State Consumer Disputes Redressal Commission
Smt Kalpana Rajendra Chavan vs Life Insurance Corporation Of India on 11 December, 2013
C-15-16-17-2012
BEFORE
THE HON'BLE STATE CONSUMER DISPUTES REDRESSAL
COMMISSION,
MAHARASHTRA, MUMBAI
Complaint Case No. CC/12/15
1. SMT KALPANA RAJENDRA
CHAVAN
KHAMKAR PARK, FLAT NO 1/2, 2ND FLOOR, SAHYADRI NAGAR, VAI, TALUKA
WAI,
SATARA, MAHARASHTRA
...........Complainant(s)
Versus
1. LIFE INSURANCE
CORPORATION OF INDIA
SATARA DIV OFFICE THROUGH
THE BRANCH OFFICER,
JEEVAN TARA, 513 SADAR BAZAR,
SATARA
MAHARASHTRA
............Opp.Party(s)
Complaint Case No. CC/12/16
1. SMT KALPANA RAJENDRA
CHAVAN
KHAMKAR PARK, FLAT NO 1/2,
2ND FLOOR, SAHYADRI NAGAR, VAI, TALUKA WAI,
SATARA, MAHARASHTRA
...........Complainant(s)
Versus
1. LIFE INSURANCE
CORPORATION OF INDIA
SATARA DIV OFFICE THROUGH
THE BRANCH OFFICER,
JEEVAN TARA, 513 SADAR BAZAR,
SATARA
MAHARASHTRA
............Opp.Party(s)
Complaint Case No. CC/12/17
1. SMT KALPANA RAJENDRA
CHAVAN
KHAMKAR PARK, FLAT NO1/2 2ND
FLOOR, SAHYADRI NAGAR, VAI, TALUKA WAI,
SATARA, MAHARASHTRA
...........Complainant(s)
Versus
1. LIFE INSURANCE
CORPORATION OF INDIA
SATARA DIV OFFICE THROUGH
THE BRANCH OFFICER,
JEEVAN TARA, 513 SADAR BAZAR,
SATARA
MAHARASHTRA
............Opp.Party(s)
BEFORE:
HON'ABLE MRS. Usha S.Thakare
PRESIDING MEMBER
HON'ABLE MR. Narendra Kawde MEMBER PRESENT:
Mr.Balasaheb Deshmukh, Advocate for the Complainant.
Mr.Manish Kenia, Advocate for the Opponent.
COMMON ORDER IN CC/12/15, CC/12/16 & CC/12/17 Per Honble Mr.Narendra Kawde Member:
1. All these consumer complaints filed by the Complainant against the Opponent Life Insurance Corporation of India involve a common question of law and facts between the parties. Therefore, we have heard all the three complaints simultaneously and now reserved for orders for disposal. Therefore, all these complaints are disposed of by this common order.
2. Complainant has filed three separate complaints bearing Nos.12/15, 12/16 and 12/17 against Life Insurance Corporation of India (hereinafter referred to as the Opponent Insurance Corporation) alleging deficiency in service against the Opponent Insurance Corporation for wrongful repudiation of insurance claim payable under each policy on account of death of the husband of the Complainant.
3. Late Shri Rajendra Chavan, husband of the Complainant availed various policies issued by the Opponent Insurance Corporation. The Policy bearing Nos.943184300 (in Consumer Complaint No.CC/12/15), 942532999 (in Consumer Complaint No.CC/12/16) and 943183398 (in Consumer Complaint No.CC/12/17), were undisputedly issued in the name of Shri Rajendra Chavan by the Opponent Insurance Corporation. Shri Rajendra Chavan, Life Assured under the policies died on 06.09.2010 due to mouth cancer. Incidence of the Deceased Life Assured (hereinafter referred to as the DLA in short) was intimated to the Opponent Insurance Corporation. The claims payable under these three policies were submitted by the Complainant well in time. However, since the DLA expired within first two years from the date of commencement of the policies, the Opponent Insurance Corporation invoked the provisions of Section 45 of the Insurance Act, 1938 to investigate into the cause of death of the DLA. The Opponent Insurance Corporation initiated process to collect medical summary of treatment given to the DLA in the hospital viz Aditya Birla Hospital, Pune, obtained confidential report of Insurance Agent of the Opponent Insurance Corporation and the reports from the pathological laboratory. On perusal of the medical summary obtained in respect of treatment of the DLA Opponent Insurance Corporation came to the conclusion that the DLA suppressed the material facts about the habit of gutkha chewing for last fourteen years and the disease called Dyspepsia as the DLA was suffering from prior to filling of the proposal form for availing insurance policies issued by the Opponent Insurance Company. After having investigated the cause of death by collecting medical summary from hospital establishment, the Opponent Insurance Company repudiated the insurance claim under all these policies by communication dated 4th April, 2011 for non-disclosure of the preexisting disease of Dyspepsia and mouth ulcer and directed the Complainant to make grievance, if any against the repudiation of these claims to the Zonal Claim Review Committee. Aggrieved thereby, the Complainant filed these three separate consumer complaints claiming amount of `30,56,750/- in Consumer Complaint No CC/12/15 under policy no.943183400, `26,78,400 in Consumer Complaint No CC/12/16 under policy no.942532999, `25,54,482 in Consumer Complaint No CC/12/17 under policy no.943183398, together with interest and also claimed compensation for mental agony of `50,000/-
and `25,000/-
towards costs of litigation in each complaint.
4. Opponent Insurance Corporation vehemently opposed the consumer complaints and the claim preferred by the Complainant under all these complaints by filing written version. The grounds taken out by the Opponent Insurance Corporation are that, while filling the proposal forms all the answers to the clauses against Question No.11 were replied by DLA stating as NO. It pertains to medical check-up and medical examination, any operation or any medical condition of the DLA. DLA was suffering from the disease named as Dyspepsia since last many years together with mouth ulcer for last six years and he was having trouble while opening mouth since last five years. DLA was also habitual with chewing gutkha for the last fourteen years. Opponent Insurance Corporation investigated medical summary from the hospital where DLA was subjected for treatment prior to availing insurance policies by invoking provisions of Section 45 of the Insurance Act, 1938. On the basis of medical summary collected the Opponent Insurance Corporation arrived at conclusion that there were sufficient grounds to show that DLA had suppressed material information about his health condition which ought to have been disclosed in the proposal form. Further, it is also submitted that the DLA received reimbursement of expenses on account of treatment under the mediclaim Insurance Policy issued by New India Assurance Co. Ltd. Prior to death, the DLA revived five policies and also purchased seven new policies with clear motive to defraud the Opponent Insurance Corporation. Opponent Insurance Corporation repudiated the claim for suppression of earlier disease.
5. Heard Ld.Advocate Mr.Balasaheb Deshmukh for the Complainant and Mr.Manish Kenia, Advocate for the Opponent Insurance Corporation and perused the record placed before us.
6. Ld.Advocate of the Complainant invited our attention to the medical examination report separately signed by panel Doctors of the Opponent Insurance Corporation.
First such report in respect of medical examination confidential report is dated 5th March, 2009 signed by Dr.Satish Babar (MD), second report is attested by Dr.Pingale on 30th April, 2009 and third one by Dr.Asha Satih Babar on 5th March, 2009 and the last report by Dr.T.S. Jagtap on 5th March, 2009. All these Doctors are on the panel of the Opponent Insurance Corporation. Prior to issue of the policies the DLA was thoroughly examined by all these panel Doctors separately and nothing abnormal concerning the health of the DLA was noticed. Thereafter, the Opponent Insurance Corporation issued subject insurance policies, as rightly argued by the Ld.Advocate of the Complainant. It was also pointed out to our attention the certificate dated 27.09.2010 issued by Dr.Jagtap was in respect of oral pains, salivation and ulcer of tongue treatment and DLA was treated by Dr.Neve of Aditya Birla Hospital for difficulty in opening mouth and condition of the DLA at the time of discharge from Birla Hospital was reported to be normal. We agree with this submission. Second time treatment administered by Dr.Jagtap to the DLA was in respect of omitting, oral pain, salivation and ulcer of the tongue. Dr.Jagtap also stated that the DLA was Gutka eater fourteen years back as reply to Question No.5(a) of the medical attendant certificate issued by Dr.Jagtap on 27th September, 2010. The medical summary/certificate of Aditya Birla Hospital and certificate issued by Dr. Jagtap nowhere shows administering treatment for oral cancer as rightly argued on behalf of the Complainant.
7. It was pleaded on behalf of the Opponent Insurance Corporation that non-disclosure of the treatment for Dyspepsia and mouth ulcer amounts to suppression of material fact. Oral cancer as pleaded was due to habit of eating Gutkha regularly since last fourteen years. However, we find that whole controversy revolves around interpretation of Gutkha Eating habit of the DLA. It is evident from the report of Dr.Jagtap that the DLA was in habit of eating Gutkha fourteen years back. However, the Opponent Insurance Corporation interpreted the same opinion of as Gutkha eating since last fourteen years. This is one of the grounds mentioned in repudiation letter, which according to the Complainant is erroneous and therefore it is tenable.
8. Complainant relied on orders of the Honble National Commission in Revision Petition No.3138/2003 and 3139/2003 decided on 26.03.2008 reported in (2008) 2 CPR (NC) 246 between LIC of India & Anr. V/s. Smt. Chandrakanta Lohande. The Honble National Commission held that, the repudiation of the claim on the ground of chronic patient of Dyspepsia and failure to disclose the same in the proposal form cannot be taken as a ground for repudiation of the claim. Dyspepsia as explained in the said judgement cannot be considered as disease as meaning of Dyspepsia as defined in the Tabers Cyclopedia Medical Dictionary is Imperfect or painful digestion. Not a disease in itself but symptomatic of other diseases or disorders.
Characterized by vague abdominal discomfort, a sense of fullness after eating, eructation, heartburn, nausea and vomiting and loss of appetite. These symptoms may occur irregularly and in different patters from time to time. The symptoms are increased in times of stress.
9. Therefore, the non-disclosure of chronic Dyspepsia in the proposal form cannot be a ground for repudiation of the claim as rightly urged on behalf of the Complainant and ruling of the Honble National Commission relied by the Complainant is applicable to the case on hand. In yet another order passed by the Himachal Pradesh State Consumer Disputes Redressal Commission, Simla in case of LIC of India & Anr.V/s. Jaimanti Sharma & Anr., reported in (2010) 4 CPR 126, it was held that, the life assured is supposed to give true and correct facts regarding state of health in the proposal form. However, it was held that it cannot be presumed that the deceased was well aware regarding his state of health (throat cancer) while filling the proposal form and the appeal of LIC was dismissed.
The reliance of the Complainant on these orders cannot be faulted with especially when more than one panel Doctors of Opponent Insurance Corporation have medically examined the DLA and submitted confidential reports without noticing abnormalities or alleged suppression of the disease called Dyspepsia and mouth ulcer. Therefore, submissions made on behalf of the Complainant against unjust and arbitrary repudiation of the insurance claim are sustainable. It is the case of Opponent Insurance Corporation that though the Complainant was aware of the disease, yet he hurriedly revived five lapsed policies and also purchased new policies prior to his death within a period of one to two years. However, there is no mention about which policies were revived and how the revival was approved by LIC on payment of premiums in arrears.
10. On going through the documents available on record, written version, affidavit in evidence of the parties and the medical summary relied upon by the Opponent Insurance Corporation to repudiate the claims, we find that Opponent Insurance Corporation acted in arbitrary manner to repudiate the claim incurring deficiency in service on their part. There is no valid document to rely on the contention of Opponent Insurance Corporation to establish that the oral cancer was detected prior to submission of the proposal form. The fact remains that, several panel Doctors of Opponent Insurance Corporation have examined the DLA independently and certified about the health of DLA prior to issue of the policies and there is no conclusive evidence to establish theory of Opponent Insurance Corporation to show that the oral cancer was prevailing prior to issue of the policies. On the contrary there is certificate of Dr.Rajesh Neve of Aditya Birla Memorial Hospital signed by Consulting Onco Surgeon on 29.09.2010 stating that duration of the cancer was for one month. The second medical certificate signed by Dr.T.J. Jagtap on 27.09.2010 about Guthka chewing habit of the DLA specifically referring to fourteen years back, precisely H/O Gutka Eater Fourteen years back. In reply to query 5(a) in the medical Attendants Certificate there is no counter to these documents which establishes development of oral cancer only prior to one month of death of DLA.
11. It was submitted across the Bar that the DLA was a most enterprising Development Officer in the services of the Opponent Insurance Corporation who always was on forefront in procurement of business for the Opponent Insurance Corporation. This statement is not denied by the Opponent Insurance Corporation during the course of arguments. On the basis of unreasonable grounds repudiating the insurance claim is certainly amounts to arbitrariness on the part of the Opponent Insurance Corporation leading to deficiency in service on their part. We have dealt these cases in their entirety by thoroughly examining the various documents available on record. We are of the considered opinion that the Opponent Insurance Corporation has wrongfully and arbitrarily rejected the claims of the Complainant payable under the insurance policies on demise of the DLA.
Complainant has undoubtedly proved deficiency in service against Opponent Insurance Corporation. In view of the aforesaid observations the Complainant is entitled to receive the sum insured under each of the policies mentioned herein below as per the terms and conditions stipulated therein:
(i) In Complaint No.CC /12/15 as per the terms of the policy the Complainant is entitled to get triple sum assured. Thus she is entitled to get `30,00,000/- with interest @ 6% per annum.
(ii) In Complaint No.CC /12/16 as per the terms of the policy the Complainant is entitled to get triple sum assured. Thus she is entitled to get `27,00,000/- with interest @ 6% per annum.
(iii) In Complaint No.CC /12/17 as per the terms of the policy the Complainant is entitled to get triple sum assured + refund of premium. Thus he is entitled to get `25,00,000/-
plus amount of premiums paid excluding first year premiums paid with interest @ 6% per annum.
We hold accordingly and pass the following order:
O R D E R (1) (i) Consumer complaint no.CC/12/15 is partly allowed.
(ii) In Complaint No.CC/12/15 Opponent Insurance Corporation is directed to pay to the Complainant `30,00,000/-
(triple S.A.) with interest @ 6% per annum from the date of repudiation of the claim i.e. from 04/04/2011 under policy No.943183400.
(iii) Opponent Insurance Corporation to bear their own costs and pay `15,000/- as cost of litigation to the complainant.
(2)(i) Consumer complaint no.CC/12/16 is partly allowed.
(ii) In Complaint No.CC/12/16 Opponent Insurance Corporation is directed to pay to the Complainant `27,00,000/- with interest @ 6% per annum from the date of repudiation of the claim i.e. from 04/04/2011 under policy No.942532999.
(iii) Opponent Insurance Corporation to bear their own costs and pay `15,000/- as cost of litigation to the complainant.
(3) (i) Consumer complaint no.CC/12/17 is partly allowed.
(ii) In Complaint No.CC/12/17 Opponent Insurance Corporation is directed to pay to the Complainant `25,00,000/- plus amount of premium paid excluding first years premium with interest @ 6% per annum from the date of repudiation of the claim i.e. from 04/04/2011 under policy No.943883398 with bonus accrued, if any.
(iii) Opponent Insurance Corporation to bear their own costs and pay `15,000/- as cost of litigation to the complainant.
(4) Opponent Insurance Corporation is directed to make all these payments to the complainant within a period of 60 days from the date of this order.
Pronounced on 11th December, 2013.
[HON'ABLE MRS. Usha S.Thakare] PRESIDING MEMBER [HON'ABLE MR. Narendra Kawde] MEMBER ep