision Petition, with no order as to cost.            

                                                        …………………………..

(ANUPAM DASGUPTA)

                                                        PRESIDING MEMBER

 

                                                        ……………………………

                                                        (SURESH CHANDRA)

SSB                                                                 MEMBER

 

 

 

 

 

  

 

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