National Consumer Disputes Redressal
Branch Manager, Life Insurance ... vs Laxman Swaroop on 11 January, 2013
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI FIRST APPEAL NO. 665 OF 2007 (Against the order dated 13.09.2007 in Complaint Case No. 80/2000(Hry)/RBT No. 121/2007 of the State Consumer Disputes Redressal Commission, U.T. Chandigarh) 1. Branch Manager Life Insurance Corporation of India Branch 11U, Plot No. 8, Sector-11 Mathura Road, Faridabad 2. Senior Divisional Manager Life Insurance Corporation of India Divisional Office-II Jeevan Pragati, Plot No.6 District Centre, Laxmi Nagar Delhi Through Assistant Secretary Life Insurance Corporation of India Northern Zonal Office Jeevan Bharti, Connaught Circus New Delhi Appellants Versus Laxman Swaroop S/o Raja Ram C/o M/s Goel Electronics Main Bazaar Old Faridabad Respondent BEFORE: HON'BLE MR. JUSTICE ASHOK BHAN, PRESIDENT HON'BLE MRS. VINEETA RAI, MEMBER For Appellants : Mr. Ashok Kashyap, Advocate For Respondent : Mr. Narender S. Yadav, Advocate with Mr. A. Anandan, Advocate Pronounced on 11th January, 2013 ORDER
PER VINEETA RAI, MEMBER
1. This appeal has been filed by Life Insurance Corporation of India and another (hereinafter referred to as appellants) being aggrieved by the order of the State Consumer Disputes Redressal Commission, U.T. Chandigarh (hereinafter referred to as State Commission), which had allowed the complaint of Shri Laxman Swaroop (respondent-complainant herein).
FACTS : -
2. In his complaint before the State Commission respondent-complainant had contended that his wife Smt. Sunita Devi (hereinafter referred to as the life assured) had taken a life insurance policy for an assured sum of Rs.3 Lakhs with the maturity date of 07.11.2027. It was a double benefit accident policy and, therefore, as per the terms of the policy in case of death of the life assured, respondent/complainant was to be paid an additional sum equivalent to the sum assured under the policy, if the death was caused solely and directly as a result of an accident. It was further contended that before issuing the insurance policy, thorough enquiries about the health of the life assured had been made by the appellant/Insurance Company and she was also examined by its doctors and found to be in good health.
On 15.01.1998 the life assured fell down from the staircase in her own house and sustained serious and multiple injuries, including head injuries. She was immediately taken to City Hospital and Maternity Home, Fariabad, where from she was referred to Dr. Puneet Mittal, Orthopedic Surgeon, Faridabad on the same day. She, however, died three days later i.e. on 18.01.1998 due to the above serious injuries received by her as a result of her falling down from the staircase. After the death of his wife, respondent/complainant visited the office of the appellant-Insurance Company and informed it about the same and being a nominee of the life assured filed the necessary claim supported by relevant documents. However, even though all the required formalities were completed, the appellant-Insurance Company repudiated the claim vide its letter dated 02.11.1998 by leveling false allegations that the life assured was suffering from Kochs Chest (Tuberculosis) for over one year and she had consulted a medical practitioner for treatment and this important material information was suppressed while taking the insurance policy and, therefore, the appellant-Insurance Company was fully justified in repudiating the claim. Being aggrieved by the repudiation of the claim both on account of the death of his wife as also non-payment of the additional sum as per the double benefit accident clause, respondent-complainant filed a complaint before the State Commission alleging deficiency in service and requested that the appellant-Insurance Company be directed to pay the claim amount of Rs.6 Lakhs under the life insurance policy taken by the life assured Smt. Sunita Devi since it was a double benefit accident policy along with interest @ 18% per annum from the date of her death till the date of actual payment to the respondent-complainant and also Rs.1 Lakh as damages and Rs.11,000/- as litigation cost.
3. Appellant-Insurance Company on being served filed written statement refuting these charges. It was contended that the contract of insurance being one of uberrima fides i.e. contract of utmost good faith, the life assured was legally bound to disclose all material facts, including the status of her health, which she failed to do. On the other hand, as per information available from the City Hospital And Maternity Home, Faridabad dated 29.04.1997, it was clearly established that the life assured had been admitted in that hospital for medical complaints, which included Kochs Chest i.e. Tuberculosis. Therefore, appellant-Insurance Company was fully justified in repudiating this claim as per conditions of the insurance policy. Apart from this, it was further submitted that her death was not caused because of any injuries that she sustained when she fell down from the staircase, as contended by respondent-complainant, because as per the medical records these injuries were of minor nature and could not have caused her death. Therefore, the claim was rightly repudiated.
4. The State Commission after hearing both the parties and on the basis of evidence filed before it allowed the complaint by concluding that the appellants-Insurance Company has not been able to conclusively prove that the life assured was suffering from Kochs Chest (Tuberculosis) and that she had suppressed this material fact. The State Commission also concluded that the terms and conditions of the policy were not brought to the notice of the life assured and in the absence of doing so it cannot be held that the policy was void and that the life assured had withheld certain material information regarding her health. The State Commission, therefore, directed the appellant-Insurance Company to pay the respondent-complainant Rs.6 Lakhs under the insurance policy with interest @ 9% per annum after three months of the death of the life assured i.e. 18.04.1998 till payment. Sum of Rs.5000/- was also awarded as compensation. Being aggrieved by this order, this first appeal has been filed.
5. Learned counsel for both the parties made oral submissions.
6. Learned counsel for the appellant-Insurance Company stated that the State Commission erred in not taking cognizance of the important documentary evidence filed before it, namely, the admission file of the City Hospital and Maternity Home, Faridabad dated 29.04.1997, wherein it was clearly stated that the life assured had been suffering from Kochs Chest (Tuberculosis) and was on ATT for over one year. This amounted to suppression of material facts and by withholding this information, the contract based on utmost good faith was clearly breached. Apart from this, from the medical report of Dr. Puneet Mittal, the orthopedic surgeon, who treated the life assured after her fall, it is clear that the injuries caused were to the phalanx, little finger and shoulder. There was no mention of any serious injury, including head injury. She was given syrup Crilinctus and was advised review after one week. Clearly, these injuries were not serious enough to have caused her death.
Under the circumstances, the claim under the double benefit accident policy was justifiably repudiated.
7. Learned counsel for the respondent-complainant on the other hand stated that the State Commission has rightly concluded that there was no credible evidence to confirm that the life assured suffered from Tuberculosis and the admission file from the City Hospital and Maternity Home, Faridabad could not be relied on since it did not have any signatures and was not supported by any evidence or affidavit, in this respect. It was again contended that admittedly the life assured had fallen accidentally on 15.01.1998 and died within three days of the same. Thus, there was clearly a nexus between her accidental fall and her death and, therefore, there was no justification in the repudiation of the claim under the double benefit accident policy.
8. We have heard learned counsel for the parties. We agree with the view taken by the State Commission that the appellants-Insurance Company was not able to produce any credible evidence to prove that the life assured was suffering from Kochs Chest disease prior to her having taken the insurance policy. Production of a document to this effect does not amount to proving the same and in this case mere production of an admission file, whose authenticity has not been verified/confirmed, is not adequate proof of any pre-existing disease. However, we find force in the contention of the appellant-Insurance Company that from the documentary evidence produced by the respondent-complainant i.e. the medical report from Dr. Puneet Mittal, the orthopedic surgeon, who treated the life assured after her fall, does not indicate any serious injury which could have caused her death. There was no mention whatsoever of any head injury nor was she advised hospitalization which could have been necessary had she sustained any major injury. Only minor injuries to the phalanx, little finger and shoulder were mentioned in the report and respondent-complainant has not been able to produce any evidence including the post mortem report to support his statement that his wife died because of a serious head injury.
9. Keeping in view the above facts, we are unable to uphold the order of the State Commission directing the appellant-Insurance Company to pay the respondent-complainant the entire amount of Rs.6 Lakhs under the double benefit accident policy and set aside the same. However, since the life assured had admittedly died during the validity of the policy, the respondent-complainant is entitled to Rs.3 Lakhs being the amount for which the life was insured.
10. In view of these facts, appellant-Insurance Company is directed to pay the respondent-complainant Rs.3 Lakhs with interest @ 9% per annum from the date of repudiation of the claim till its payment as also litigation cost of Rs.5000/-.
11. The appeal stands disposed of in the above terms.
Sd/-
(ASHOK BHAN, J.) PRESIDENT Sd/-
(VINEETA RAI) MEMBER Mukesh