State Consumer Disputes Redressal Commission
Life Insurance Corporation Of India vs Asha Devi on 22 February, 2008
IN THE STATE COMMISSION: DELHI IN THE STATE COMMISSION: DELHI (Constituted under section 9 clause (b) of the Consumer Protection Act, 1986) Date of decision:22.02.2008 First Appeal No.07/929 (Arising from the order dated 06.11.2007 passed by District Forum(Central) Kashmere Gate, Delhi in Complaint Case No.225/2007) Life Insurance Corporation of India, Appellant Through Manager, through Ms. M.N.Chaudhary Divisional Office I, 25, K.G. Marg, advocate. New Delhi. Divisin -1, Branch Unit -124, Bapu Sadan, Sant Nagar, New Delhi Versus Smt. Asha Devi Respondent W/o Late Sh. Het Ram, 574, Kabir Basti, Nehru Kutia, Malka Ganj, Delhi. CORAM: Justice J.D. Kapoor, ... President Ms. Rumnita Mittal Member
1. Whether reporters of local newspapers be allowed to see the judgment?
2. To be referred to the Reporter or not?
Justice J.D. Kapoor, President(ORAL)
1. Respondent is the widow of Late Sh. Het Ram, who was holder of life insurance policy issued by the appellant for a sum of Rs.1,00,000/-. The policy was taken on 28.10.2003. He started taking treatment of Tuberculosis from R.B.T.B. Hospital from 20.11.2003 and died on 08.09.2004. The claim was repudiated on the ground that the life assured had given wrong date of birth and also concealed the factum of suffering from T.B. Feeing aggrieved the respondent filed the instant complaint before District Forum.
2. Vide impugned order dated 06.1.2007, the appellant has been directed to pay sum of Rs.1,00,000/- with interest @9% from 03.02.2005 besides Rs.5,000/- as compensation and Rs.2,000/- as cost of litigation.
3. Feeling aggrieved the appellant has preferred this appeal.
4. We have perused the impugned order and find that not a single document was produced by the appellant before the District Forum to substantiate its version inspite of having been provided 3-4 opportunities to file the documents i.e. on 12.09.2007, 15.09.2007 and 30.10.2007 and District Forum has also held that the insurance policy was issued on 28.10.2003 whereas the deceased started getting treatment from 20.11.2003.
5. On the concept of import and meaning of words disease and pre-existing disease in the context of insurance policy as well as dictionary meaning, we have came out with certain criteria for repudiating the claim on the ground of concealment of pre-existing disease in highly dissective and extensive manner and these conclusions are as under:
(i) Disease means a serious derangement of health or chronic deep-seated disease frequently one that is ultimately fatal for which an insured must have been hospitalized or operated upon in the near proximity of obtaining the mediclaim policy.
(ii) Such a disease should not only be existing at the time of taking the policy but also should have existed in the near proximity. If the insured had been hospitalized or operated upon for the said disease in the near past, say, six months or a year he is supposed to disclose the said fact to rule out the failure of his claim on the ground of concealment of information as to pre-existing disease.
(iii) Malaise of hypertension, diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day to day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.
(iv) If insured had been even otherwise living normal and healthy life and attending to his duties and daily chores like any other person and is not declared as a diseased person as referred above he cannot be held guilty for concealment of any disease, the medical terminology of which is even not known to an educated person unless he is hospitalized and operated upon for a particular disease in the near proximity of date of insurance policy say few days or months.
(v) Disease that can be easily detected by subjecting the insured to basic tests like blood test, ECG etc. the insured is not supposed to disclose such disease because of otherwise leading a normal and healthy life and cannot be branded as diseased person.
(vi) Insurance Company cannot take advantage of its act of omission and commission as it is under obligation to ensure before issuing medi-claim policy whether a person is fit to be insured or not. It appears that insurance Companies dont discharge this obligation as half of the population is suffering from such malaises and they would be left with no or very little business.
Thus any attempt on the part of the insurer to repudiate the claim for such non-disclosure is not permissible, nor is exclusion clause invokable.
(vii) Claim of any insured should not be and cannot be repudiated by taking a clue or remote reference to any so-called disease from the discharge summary of the insured by invoking the exclusion clause or non-disclosure of pre-existing disease unless the insured had concealed his hospitalization or operation for the said disease undertaken in the reasonable near proximity as referred above.
(viii) Day to day history or history of several years of some or the other physical problem one may face occasionally without having landed for hospitalization or operation for the disease cannot be used for repudiating the claim. For instance an insured had suffered from a particular disease for which he was hospitalised or operated upon 5, 10 to 20 years ago and since then had been living healthy and normal life cannot be accused of concealment of pre-existing disease while taking mediclaim policy as after being cured of the disease, he does not suffer from any disease much less the pre-existing disease.
(ix) For instance, to say that insured has concealed the fact that he was having pain in the chest off and on for years but has never been diagnosed or operated upon for heart disease but suddenly lands up in the hospital for the said purpose and therefore is disentitled for claim bares dubious design of the insurer to defeat the rightful claim of the insured on flimsy ground. Instances are not rare where people suffer a massive attack without having even been hospitalised or operated upon at any age say for 20 years or so.
(x) Non-disclosure of hospitalization/or operation for disease that too in the reasonable proximity of the date of mediclaim policy is the only ground on which insured claim can be repudiated and on no other ground.
6. On the aforesaid premise and in view of the finding of facts returned by the District Forum on the material and documents produced before it, there is no infirmity in the impugned and as such we do not find any merit in the appeal and dismiss the same being devoid of merit. The appeal is dismissed.
7. The order shall be complied with within one month from the date of receipt of this order.
8. Bank Guarantee/FDR, if any, furnished by the appellant be returned forthwith.
9. A copy of this order as per the statutory requirements be forwarded to the parties free of charge and also to the concerned District Forum and thereafter the file be consigned to Record Room.
Announced today on 22nd day of February 2008.
(Justice J.D. Kapoor) President (Rumnita Mittal) Member Tri