State Consumer Disputes Redressal Commission
Lic Of India vs Kumar Pradeep & Ors. on 22 April, 2009
APPEAL NO: 759/2004 Divisional Manager, Life Insurance Corporation of India, Bikaner through Manager, L & HPF Divisional Office, Jaipur. Opposite party -appellant Vs. Ramesh r/o Harihano Ki Badi, Near Prakeshnathji ke mandi, Bikaner. Complainant-respondent Date of judgment 22.4.09 Before: Mr.Justice Sunil Kumar Garg- President Mrs.Vimla Sethia-Member
Mr.Sandeep Saxena counsel for the appellants Mr.Chain Singh Rathore counsel for the respondent This appeal has been filed by the appellants LIC against order dated 12.3.04 passed by the District Forum,Bikaner in complaint no.109/2003 by which the complaint of the complainant was allowed in the manner that the appellants were directed to pay a sum of Rs. 25,000/- , the amount of the LIC 2 policy within one month failing which the appellants would pay interest @ 6% p.a. and further to pay Rs.500/- as costs.
2. It arises in the following circumstances-
That the complainant respondent had filed a complaint before the District Forum, Bikaner on 25.2.03 inter alia stating that his mother Dropadi,, now deceased had taken a life insurance policy for a sum of Rs. 25,000/- from the appellants bearing policy no. 500630418 on 27.3.99. It was further stated in the complaint that the deceased had died on 25.11.01 and after the death of the deceased claim was preferred by the complainant respondent being the son and nominee of the deceased before the office of the appellants but that claim was repudiated by the appellants through letter dated 28.3.02 on the ground that before taking the policy in question the deceased had filled in up a declartion form regarding her health on 27.3.99 in which she had not mentioned that he was suffering from any kind of disease but they had the sufficient proof to prove the fact that prior to that , the deceased was suffering from TB since 1997 and had consulted the medical man and had taken the treatment from the doctor and since these facts were not disclosed by the deceased in her declaration form on 27.3.99 at the time of taking the policy, therefore, the deceased was guilty of suppression of material facts regarding her health. Thereafter the present complaint was filed.
A reply was filed by the appellants on 29.4.03 and in the reply they have taken the same pleas which were taken 3 by them in the repudiation letter dated 28.3.02. It was further stated in the reply that the deceased had taken the treatment from SP Medical College- TB & Chest Hospital, Bikaner where she was got admitted on 15.12.97 and was discharged on 30.12.97 and provisional diagnosis which was made by the hospital was TB and thereafter she had taken the treatment there and since these facts were not disclosed by the deceased in her declaration form dated 27.3.99, therefore, it was a case of suppression of material facts regarding health on the part of the deceased and it was prayed that claim was rightly repudiated by the appellants and complaint be dismissed.
After hearing the parties the District Forum, Bikaner through impugned order dated 12.3.04 had allowed the complaint inter alia holding that -
(i) That since the deceased had died after expiry of two years from the date of issuance of the policy, therefore, the complainant was entitled for the benefit of S.45 of the Insurance Act.
(ii) That since the policy was taken by the deceased on 27.3.99 and if the deceased was a patient of TB on 15.12.97 and therefore, there was possibility that she would have cured and thus it was not a case of suppression of material facts regarding health on the part of the deceased.
(iii) That the appellants were not justified in repudiating the claim of the complainant respondent and it had 4 amounted to deficiency in service on the part of the appellants.
Aggrieved from that order dated 12.3.04 passed by the District Forum, Bikaner , this appeal has been filed by the appellants.
3. In this appeal the main contention of the learned counsel for the appellants is that before issuance of policy in question, the deceased was suffering from the disease of TB and since these facts were not disclosed by the deceased deliberately in his declaration form on 27.3.99 , therefore, she was guilty of suppression of material facts regarding health and thus on that ground the claim of the complainant respondent was rightly repudiated by the appellants through letter dated 28.3.02 and the District Forum had committed serious error and illegality in decreeing the claim of the complainant respondent. Hence the impugned order could not be sustained and liable to be quashed and set aside and this appeal deserves to be allowed.
4. On the other hand, the learned counsel appearing for the respondent has supported the impugned order of the District Forum .
5. We have heard the learned counsel for the appellants as well as for the respondent and gone through the entire materials available on record.
6. There is no dispute on the point that the deceased had taken a life insurance policy for a sum of Rs. 25,000/- from the appellants bearing policy no. 500630418 on 27.3.99.
57. There is also no dispute on the point that at the time of taking insurance policy , a declaration was made by the deceased and in that declaration on 27.3.99 , she had not mentioned that he was suffering from any kind of disease or had taken any treatment from any hospital.
8. There is also no dispute on the point that at the time of taking the policy on 27.3.99 in the declaration form regarding health there was a specific question which was put to the deceased was whether she was a patient of TB or not and the answer of that question was given in negative.
9. There is also no dispute on the point that deceased had died on 25.11.01 .
10. There is no dispute on the point that the claim of the above mentioned policy was repudiated by the appellants through letter dated 28.3.02 on the grounds mentioned therein.
11. On file there is a record of SP Medical College, TB and Chest Hospital, Bikaner which shows that the deceased was admitted in the hospital on 15.12.97 which shows that the deceased was a patient of TB and thus prior to taking the policy the disease of TB had been diagnosed by the doctor of the TB Hospital.
12. It may be stated here that in the prescription slip of the PBM Hospital, Bikaner dated 15.12.97 it was clearly mentioned that she was advised to admit in the ward as she was having cough fever and pain in chest and thereafter she was admitted in the hospital on 15.12.97 and was discharged on 30.12.97 and the deceased had 6 taken the treatment of TB and therefore, if the fact of TB was not disclosed by the deceased in her declaration form dated 27.3.99, it would amount to suppression of material facts regarding health on the part of the deceased.
13. Thus, in the above circumstances the benefit of S.45 of the Insurance Act could not be given to the complainant respondent as from the record it has been proved by the appellants by cogent evidence that prior to taking the policy i.e. on 27.3.99 the deceased was a patient of TB and this fact was not disclosed by the deceased in her declaration form regarding her health on 27.3.99, therefore, it could easily be said that the deceased had suppressed material facts regarding her health with ulterior motive and since the fact which was to be disclosed by the deceased had not disclosed by the deceased, therefore, it was a case of suppression of material facts regarding health on the part of the deceased.
14. For the reasons stated above, it is held that repudiation of claim of complainant respondent by the appellants through letter dated 28.3.02 on ground of suppression of material facts regarding health by the deceased was justified and no illegality or irregularity has been committed by the appellants in repudiating the claim of complainant respondent and in view of this, the findings of the District Forum decreeing the claim of the complainant respondent could not be sustained and the same are liable to quashed and set aside as they are wholly illegal, erroneous and perverse one and the appeal deserves to be allowed.
15. During the course of arguments the learned counsel for the complainant respondent has argued that in case the appeal of the 7 appellants is going to be allowed, in such circumstances some amount of compensation as ex-gratia or paid up value be allowed to the complainant respondent as prior to death of the deceased premium had already been paid to some extent.
16. Looking to the fact that the policy in question has run more than two years and the deceased had paid the premium in her life time , therefore, this Commission thinks it just and proper to award a sum of Rs.10,000/- in lumpsum to the complainant appellant and this amount be treated either as ex-gratia or as paid up value.
17. In view of the discussions made above, this appeal filed by the appellants is allowed and the impugned order dated 12.3.04 passed by the District Forum, Bikaner is quashed and set aside and the complaint of the complainant respondent is dismissed. However, the appellants would pay a sum of Rs.10,000/- in lumpsum as ex-gratia payment or as paid up value to the complainant respondent. It may be stated here that while preferring the appeal, the appellants had deposited a sum of Rs.14,973/- before the District Forum, Bikaner and therefore, the District Forum is directed to make payment of a sum of Rs. 10,000/- to the complainant respondent and rest amount be returned to the appellants.
Member President APPEAL NO: 759/2004 Divisional Manager, Life Insurance Corporation of India, Bikaner through Manager, L & HPF Divisional Office, Jaipur. Opposite party -appellant Vs. Ramesh r/o Harihano Ki Badi, Near Prakeshnathji ke mandi, Bikaner. Complainant-respondent Date of judgment 22.4.09 Before: Mr.Justice Sunil Kumar Garg- President Mrs.Vimla Sethia-Member Mr.Sandeep Saxena counsel for the appellants Mr.Chain
Singh Rathore counsel for the respondent This appeal has been filed by the appellants LIC against order dated 12.3.04 passed by the District Forum,Bikaner in complaint no.109/2003 by which the complaint of the complainant was allowed in the manner that the appellants were directed to pay a sum of Rs. 25,000/- , the amount of the LIC 2 policy within one month failing which the appellants would pay interest @ 6% p.a. and further to pay Rs.500/- as costs.
2. It arises in the following circumstances-
That the complainant respondent had filed a complaint before the District Forum, Bikaner on 25.2.03 inter alia stating that his mother Dropadi,, now deceased had taken a life insurance policy for a sum of Rs. 25,000/- from the appellants bearing policy no. 500630418 on 27.3.99. It was further stated in the complaint that the deceased had died on 25.11.01 and after the death of the deceased claim was preferred by the complainant respondent being the son and nominee of the deceased before the office of the appellants but that claim was repudiated by the appellants through letter dated 28.3.02 on the ground that before taking the policy in question the deceased had filled in up a declartion form regarding her health on 27.3.99 in which she had not mentioned that he was suffering from any kind of disease but they had the sufficient proof to prove the fact that prior to that , the deceased was suffering from TB since 1997 and had consulted the medical man and had taken the treatment from the doctor and since these facts were not disclosed by the deceased in her declaration form on 27.3.99 at the time of taking the policy, therefore, the deceased was guilty of suppression of material facts regarding her health. Thereafter the present complaint was filed.
A reply was filed by the appellants on 29.4.03 and in the reply they have taken the same pleas which were taken 3 by them in the repudiation letter dated 28.3.02. It was further stated in the reply that the deceased had taken the treatment from SP Medical College- TB & Chest Hospital, Bikaner where she was got admitted on 15.12.97 and was discharged on 30.12.97 and provisional diagnosis which was made by the hospital was TB and thereafter she had taken the treatment there and since these facts were not disclosed by the deceased in her declaration form dated 27.3.99, therefore, it was a case of suppression of material facts regarding health on the part of the deceased and it was prayed that claim was rightly repudiated by the appellants and complaint be dismissed.
After hearing the parties the District Forum, Bikaner through impugned order dated 12.3.04 had allowed the complaint inter alia holding that -
(i) That since the deceased had died after expiry of two years from the date of issuance of the policy, therefore, the complainant was entitled for the benefit of S.45 of the Insurance Act.
(ii) That since the policy was taken by the deceased on 27.3.99 and if the deceased was a patient of TB on 15.12.97 and therefore, there was possibility that she would have cured and thus it was not a case of suppression of material facts regarding health on the part of the deceased.
(iii) That the appellants were not justified in repudiating the claim of the complainant respondent and it had 4 amounted to deficiency in service on the part of the appellants.
Aggrieved from that order dated 12.3.04 passed by the District Forum, Bikaner , this appeal has been filed by the appellants.
3. In this appeal the main contention of the learned counsel for the appellants is that before issuance of policy in question, the deceased was suffering from the disease of TB and since these facts were not disclosed by the deceased deliberately in his declaration form on 27.3.99 , therefore, she was guilty of suppression of material facts regarding health and thus on that ground the claim of the complainant respondent was rightly repudiated by the appellants through letter dated 28.3.02 and the District Forum had committed serious error and illegality in decreeing the claim of the complainant respondent. Hence the impugned order could not be sustained and liable to be quashed and set aside and this appeal deserves to be allowed.
4. On the other hand, the learned counsel appearing for the respondent has supported the impugned order of the District Forum .
5. We have heard the learned counsel for the appellants as well as for the respondent and gone through the entire materials available on record.
6. There is no dispute on the point that the deceased had taken a life insurance policy for a sum of Rs. 25,000/- from the appellants bearing policy no. 500630418 on 27.3.99.
57. There is also no dispute on the point that at the time of taking insurance policy , a declaration was made by the deceased and in that declaration on 27.3.99 , she had not mentioned that he was suffering from any kind of disease or had taken any treatment from any hospital.
8. There is also no dispute on the point that at the time of taking the policy on 27.3.99 in the declaration form regarding health there was a specific question which was put to the deceased was whether she was a patient of TB or not and the answer of that question was given in negative.
9. There is also no dispute on the point that deceased had died on 25.11.01 .
10. There is no dispute on the point that the claim of the above mentioned policy was repudiated by the appellants through letter dated 28.3.02 on the grounds mentioned therein.
11. On file there is a record of SP Medical College, TB and Chest Hospital, Bikaner which shows that the deceased was admitted in the hospital on 15.12.97 which shows that the deceased was a patient of TB and thus prior to taking the policy the disease of TB had been diagnosed by the doctor of the TB Hospital.
12. It may be stated here that in the prescription slip of the PBM Hospital, Bikaner dated 15.12.97 it was clearly mentioned that she was advised to admit in the ward as she was having cough fever and pain in chest and thereafter she was admitted in the hospital on 15.12.97 and was discharged on 30.12.97 and the deceased had 6 taken the treatment of TB and therefore, if the fact of TB was not disclosed by the deceased in her declaration form dated 27.3.99, it would amount to suppression of material facts regarding health on the part of the deceased.
13. Thus, in the above circumstances the benefit of S.45 of the Insurance Act could not be given to the complainant respondent as from the record it has been proved by the appellants by cogent evidence that prior to taking the policy i.e. on 27.3.99 the deceased was a patient of TB and this fact was not disclosed by the deceased in her declaration form regarding her health on 27.3.99, therefore, it could easily be said that the deceased had suppressed material facts regarding her health with ulterior motive and since the fact which was to be disclosed by the deceased had not disclosed by the deceased, therefore, it was a case of suppression of material facts regarding health on the part of the deceased.
14. For the reasons stated above, it is held that repudiation of claim of complainant respondent by the appellants through letter dated 28.3.02 on ground of suppression of material facts regarding health by the deceased was justified and no illegality or irregularity has been committed by the appellants in repudiating the claim of complainant respondent and in view of this, the findings of the District Forum decreeing the claim of the complainant respondent could not be sustained and the same are liable to quashed and set aside as they are wholly illegal, erroneous and perverse one and the appeal deserves to be allowed.
15. During the course of arguments the learned counsel for the complainant respondent has argued that in case the appeal of the 7 appellants is going to be allowed, in such circumstances some amount of compensation as ex-gratia or paid up value be allowed to the complainant respondent as prior to death of the deceased premium had already been paid to some extent.
16. Looking to the fact that the policy in question has run more than two years and the deceased had paid the premium in her life time , therefore, this Commission thinks it just and proper to award a sum of Rs.10,000/- in lumpsum to the complainant appellant and this amount be treated either as ex-gratia or as paid up value.
17. In view of the discussions made above, this appeal filed by the appellants is allowed and the impugned order dated 12.3.04 passed by the District Forum, Bikaner is quashed and set aside and the complaint of the complainant respondent is dismissed. However, the appellants would pay a sum of Rs.10,000/- in lumpsum as ex-gratia payment or as paid up value to the complainant respondent. It may be stated here that while preferring the appeal, the appellants had deposited a sum of Rs.14,973/- before the District Forum, Bikaner and therefore, the District Forum is directed to make payment of a sum of Rs. 10,000/- to the complainant respondent and rest amount be returned to the appellants.
Member President APPEAL NO: 863/2008 Life Insurance Corporation of India, throuh Sr.Divisional Manager, Alwar. through Manager (Legal) LIC of India Divisional Office, Jaipur. Opposite party -appellant Vs. 1. Kumar Pradeep s/o Late Sh. Shiv Raj 2. Kumari Maya d/o Late Sh.Shiv Raj both minors through Sh.Sanwara Jat r/o village Tihari,Teh.Nasirabad, Distt. Ajmer. Complainants -respondents Date of judgment 22.4.09 Before: Mr.Justice Sunil Kumar Garg- President Mrs.Vimla Sethia-Member Mr.Ram
Kalyan Sharma counsel for the appellants Mr.Naveen Kumar Sharma counsel for the respondents This appeal has been filed by the appellants LIC against order dated 10.4.08 passed by the District Forum, Ajmer in 2 complaint no.330/2007 by which the complaint of the complainant was allowed in the manner that the appellants were directed to pay the rest amount of the LIC policy alongwith interest @ 9% p.a. and further to pay a sum of Rs.1500/- as costs.
2. It arises in the following circumstances-
That the complainants respondents who are minor children of deceased Shivraj had filed a complaint before the District Forum, Ajmer on 5.9.07 throuh their grand father inter alia stating that their mother Shanti now deceased and wife of late Sh. Shivraj Chaudhary and their deceased father Shivraj both have taken a joint life insurance policy with double accidental benefit for a sum of Rs. 1 lac from the appellants bearing policy no. 0184861538 on 26.3.03. It was further stated in the complaint that their mother had also died on 24.3.05 and since the policy was joint one , therefore, after the death of their mother claim was preferred by the complainants respondents through their grand father before the office of the appellants but that claim was repudiated by the appellants through letter dated 30.3.07 on the ground that before taking the policy in question the deceased had filled in up a declartion form regarding her health on 12.3.03 in which she had not mentioned that he was suffering from any kind of disease but they had the sufficient proof to prove the fact that prior to that , the deceased was suffering from AIDS (HIV + ) since 2003 and heart patient since 1993-94 & and had consulted the medical man and had taken the treatment from the doctor and since these facts were not disclosed by the deceased in her declaration form on 3 12.3.03 at the time of taking the policy, therefore, the deceased was guilty of suppression of material facts regarding her health. Thereafter the present complaint was filed.
A reply was filed by the appellants on 9.1.08 and in the reply they have taken the same pleas which were taken by them in the repudiation letter dated 30.3.07 and it was prayed that claim was rightly repudiated by the appellants and complaint be dismissed.
After hearing the parties the District Forum,Ajmer through impugned order dated 10.4.08 had allowed the complaint inter alia holding that -
(i) That from the record which was produced by the appellants, it could not be gathered that the deceased was a patient of heart prior to taking the policy on 12.3.03 and thus it was not a case of suppression of material facts regarding health on the part of the deceased.
(ii) That the appellants were not justified in repudiating the claim of the complainant respondent and it had amounted to deficiency in service on the part of the appellants.
Aggrieved from that order dated 10.4.08 passed by the District Forum, Ajmer , this appeal has been filed by the appellants.
43. In this appeal the main contention of the learned counsel for the appellants is that before issuance of policy in question, the deceased was suffering from the disease of AIDS (HIV + ) since 2003 and heart patient since 1993-94 and since these facts were not disclosed by the deceased deliberately in her declaration form on 12.3.03 , therefore, she was guilty of suppression of material facts regarding health and thus on that ground the claim of the complainant respondent was rightly repudiated by the appellants through letter dated 30.3.07 and the District Forum had committed serious error and illegality in decreeing the claim of the complainants respondents. Hence the impugned order could not be sustained and liable to be quashed and set aside and this appeal deserves to be allowed.
4. On the other hand, the learned counsel appearing for the respondents has supported the impugned order of the District Forum .
5. We have heard the learned counsel for the appellants as well as for the respondents and gone through the entire materials available on record.
6. There is no dispute on the point that father and mother of complainants respondents both deceased had taken a joint life insurance policy with double accidental benefit for a sum of Rs. 1 lac from the appellants bearing policy no. 0184861538 on 12.3.03.
7. There is also no dispute on the point that father of complainants respondents Shivraj had died on 21.1.04 and claim in respect of his death had been settled and a sum of Rs. 1 lac had 5 been paid by the appellants to his wife Shanti Devi, now deceased.
8. There is also no dispute on the point that Shanti Devi had also died on 24.3.05 meaning thereby within two years of issuance of the policy.
9. There is no dispute on the point that the claim of the above mentioned policy was repudiated by the appellants through letter dated 30.3.07 on the grounds mentioned therein.
10. On file there is a document Anx. R-3 which is cash memo of Rameshwar Medicals dated 10.6.99 which shows that some medicines were purchased.
11. On file there is another document Anx. R-4 dated 9.7.99 which is an investigation report.
Note- In this report it was not mentioned that from which disease the deceased was suffering.
12. Further there is Anx.R-5 which is a report of Baba Diagnostic Clinic dated 23.12.99 which shows pus cells were 12-15.
13. On file there is another investigation report of Baba Diagnostic Clinic dated 23.12.99 and that report also does not show of which disease the deceased was suffering.
14. On file there is a certificate of doctor;s treatment Anx. R-7 dated 10.1.07 which shows that she had taken the treatment from Dr.C.L.Nawal but no record had been produced.
615. Thus, in the facts and circumstances just narrated above, the question for consideration is whether the findings recorded by the District Forum could be sustained or not and whether the repudiation of the claim of the complainants respondents by the appellants was justified or not.
16. It may be stated here that from perusing the Anx. R-3 to R-7, it could not be held that the deceased was a patient of AIDS or Heart as mentioned in the repudiation letter dated 30.3.07 and mere investigation reports are not sufficient to prove the fact that the deceased was a patient of the diseases for which claim of the complainants was repudiated.
17. In this case there is nothing on record to prove the fact that prior to filling in up the declaration form regarding health on the part of the deceased on 12.3.03 the deceased had ever taken treatment from any doctor or had remained admitted in any hospital. Even the prescription slips issued by the doctors by which the deceased had undergone for some tests had not been produced and in absence of that it could not be said that for what purposes they were written and further it could not be held that she was a patient of AIDS and Heart prior to taking the policy i.e. on 12.3.03 and thus the present case is a case of zero evidence on the point that the deceased had taken the policy in question after suppressing material facts regarding her health and the appellants have misrably failed to prove the fact that at the time when the declaration form was filled in up by the deceased on 12.3.03 she was suffering from the disease of AIDS or Heart and thus it could not be said that it was a case of suppression of material facts regarding health on the part of the deceased.Thus it is held that the deceased was not guilty of suppression of material facts.
718. Thus, for the reasons stated above, the appellants were not justified in repudiating the claim of the respondents complainants on the ground of suppression of material facts and the appellants have repudiated the claim of the complainant without any basis and on wrong assumption and in an arbitrary manner and in view of this the findings of the District Forum decreeing the claim of the complainant are liable to be confirmed as they are based on correct appreciation of entire materials and evidence on record and they do not suffer from any basic infirmity,illegality or perversity and this appeal deserves to be dismissed.
Accordingly, the appeal filed by the appellants is dismissed.
Member President