National Consumer Disputes Redressal
Ratna vs Life Insurance Corporation Of India & 2 ... on 7 November, 2019
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 1151 OF 2017 (Against the Order dated 20/01/2017 in Appeal No. 2184/2005 of the State Commission Maharashtra) 1. RATNA WD/O. DIGAMBARRAO THAKRE, R/O. GANESH NAGAR, WARDHA, WARDHA MAHARASHTRA ...........Petitioner(s) Versus 1. LIFE INSURANCE CORPORATION OF INDIA & 2 ORS. ZONAL MANAGER, WESTERN ZONE OFFICE YOGAKSHEM JEEVAN BEEMA MARG, MUMBAI-400021 MAHARAHSTRA 2. LIFE INSURANCE CORPORATION OF INDIA SENIOR DIVISIONAL MANAGER, NAGPUR DIVISIONAL OFFICE, NATIONAL INSURANCE BUILDING SARDAR VALLABHBHAI PATEL MARG, NAGPUR MAHARASHTRA 3. LIFE INSURANCE CORPORATION OF INDIA SR. BRANCH MANAGER, BRANCH CODE NO. 974, L.I.C, BUILDING ARVI ROAD, ARVI MOTOR STAND WARDHA MAHARASHTRA ...........Respondent(s)
BEFORE: HON'BLE MRS. JUSTICE DEEPA SHARMA,PRESIDING MEMBER
For the Petitioner : Mr. Deven S. Lambat, Advocate For the Respondent : Mr. Kamal Mehta, Advocate
Dated : 07 Nov 2019 ORDER
JUSTICE DEEPA SHARMA, PRESIDING MEMBER
1. The present Revision Petition, under Section 21(b) of Consumer Protection Act, 1986 (for short "the Act") has been filed against the order dated 20.01.2017 of the Maharashtra State Consumer Disputes Redressal Commission, Circuit Bench at Nagpur (for short "the State Commission") in Appeal No.A/05/2184 of the respondents against the order dated 02.09.2005 of the District Consumer Disputes Redressal Forum, Wardha (for short "the District Forum") in Complaint No.73 of 2014.
2. The admitted facts of the case are that deceased Digambar Anandrao Thakre purchased three policies bearing nos. 970909435 for Rs.1,00,000/-, 971057189 for Rs.1,10,000/- and 971057491 for Rs.2,00,000/-. The payment against policy no. 970909435 had been made by the respondents (hereinafter referred to as insurance company). The insurance company, however, rejected the claim in respect of other two policies. The said policies were purchased in the middle of year 2000 by deceased. The insured had expired on 13.03.2003 after a short illness. The claim was rejected on the ground that insured had concealed the information about his previous treatment and hospitalisation during the period 25.08.1999 to 07.09.1999. He at that time had suffered with breathlessness. It was also the contention of the insurance company that insured was admitted in the hospital on 13.03.2003 due to breathlessness for the last five dates and expired on the same date due to acute exacerbation of bronchial asthma. Their case was that insured had intentionally concealed this fact from the insurance company while filling the proposal form. It is the case of the complainant and not disputed by the insurance company that after the insured filled the proposal form, insurance company was not satisfied with the information and got the insured medically examined and after being satisfied that insured was hale and hearty and was not suffering with any disease, policies were issued to the insured.
3. The parties led their evidences before the District Forum and District Forum after recording the evidence on record held as under :
"2. The claim in respect of disputed policies was repudiated by O.P No. 1 to 3 on the ground that policy holder suppressed material fact at the time of obtaining disputed policies.
The entire burden lies on O.P.s to prove said defence.
The cause of death of policy holder is 'Short Illness".
Initially O.P.s No. 1 to 3 suppressed material document. However, after direction of this "Forum" produced the same.
It reveals from record that O.P.s No. 1 to 3 have not believed the declaration made by deceased in "Proposal Form" but actually verified the same by directing him to undergo medical examination by doctor duly appointed by O.Ps. prior to acceptance of his proposal. It clearly reveals from said medical examination report that deceased was medically fit at the relevant time. The medical examination report is the direct evidence in respect of matter in issue adduced by O.P.s and admitted by complainant. In this respect judgment of Delhi State Commission reported in 2004 CTJ P 893 is strongly relied upon. It be noted that at the time of earning profit O.P.s accepted said Medical Report. However, as soon as liability arose, O.P.s want to disbelieve the same.
It reveals from record that after the death of policy holder some enquiry was made by O.P.s No. 1 to 3. It was noticed by O.P.s that Five days prior to death, deceased was complaining of breathlessness and the same was increased twenty four hours i.e. one day prior to death. The diagnosis was acute asthama with hypertension. There is no convincing evidence to prove that at the time of obtaining policy he was suffering from 'Asthama". Even otherwise, "Asthama" is not a killer disease. The specific reason for death was short illness and not "Asthama".
We strongly rely upon following judgments and hold that O.P.s failed to prove its defence.
Judgments relied upon are as under:
a. 2004 ACJ 2125, Atheyee and Another Vs. LIC of India and another ( Hon'ble Madras High Court)
b. 2004 CCJ 739 Sr. Div. Manager, LIC of India and Others Vs. J Vinaya (Hon'ble National Commission)
c. 2004 CCJ 564 LIC of India Vs. Ahmadabad Jilla Grahak Sangh and Another ( Gujarat State Commission)
In short the policy holder has not suppressed any material fact at the time of obtaining policies in question and as such complainant is legally entitled for all the benefits of said policies.
3. Repudiation of claim by O.P. No. 1 to 3 amounts to deficiency in service.
ORDER
1. The complaint as against O.P. No. 1 to 3 is partly allowed.
2. In respect of policy no. 971057189, the O.Ps No. 1 to 3 are hereby directed to pay to the complainant an amount of Rs.3,30,000/- ( Rs. Three lakhs Thirty Thousand only) along with interest @ 10% p.a. from 26.11.2003 i.e. date of repudiation of claim by O.P.s till realization. The O.P.s No. 1 to 3 further directed to grant all other benefits under the said policy to the complainant.
3. In respect of Policy No. 971057491 the O.P.s No. 1 to 3 are hereby directed to pay to the complainant an amount ofRs.6,00,000/- ( Rs. Six Lakhs only) alongwith interest @ 10% P.A. from 26.11.2003 i.e. due of repudiation of claim by O.P.s till realization. The O.P.s. no. 1 to 3 are further directed to grant all other benefits under said policy to the complainant.
4. The O.P.s No. 1 to 3 are hereby directed to pay Rs.2000/- ( Rs. Two Thousand only) to the complainant towards cost of this proceedings.
5. The complainant as against O.P. no.4 stands dismissed.
The O.P.s No. 1 to 3 to comply order at Sr. No. 2, 3 and 4 within six weeks from the date of this order."
4. This order is challenged by the insurance company before the State Commission. The State Commission re-appreciated the facts and held as under:
"12. We considered the contentions of both the parties. We find that the DLA was referred on 25/08/1999 by the Doctor Bhise for haematoma with bronchial Asthma to doctor Ajay Mehata. The reference letter is on record prepared in the Natural Course of happening. The certificate given by orange city hospital dated 23/09/2003 under seal and signature that the DLA was admitted for breathlessness and traffic accident under the care of Doctor Ajay Mehata from 25/8/1999 to 7/9/1999 is also on record. The death certificate given by the hospital of Wardha dated 28/07/2003 showing that the DLA was admitted on 13/03/2003 with breathlessness for the last five dates and the diagnosis that he died on the same day with diagnosis of Acute Exacerbation of bronchial Asthma indicates that the DLA was suffering with breathlessness from the year 1999. He had taken a treatment for road accident in the hospital. There is a certificate that he died due to acute severe Broncle Asthama as per certificate issued by Hospital under seal and signature.
13. It shows that the DLA was admitted to the hospital prior to taking the two policies and had undergone the treatment which he was well aware. In such circumstances, it was incumbent upon him to give information of them while taking the policy. The certificates issued by Hospital are not claimed to be false by the respondent. The condition of breathlessness in Asthma would not be known unless told by the patient to the examining doctor. In this condition, it appears natural that the doctor of the appellant may not come to know of the ailment in its examination.
14. The evidence brought on record by the appellant cannot be discarded when it is submitted under the seal and signature of the authorized doctors of the hospital. We have therefore to hold that the DLA was aware of the hospital treatment prior to taking the policy which he concealed while taking the policies. It is proved by the appellant by cogent evidence. Therefore we find that the case laws submitted by the respondent do not come to her help and we have to hold that the DLA has knowingly suppressed the material information which he should have disclosed in proposal of policies. He therefore committed the breach of the policy condition as the treatment has bearing on the cause of death of the DLA. Hence the repudiation needs to be accepted as justifiable and correct.
15. We find that the learned Forum overlooked the fact that the DLA had died of the same reason for which he had taken the treatment when he was referred to the hospital. Hence the part 2 of Section 45 of the Insurance Act gets fully complied by the appellant. The evidence submitted needs to be accepted. Hence the view taken by learned Forum does not stand the correct ground. It therefore deserves setting aside.
16. We also find that the policy vide No. 971057491 does not provide for triple benefit and the advocate of the respondent also could not show the provision. Hence the direction to provide triple benefit by the leaned Forum does not stand ground. Thus, the order of the learned forum, deserves to be set aside being erroneous. Hence the order below.
ORDER The appeal is allowed.
The order of the learned Forum is set aside.
In the event the complaint stands dismissed.
Parties to bear their own cost.
Copy of the order be given to both the parties, free of cost."
5. This order is impugned before me. It is argued by learned counsel for the complainant that what is required to be seen by the Commission is whether at the time of taking up the policy, the insured was suffering with the disease which caused his death. It is argued that asthma or breathlessness is not life threatening disease. It is further submitted that at the time of taking the policy, the insured was not suffering with any disease and that insurance company had also satisfied itself by getting the insured examined by their doctor. It is argued that in the light of these facts, there is no suppression of material facts for obtaining the insurance policy and, therefore, denial of claim was illegal and amounts to deficiency in service and the findings of the State Commission are perverse and are liable to be set aside.
6. It is argued on behalf of the insurance company that insured had been referred by Dr. Bhise on 25.08.1999 with bronchial asthma to Dr. Ajay Mehata and that reference letter on record was prepared by the doctor in the natural course of happening. It is, however, submitted that Orange City Hospital in its certificate dated 23.09.2003 has also given under its signature that insured was admitted for breathlessness and traffic accident under the care of doctor Ajay Mehata from 29.08.1999 to 07.09.1999 and this fact is concealed by the insured.
7. In order to prove that deceased was suffering earlier with asthma and was treated for that, the insurance company has relied on a document issued by Dr. Bhise, which only is a reference written by him to one Dr. Ajay Mehata. No treatment record of Dr. Ajay Mehata has been placed on record by the insurance company. Neither Dr. Bhise nor doctor Ajay Mehata has been examined in order to prove that they had treated the deceased insured at any point of time. This document on which the insurance company is relying in order to prove earlier admission of the deceased insured for this treatment also does not bear the stamp of the doctor. No admission document or discharge certificate has been produced on record. No certificate from Dr. Ajay Bhise or his hospital has been placed on record. The original treatment documents of insured deceased of the hospital where he was treated for his disease has been produced on record by the insurance company which could prove that the hospital had the documents of any earlier treatment of the insured with them to justify the mention of the fact of earlier treatment of insured in the certificate issued to the insurance company. No substantive evidence to prove the earlier treatment of insured in any hospital prior to issuance of insurance policies has been proved on record. Even if for the sake of arguments it is accepted that insured got some treatment for asthma or any other disease way back in the year 1999, he had been medically examined by the doctors at the time of issuance of the policies and admittedly the doctor found him physically fit. It was on the basis of this medical certificate that the insurance company had issued the policies. This shows that even if the insured deceased had some breathlessness on the earlier occasion, he had been fully cured and he was physically fit, hale and hearty and not suffering with any disease on the date when the policies were issued. The policies were issued on the basis of physical condition of the deceased and he had been found physically fit and, therefore, it cannot be said that any suppression or any earlier ailment had vitiated the contract of issuing policy to the deceased insured. A contract of this nature cannot be termed bad and be terminated on ground of having obtained by fraud or can be declared as vitiated on facts which were not in existence on the day of contract. There is no evidence that the deceased insured was suffering with any disease on the day the policies were issued to him.
8. The District Forum has rightly concluded that rejection of claim on the part of the insurance company amounted to deficiency in service. The State Commission had exercised its jurisdiction wrongly and had neglected very vital piece of evidence. The order of State Commission is perverse and is not tenable and is, hereby, set aside. The order of the District Forum dated 02.09.2005 is, hereby, confirmed. The Revision Petition stands disposed of in these terms.
......................J DEEPA SHARMA PRESIDING MEMBER