State Consumer Disputes Redressal Commission
Jagmohan Bajaj vs Life Insurance Corporation Of India on 9 December, 2011
2nd Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB
SECTOR 37-A, DAKSHIN MARG, CHANDIGARH.
First Appeal No.1225 of 2006.
Date of Institution: 26.09.2006.
Date of Decision: 09.12.2011.
Jagmohan Bajaj C/o Jaswant Rai & Sons, Ghee Merchants, Mandi Road,
Jalandhar City.
.....Appellant.
Versus
1. Life Insurance Corporation of India, Divisional Office, Model Town
Road, Jalandhar-144001 through its Senior Divisional Manager.
2. Manager (Claims), Life Insurance Corporation of India Divisional
Office, Model Town Road, Jalandhar.
3. Manager (NB & Actl), Life Insurance Corporation of India, Divisional
Office, Model Town Road, Jalandhar.
...Respondents.
First Appeal against the order dated
11.08.2006 of the District Consumer
Disputes Redressal Forum, Jalandhar.
Before:-
Shri Inderjit Kaushik, Presiding Member.
Shri Piare Lal Garg, Member.
Present:-
For the appellant : Sh. Munish Goel,Advocate.
For the respondents : Sh. Rajneesh Malhotra, Advocate.
INDERJIT KAUSHIK, PRESIDING MEMBER:-
Sh. Jagmohan Bajaj, appellant/complainant (In short "the appellant") has filed this appeal against the order dated 11.08.2006 passed by the learned District Consumer Disputes Redressal Forum, Jalandhar (in short "the District Forum").
2. Facts in brief are that the appellant filed a complaint under section 12 of the Consumer Protection Act, 1986 (in short, "the Act") against the respondents, pleading that Mohit Bajaj (since deceased) son of the appellant took a policy of insurance on his life for Rs.1.00 lac through the authorized agent of the respondent, bearing no.131357362 under Table First Appeal No.1225 of 2006 2 no.133 for a term of 25 years. The premium was to be paid yearly and the insurance policy commenced on 28.02.2001. The main feature of the said policy i.e. Jeevan Mitra Policy was that it covered three risks. On survival of the policy holder till the end of the term, the policy holder was to get the sum assured plus bonus. In case of death before maturity, the nominee gets triple the amount of sum assured plus bonus. In case of accidental death, the nominee would get four times the sum assured plus bonus.
3. The proposal for insurance of his own life dated 20th March, 2001 was accepted and the life assured underwent thorough medical check- up by the authorized medical examiner Dr. D.V. Arora of the choice of the respondents. The life assured was in good health with no sign of any physical impairment or disease and it was so certified by the medical examiner in Form no.300 and it was further certified that there was no evidence of injury due to accident or otherwise.
4. The respondents also obtained reports on requisite forms from 'securing agent', development officer and 'moral hazard report' etc. at the time of taking the proposal and all the reports recommended for insurance. The risk was accepted at ordinary rate of premium after due scrutiny and after verifying the reports and satisfying about the health and habits, physical conditions and insurability as standard life.
5. The insurer had other policy no.130228982 for Rs.1.00 lac and another policy no.131130228 for Rs.1.00 lac and the death claim has been paid to the appellant. The life assured was not harbouring and labouring under any disease and had no injury due to the accident or otherwise, nor took any treatment prior to seeking the insurance.
6. The appellant is the nominee appointed u/s 39 of the Insurance Act, 1938 and is a consumer and is competent to file the complaint and to seek redress of his grievance for deficiency in service and unfair trade practice. Unfortunately, the life assured expired on 23.05.2002 due to natural death and the cause for death was septicemia (blood poisioning) and the First Appeal No.1225 of 2006 3 appellant being nominee filed the claim for triple of the sum assured plus bonus and completed all the formalities and submitted the claim form complete in all respects, but the same was repudiated vide letters dated 05.05.2003/28.05.2003 by respondent no.3 illegally and arbitrarily.
7. Respondent no.2 for extraneous considerations compelled the appellants to pay 10% of the claim amount, to clear the claim of the appellant but when the appellant declined, then respondent no.2 threatened that he will get the claim rejected by hook or crook. The repudiation letter was issued after the expiry of two years from the date of insurance i.e. 28.02.2001, hence exceeding the period mentioned in section-45 of the Insurance Act, 1938.
8. The life assured never made any incorrect or mis-statement and disclosed all the material facts at the time of taking the insurance. All the questions were correctly answered. The respondents have not stated as to how they came to the conclusion that the life assured had received head injuries and got fractured nasal bone and was treated for it and, ultimately, died of it. There was no nexus between the alleged head injuries and fractured nasal bone and death of life assured due to septicemia and the same are un-related. The claim was wrongly repudiated which amounts to deficiency in service and the appellant prayed that the following reliefs be granted:-
a) to pay to the appellant triple of the sum assured i.e. Rs.3,00,000/- plus bonus accrued;
b) award interest @ 18% p.a. on claim amount (i.e. triple of the sum assured plus bonus accrued) from the date of death of life assured upto the date of actual payment;
c) award compensation and punitive damages to the tune of Rs.75,000/-
u/s 14 (1) (d) of the Act for mental tension, agony and harassment and
d) award costs of complaint to the tune of Rs.5500/-.
9. In the reply filed on behalf of the respondents, preliminary objections were taken that the contract of insurer and the insured is a contract of utmost good faith and the proposer has to disclose correctly about the state of health, but in the present case, material facts were suppressed and the First Appeal No.1225 of 2006 4 complaint is not maintainable. The life assured earlier took two policies i.e. policy no.131130228 for Rs.50,000/- in November, 1997 and the same was revived on 12.07.2000 and the death claim was paid. The second policy no.131357362 was for Rs.1.00 lac and the total risk was Rs.3.00 lacs plus AB Rs.1.00 lac, aggregating to Rs.5.00 lacs and the risk was accepted on 29.03.2001. The life assured died on 23.05.2002 after approximately one year and one month of the risk covered. He was admitted in Dayanand Medical College (DMC) & Hospital, Ludhiana on 21.04.2002 with complaint of pain in lower abdomen for 13 days, memory loss about 13 days, excessive sleeping 10 days and was discharged on 30.04.2002. He was again admitted in Ruby Hospital on 17.05.2002 and ultimately, he died on 23.05.2002. From the record of the DMC Hospital, Ludhiana, it was gathered that the life assured had head injury and nasal bone fracture before submission of the proposal, but he never disclosed the same and the claim was rightly repudiated.
10. Section 45 of the Insurance Act is applicable. The appellant filed wrong affidavit stating wrong facts. On merits, taking of the policy was admitted. It was further pleaded that the respondent-LIC is a corporate body and investigation is to be done in every case properly according to rules. After the investigation, full body decided that the claim is not genuine and the claim was repudiated. All other allegations of the complaint were denied and similar pleas were repeated and it was prayed that the complaint may be dismissed with costs.
11. Parties led evidence in support of their respective contentions by way of affidavits and documents.
12. After going through the documents and material placed on file and after hearing the learned counsel for the parties, the learned District Forum observed that the respondents have proved the previous injuries and effect of injuries on the deceased from the documents of DMC & Hospital, Ludhiana Ex.OB and also from Ex.C14 and Ex.C5 and it is proved that the First Appeal No.1225 of 2006 5 insured made wrong statement about his health on 20.03.2001, and dismissed the complaint.
13. Aggrieved by the impugned order dated 11.08.2006, the appellants have come up in appeal.
14. We have gone through the pleadings of the parties, perused the record of the learned District Forum and have heard the arguments advanced by the learned counsel for the parties.
15. Learned counsel for the appellant contended that admittedly, the deceased life assured had taken the policy on 28.02.2001 and at that time in Ex.O4 in the history, pain in left lower abdomen for 13 days; fever and headache for 13 days, memory loss for 13 days, excessive sleeping 10 days, was mentioned and it has no nexus that any accident or nasal fracture which never took place. Dr. S.P. Singh Grover in his affidavit Ex.C10 has also admitted that Form no.3816 and Form no.3784 of LIC were filled in and signed by him after verifying the facts from the record of the hospital. Letter Ex.C5 further proves that there was a minor accident and with minor injuries and that cannot result into septicemia. It has been contended that there is no evidence to prove that the life assured was suffering from pre-existing disease at the time of filling the proposal form and the District Forum has dismissed the complaint, without there being any medical evidence of pre- existing disease, and the appeal may be accepted and the impugned order may be set aside.
16. On behalf of the respondents, it was contended that the death claim was already paid, but from the record produced on the file, it was clear that the life assured met with an accident and suffered nasal fracture and he was admitted in DMC & Hospital, Ludhiana as well as Ruby Hospital and these facts were not disclosed and the claim has been rightly repudiated and the appeal may be dismissed.
First Appeal No.1225 of 2006 6
17. We have considered the respective contentions advanced by the learned counsel for the parties and have minutely examined the entire record.
18. The life assured took the policy on 28.02.2001 and he was admitted in the hospital on 21.04.2002 as per Ex.O4 certificate of hospital treatment relied upon by the respondent and at that time, the history of illness was referred as 'pain in the left lower abdomen for 13 days; fever, headache for 13 days, loss of memory for 13 days, excessive sleeping for 10 days'. Sh. Surinder Singh Negi, Senior Clerk, Medical Record Department, DMC, Ludhiana brought the record from the DMC, Ludhiana and deposed that Mohit Bajaj, patient was admitted in the hospital on 21.04.2002 to 30.04.2002. He has seen Form No.3816 which is signed by Dr. Ravinder Pal Singh, Registrar in Uro-surgery and Dr. Baldev Singh Olakh, Reader in Urology Unit, Department of Surgery. Copy of the same is Ex.O4. The related documents are Ex.OA to Ex.OD. In his cross-examination, he has deposed that he has not filled any of the documents.
19. As stated above, the document Ex.O4 and documents Ex.OA to Ex.OD are regarding the admission of the patient Mohit Bajaj on 21.04.2002. In 'case summary and discharge slip' Ex.OB, the past history is recorded in which it is mentioned that the patient had road accident and had head injury and fractured nasal bone and had no memory about time, place, person. Ex.C10 is the affidavit of Dr. S.P. Singh Grover, Consultant Physician and Heart Specialist and he has deposed that Mohit Bajaj s/o Jagmohan Bajaj was admitted on 03.05.2002 to 11.05.2002 and again on 17.05.2002 till his death in New Ruby Hospital & Nursing Home, Jalandhar City and he died on 23.05.2002 due to septicemia. He further deposed that the primary cause of death of Mohit Bajaj was septicemia. Form no.3816 (Claim Form-B1) and Form No.3784 (Claim Form-B) of LIC were filled in and signed by him after verifying the facts from the record of the hospital.
First Appeal No.1225 of 2006 7
20. The respondents vide letter dated 09.04.2003 Ex.C13 asked the appellant to provide the information about the name of doctor/hospital, who treated the life assured for the injuries which the life assured received in an accident, including the fractured nasal bone. Ex.C14 is the reply filed by the appellant to the letter Ex.C13, wherein the appellant stated as follows (relevant portion):-
"my said son was going to Model Town Market, Jalandhar on 28th October, 2000 at about 5.20 p.m. on his Yamaha motorcycle. When he reached near Gurudwara Singh Sabha, Model Town, Jalandhar, collided with another motorcycle coming from the opposite direction, while saving a rickshaw puller crossing the road with lady passengers. Both the riders fell down.
My son got a very minor scratch on his nose and the other fellow got slight injury on his right elbow. In the meanwhile, some unknown passerby after collecting the telephone number of our shop from my son gave us a call.
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As soon as we reached there, we saw both the persons (riders of motorcycle) talking with each other in normal way and in full senses. We enquired of them whether any of them has got any injury and in reply they told us that they both are safe and have been saved by the 'Almighty God'.
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I may add here further that my son Mr. Mohit neither consulted any doctor nor any hospital just for a minor scratch on his nose at that time or thereafter. There was absolutely no head injury or nasal fracture occurred at the time of accident".
21. It was for the respondents to prove that the son of the appellant, namely Mohit Bajaj suffered such an injury which resulted in nasal fracture and head injury for which he took treatment from some doctor or was admitted in some hospital. The respondents have mainly relied upon the case summary/discharge slip Ex.OB, wherein the factum of accident in the year 2000 was mentioned. The appellant replied vide Ex.C14 that it was minor First Appeal No.1225 of 2006 8 scratch and there was no fracture and no doctor was consulted for a minor injury. From the date of accident i.e. 28.10.2000 till the patient Mohit Bajaj was admitted on 21.04.2002 in DMC, Ludhiana for the above ailments, there is nothing on record to prove that the deceased had taken any treatment or remained admitted in any hospital. The life assured was admitted on 21.04.2002 in DMC, Ludhiana and thereafter in Ruby Hospital on 17.05.2002 and he died on 23.05.2002 because of septicemia and the cause of death was diagnosed as septicemia by Dr. S.P.Singh Grover, but the respondents have failed to connect it with the accident which occurred on 28.10.2000. The minor injuries just like scratches cannot develop into septicemia i.e. blood poisoning, or else the life assured must have taken treatment from some doctor and it has no nexus with the cause of death. The respondents merely relying upon the past history have repudiated the claim, without there being any evidence, nor there was any such concealment at the time of filling the proposal form.
22. This Commission in case "Life Insurance Corporation of India Vs Satinder Kaur", III(2008) CPJ-279(Punjab State Commission), observed in para no.10 as follows:-
"We are not convinced from this document that the cause of death of the deceased is pre-existing and due to alcohol. In our opinion, the suppression of the material or the wrong answer must have some direct bearing or nexus with the ultimate cause of death, which in this case is not proved. It is also not proved by the appellant that the deceased had alcoholic and previously admitted in the hospital due to drinking of alcohol and it is also not proved that the death of the deceased was due to pre-existing disease or deceased has taken any treatment".
23. In view of above discussion, the order passed by the District Forum is against the facts, evidence and law and cannot be sustained.
24. Therefore, the appeal is accepted and the impugned order dated 11.08.2006 under appeal passed by the District Forum is set aside. Consequently, the complaint filed by the appellant/complainant is allowed and First Appeal No.1225 of 2006 9 the respondents are directed to pay to the claimant/appellant the sum assured plus bonus if accrued, along with interest @ 7.5% per annum from the date of repudiation of the claim till realization and Rs.2000/- as costs of litigation within two months from the receipt of copy of the order.
25. The arguments in this appeal were heard on 29.11.2011 and the order was reserved. Now the order be communicated to the parties.
26. The appeal could not be decided within the stipulated timeframe due to heavy pendency of court cases.
(Inderjit Kaushik) Presiding Member (Piare Lal Garg) Member December 09, 2011.
(Gurmeet S)