State Consumer Disputes Redressal Commission
Smt. Baljit Kaur Wd/O Late Joginder ... vs Life Insurance Corporation Of India, on 22 December, 2011
2nd Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB,
SECTOR 37-A, DAKSHIN MARG, CHANDIGARH
First Appeal No. 707 of 2007
Date of institution : 21.5.2007
Date of Decision : 22.12.2011
Smt. Baljit Kaur wd/o Late Joginder Singh s/o Chuhar Singh r/o Kaki Pind Road,
Suryaran Da Khoo, Dakoha, Distt. Jalandhar, through Sh. Tarsem Lal Wahi s/o
Sh. F.S. Wahi c/o Punjab National Bank, Rama Mandi, Jalandhar, her lawful
attorney.
....Appellant.
Versus
Life Insurance Corporation of India, Division Office Jeevan Parkash, Model Town
Road, through its Sr. Divisional Manager.
...Respondent.
First Appeal against the order dated 2.4.2007 of
the District Consumer Disputes Redressal Forum,
Jalandhar.
Before:-
Shri Inderjit Kaushik, Presiding Member.
Shri Piare Lal Garg, Member.
Present:-
For the appellant : Sh. Arun Bakshi, Advocate
For the respondent : Sh. Rajneesh Malhotra, Advocate
PIARE LAL GARG, MEMBER:
This is an appeal filed by the appellant/complainant-Smt. Baljit Kaur (hereinafter called 'the appellant') against the order dated 2.4.2007 of the District Consumer Disputes Redressal Forum, Jalandhar(hereinafter called the 'District Forum') by which the complaint of the appellant was dismissed by the District Forum.
2. Brief facts of the case are that the respondent's husband had purchased life insurance policy No. 131706554 on 12.6.2003 for a sum of Rs. 6,00,000/-, which commenced from 15.6.2003. The said policy was issued for the term of 20 years with profits plus accident benefits. The respondent was nominee in the said policy and the said policy was issued First Appeal No. 707 of 2007 2 to the appellant's husband after conducting tests by authorized doctors/medical examiner. Appellant's husband unfortunately died on 16.8.2004 due to Cellulites Right leg/septicemia i.e. swollen right leg. Thereafter, the appellant had filed the claim with the respondent for the payment of the insurance amount after completing all the formalities. But the respondent had repudiated her claim vide letter dated 26.3.2005 on the ground that the life assured had concealed the material information in the proposal form with regard to his health. It was pleaded that the life assured was not required to nor was expected to remember the minor ailments, such, as head-ache for which a person avails leave from his employer. The said allegations were illegal and without any basis because the life assured was hale and hearty at the time of taking the insurance policy. Complaint was filed on the ground that her claim was wrongly/illegally repudiated and prayed that the respondent may be directed to pay the policy amount of Rs. 6,00,000/- alongwith all the benefits accrued under the policy with interest @ 18% per annum from the date of death till payment, compensation of Rs. 1,00,000/- on account of mental tension and harassment as well as Rs. 10,000/- as litigation expenses was also prayed for.
3. Upon notice, the respondent replied by taking preliminary objections that the complaint was not in the proper form, hence, the same was liable to be dismissed, appellant was estopped by her own act and conduct to file the present complaint, appellant has not come to the District Forum with clean hands, the complaint involves complicated questions of law and facts. On merits, it was admitted that the husband of the appellant had purchased insurance policy for a sum of Rs. 6,00,000/- from the respondent, which was issued on the basis of proposal form, which was duly filled and signed by the life assured but the deceased did not disclose First Appeal No. 707 of 2007 3 true facts in the proposal form regarding his ailment at the time of execution of the proposal form. If he had disclosed the same then the respondent might have called for special tests, as his illness may effect the under writing decision in assessing the risk on his life. The medical examination was conducted on the basis of information supplied by the life assured and the same was only of questionnaire type and no clinical tests or examination was conducted. It was admitted that the life assured had died on 16.8.2004 due to high fever, which was proved from Form No. 3783. The appellant had filed the claim, which was repudiated on 26.3.2005 after due deliberation and application of mind as the deceased had concealed the fact of his ill health and leave taken on sick/medical ground. The life assured remained under treatment for P.U.O. for one month as per Form No. 3816 i.e. "Certificate of Hospital Treatment of Northern Railway, Jalandhar Cantt", which was not a minor ailment and he had intentionally suppressed this information. It was denied that the claim was wrongly, illegally and arbitrarily repudiated. It was pleaded that the appellant is not entitled for any claim amount as her claim was rightly repudiated after due application of mind. All other allegations were denied and dismissal of the complaint was prayed.
4. Learned District Forum after hearing the learned counsel for the parties and going through the record, dismissed the complaint.
5. Hence, the appeal.
6. We have gone through the pleadings of the parties, perused the record of the learned District Forum and heard the arguments of the learned counsel for the parties.
First Appeal No. 707 of 2007 4
7. The appeal is filed by the appellant on the grounds that the District Forum has dismissed the complaint without considering the facts that there is no nexus between the cause of death i.e. septicemia in right leg and the pyrexia of unknown origin for which the deceased/insured had taken the treatment before taking the insurance policy from the respondent. The insured died on 16.8.2004 i.e. after about more than one year from the previous disease i.e. Septicemia of unknown origin in right leg. The District Forum has totally overlooked the affidavit of Dr. Anil Kumar and Dr. Vinod Kumar Batra, who treated the insured for the disease for which the insured was suffering and the deceased had not deliberately suppressed any fact regarding his ailment, which was material and taken the policy fraudulently and given the false information which was material to discuss, as such, the order of the District Forum is liable to be set-aside.
8. There is no dispute between the parties that the husband of the appellant Sh. Joginder Singh had taken the insurance policy of the respondent for Rs. 6 lacs on 12.6.2003 for a term of 20 years with profits plus accident benefits, which commenced from 15.6.2003 and the appellant was nominated as nominee by the insured.
9. There is also no dispute between the parties that the insured died on 16.8.2004 due to Cellulites Right Leg/Septicemia i.e. swollen right leg. The appellant filed the claim before the respondent but the same was repudiated by the respondent on 26.3.2005 vide letter Ex. O-17 on the following grounds:-
"RE: REPUDIATED DEATH CLAIM U/POL.NO. 131706554 FVG. SH. JOGINDER SINGH With reference to your claim under the above policy on the life of your deceased husband, we have to inform you that we have decided to repudiate all liability under the policy on account of deceased having with- First Appeal No. 707 of 2007 5 held material information regarding his health at the time of effecting the assurance with us.
In this connection, we have to inform you that in the proposal for assurance dated 12.06.2003, signed by the deceased assured on 12.06.2003, the risk under this proposal was accepted on 19.07.2003. At the time of submission of his proposal, he had answered the following questions as under noted:-
QUESTIONS ANSWERS
11.(a) During the last five years did you consult a NO
Medical Practitioner for any ailment
requiring treatment for more than a week?
(c) Have you ever remained absent from place NO
or work on grounds of health during last 5
years?
(d) Are you suffering from or have you ever NO
suffered from ailments pertaining to Liver,
Stomach, Heart, Lungs, Kidney, Brain or
Nervous System?
(e) Are you suffering from or have ever NO
suffered from diabetes, tuberculosis, high
blood pressure hydrocele, leprosy or any
other disease?
(i) What has been your usual state of health? GOOD
10. Against the repudiation of the claim, the complaint was filed by the appellant before the District Forum, which was also dismissed on the ground that the insured had made false statement regarding his health, medical leave and existence of pre-existing disease before taking the policy.
11. The appellant has not denied the fact that the insured had taken the treatment from 12.9.2002 to 11.10.2002 from the Railway Hospital, Jallandhar Cantt. as he was suffering from Pyrexia (fever of unknown origin) as a outdoor patient.
12. As per medical literature available from Wikipedia, the free encyclopedia; the pyrexia disease is also known as fever. Fever is not a disease but a symptom of disease, which is reproduced:-
"Fever (also know as pyrexia from the Greek pyretos meaning fire, or a febrile response from the Latin word febris, meaning fever, and archaically First Appeal No. 707 of 2007 6 known as ague) is a frequent medical symptom that describes an increase in internal body temperature to levels that are above normal (the common oral measurement of normal human body temperature is 36.8±0.7 °C or 98.2±1.3 °F). Fever is most accurately characterize d as a temporary elevation in the body's thermoregulatory set-point, usually by about 1-2°C. Fever differs from hyperthermia, which is an increase in body temperature over the body's thermoregulatory set-point (due to excessive heat production or insufficient thermoregulation, or both). Carl Wunderlich discovered that fever is not a disease but a symptom of disease."
13. So from the above medical reference, the pyrexia fever of unknown origin was not a disease, which was not disclosed by the deceased/insured to the respondent at the time of filling of the proposal form. So the questions asked to the insured and replied by him as referred by the respondent are also not having any material significance which points out towards material suppression of facts on the part of the insured.
14. There is no dispute between the parties that the insured died on 16.8.2004 at 2.10 p.m. in Guru Nanak Mission Hospital, Jalandhar as per Form No. 3785 Ex. C-2 and the cause of death is mentioned as cellulites Rt. Leg.. The duration of the illness in the said form is mentioned 15 days only.
15. So from the above certificate, it is established that the insured had only remained ill for 15 days due to cellulites in right leg.
16. The appellant has also tendered into evidence affidavit of Dr. Vinod K. Batra Ex. C-3 and certificate Ex. C-4, who had stated that the insured was admitted in Batra Hospital, Mission Compound, Jalandhar City on 6.8.2004 and was discharged 13.8.2004 for the treatment of Cellulites in right leg/ septicemia, which was not related to any earlier disease.
17. So from the above certificate of the Doctor, it is also proved that there was no nexus with the disease i.e. pyrexia of unknown origin and Cellulites in right leg/septicemia due to which the deceased had died. First Appeal No. 707 of 2007 7 Even the insured was not admitted in any of the hospital for getting the treatment of P.U.O. The respondent has also not produced any evidence that after taking the policy, the insured had taken any treatment from any hospital prior to his admission in Batra Hospital, Mission Compound, Jallandhar for the ailment of Cellulites in right leg/septicemia or he had taken the treatment of pyrexia of unknown origin(PUO) after 12.10.2002.
18. So from the above discussion, it is proved that pyrexia of unknown origin (PUO) is not a fatal one and non-disclosing of such type of disease at the time of filling the declaration form would not amount to concealment of material fact. The cause of death of the insured was also not due to pyrexia of unknown origin. The Hon'ble Apex Court in case "P.C. Chacko and another Vs. Chairman, Life Insurance Corporation of India and others", (2008) 1 SCC 321, held that three conditions essential for application of Section 45 of the Insurance Act, 1938 are as under:-
(a) the statement must be on a material matter or must suppress facts which it was material to disclose;
(b) the suppression must be fraudulently made by the policy holder; and
(c) the policy-holder must have known at the time of making the statement that it was false or that it suppressed facts which it was material to disclose.
19. The respondent has not produced an iota of evidence to prove that the material facts to defraud the respondent were concealed by the insured at the time of filling the proposal form. Non-disclosure of fever and leave taken by the insured on medical ground are not the material facts, which could cause the repudiation of the claim of the appellant. First Appeal No. 707 of 2007 8
20. So as per the above discussion, it is clear that the claim of the appellant does not come within the ambit of suppression of material facts/fraud committed by the insured whereupon the claim can be repudiated by the respondent.
21. The repudiation of the claim of the appellant is illegal. Accordingly, the appeal is accepted and the order under appeal is set- aside, which is against the evidence available on the file. Consequently, the complaint filed by the complainant is accepted and the respondent is directed to pay to the appellant the policy amount with all consequential benefits with interest @ 9% per annum (after three months from the date of filing of the claim) till its realization. No order as to costs.
22. The arguments in this appeal were heard on 16.12.2011 and the order was reserved. Now the order be communicated to the parties.
23. The appeal could not be decided within the statutory period due to heavy pendency of Court cases.
(Inderjit Kaushik)
Presiding Member
December 22, 2011. (Piare Lal Garg)
as Member