State Consumer Disputes Redressal Commission
Life Insurance Corporation Of India vs Smt. Tetara Devi on 28 May, 2009
STATE CONSUMER DISPUTES REDRESSAL COMMISSION UTTARAKHAND
DEHRA DUN
FIRST APPEAL NO. 139 / 2007
1. Life Insurance Corporation of India
having one of its Divisional Office at
Jeevan Prakash Building, Haridwar Road, Dehradun
through its Divisional Manager
2. Regional Manager, Life Insurance Corporation of India
North Middle Regional Office
16/98, Mahatma Gandhi Marg
"Jeevan Vikas", Post Box No. 181, Kanpur - 208001
through its Authorised Signatory
3. Divisional Manager, Life Insurance Corporation of India
Divisional Office, Jeevan Prakash Building
Haridwar Road, Dehradun through its Authorised Signatory
4. Branch Manager, Life Insurance Corporation of India
Branch Office-II, Haridwar
through its Authorised Signatory
......Appellants / Opposite Parties
Versus
Smt. Tetara Devi W/o late Sh. Ramdarshan Ram
R/o Quarter No. 618, Type-2, Sector-1
BHEL, Ranipur, P.S. Ranipur
District Haridwar
.....Respondent / Complainant
Sh. T.S. Bindra, Learned Counsel for the Appellants
Sh. Sudhanshu Dwivedi, Learned Counsel for Respondent
Coram: Hon'ble Justice Irshad Hussain, President
Smt. Kusum Lata Sharma, Member
Dated: 28.05.2009
ORDER
(Per: Justice Irshad Hussain, President):
Insurance company filed this appeal against the order dated 03.04.2007 passed by the District Forum, Haridwar, allowing consumer complaint No. 59 / 2006 with cost of Rs. 1,000/- and further directing the appellants to pay to the complainant insured sum of 2 Rs. 1,00,000/- with interest @9% p.a. from the date of filing of the complaint till payment. The claim pertain to insurance policy No. 270788648 for sum of Rs. 1,00,000/- purchased on 09.12.2000 by late Sh. Ramdarshan Ram, the husband of the complainant and who had died on 24.04.2003. The complaint came to be filed with the allegation of deficiency in service made by the appellants by repudiation of the claim under the policy, on the ground that the insured had concealed the material fact that he was suffering from diseases at the time of taking the insurance policy, by fraudulently and deliberately giving false answers to the interrogatories contained in the proposal form.
2. The District Forum rejected the stand of the insurance company, by observing that at the time of taking the policy, the panel doctor of the insurance company, on medical examination, had found the insured as medically fit; that at the time of getting the insurance proposal, the agent of the insurance company show utmost liberal attitude and himself fill in the proposal form, on which the signatures of the life insured are only obtained without giving the life insured required information about the terms, conditions etc. of the policy and that in the case in hand, similar procedure was adopted, as has been affirmed by the averment of the affidavits of the complainant Smt. Tetara Devi, her son Sh. Ashok Kumar and another witness Sh. Anand. The District Forum also observed that the diseases, namely, hypertension, coronary artery disease and case of renal failure (HTN, CAD and CRF), with which the life insured was shown suffering for the last about five years per endorsement in the medical attendant's certificate as well as certificate of hospital treatment, relied upon by the insurance company, were not corroborated by any expert evidence or evidence of any medical officer and, therefore, the insurance company failed to fully rebut the allegation of the complainant and 3 also to prove that the life insured fraudulently and deliberately concealed the material fact that he was suffering from such diseases at the time of taking the insurance policy. On this premise, the insurance company was attributed deficiency in service in repudiating the claim and the complaint was allowed by the impugned order to award compensation, as aforesaid to the complainant, the nominee under the policy of insurance.
3. We have heard the learned counsel for the parties and have carefully considered their submissions in the light of the facts, circumstances and legal aspects of the case. At the outset, it need to be stated that the life insured, namely, Sh. Ramdarshan Ram died after about two years and four months from purchasing the insurance policy and, therefore, Section 45 of the Insurance Act, 1938 was applicable to the facts of the case and by virtue of this, the onus lie upon the insurance company to prove that the information in the proposal form, leading to the issuance of insurance policy, was inaccurate or false and that such information was on a material fact and that it was fraudulently made by the insured. Learned counsel for the insurance company drew attention to the material on record and argued that the leave record of the life insured, papers pertaining to his treatment in his employer's hospital and referral documents, discharge summary of the treatment of the insured recorded in the document of Batra Hospital & Medical Research Centre, New Delhi, the endorsements made by the doctor of the hospital, who treated the life insured, as recorded in the medical attendant's certificate and certificate of hospital treatment, prove beyond doubt that the life insured fraudulently and deliberately gave false answers to the interrogatories contained in the proposal form and thereby concealed the material fact that he was suffering from serious diseases, namely, hypertension, coronary artery disease and renal failure at the time of taking the 4 insurance policy. According to the learned counsel, the repudiation of the claim under the policy, therefore, was fully justified and the District Forum fell in error in rejecting the stand of the insurance company, on the grounds which were merely peripheral to the actual controversy. As against this, learned counsel for the complainant supported the impugned order, by making persuasive submission that there being no expert evidence and evidence of medical officer in the form of affidavits, the documents placed on record by the insurance company, would be of no avail and the stand of the insurance company could not legally be sustained.
4. The respective submissions of the learned counsel for the parties, first of all, take us to the answers to the interrogatories given by the life insured in the proposal form for the policy of insurance and these were as under:
Question Answer
During the last five years did you consult a No
medical practitioner for any ailment requiring
treatment for more than a week?
Have you ever been admitted to any hospital No
or nursing home for general checkup,
observation, treatment or operation?
Have you remained absent from place of work No
on grounds of health during the last 5 years?
Are you suffering from or have you ever No
suffered from ailments pertaining to Liver,
Stomach, Heart, Lungs, Kidney, Brain or
Nervous System?
Are you suffering from or have you ever No
suffered from Diabetes, Tuberculosis, High
blood pressure, Low blood pressure, Cancer,
Epilepsy, Hernia, Hydrocele, Leprosy or any
other disease?
Do you have any bodily defect or deformity? No
Do you ever have an accident or injury? No
5
Do you use or have ever used?
(i) Alcoholic Drinks No
(ii) Narcotics No
(iii) Any other drugs No
(iv) Tobacco (in any form) No
What has been your usual state of health? Good
5. From above, it is evident that the life insured, on account of his answers to the interrogatories, affirmed that he was not suffering from any disease at that time; that he has not remained absent from place of work on grounds of health during the last 5 years and that he has been maintaining good health. The proposal was made on 05.12.2000 and the application of the life insured dated 08.09.2001, submitted to his employer for providing facility of visit to higher medical treatment centre for having Haemodialysis (Paper No. 52), would reveal that the life insured was permitted for onward journey from Haridwar by ambulance along with one attendant on 08.09.2001. The diseases, with which the life insured was suffering, have been mentioned as hypertension, coronary artery disease and case of renal failure (HTN; CAD and CRF). This document further endorses that the last visits to Batra Hospital & Medical Research Centre, New Delhi by the life insured were on 19.03.2001 and 08.04.2001. The discharge summary of the life insured of Batra Hospital & Medical Research Centre, New Delhi (Paper Nos. 54 to 55), would connect the earlier visit of the life insured to Batra Hospital & Medical Research Centre, New Delhi for treatment of diseases from 09.04.2001 to 17.04.2001 and the discharge summary endorses the diagnosis of the life insured as (1) End stage renal disease, (2) Hypertension and (3) Haemodialysis and it further clearly mention that the said patient was having hypertension since last four years and was on regular anti-hypertensive medicines and further that renal function impairment was detected in September, 2000 and the patient was on conservative management for this ailment. Further, in pursuance of the referral facility provided on 6 08.09.2001, the life insured was again admitted for treatment in Batra Hospital & Medical Research Centre, New Delhi and the discharge summary for the period of treatment from 08.09.2001 to 13.10.2001, also affirm the same diagnosis, as mentioned above together with a specific endorsement that he was also diagnosed for being suffering from tuberculosis, acute coronary insufficiency and haemodialysis. During the period from 24.09.2001 to 04.10.2001, the life insured was managed in chest care unit (CCU) for his chest pain and ECG changes (acute coronary insufficiency). He was also given multiple blood transfusions and maintained on haemodialysis. He was put on anti-tuberculosis treatment from 15.09.2001 and FNAC proven tuberculosis. Life insured having been discharged on 13.10.2001, after some time, his condition appear to have again deteriorated and his employer's hospital again referred him for better management to Batra Hospital & Medical Research Centre, New Delhi per order dated 09.11.2001 (Paper No. 53) and in pursuance thereof, he was again admitted in Batra Hospital & Medical Research Centre, New Delhi on 10.11.2001. The discharge summary for the period 10.11.2001 to 20.11.2001 (Paper Nos. 59 to 60), again confirm the same diagnosis, i.e., (1) End stage renal disease, (2) Hypertension, (3) Tuberculosis cervical, (4) Haemodialysis and (5) Fluid overload and in the discharge summary, it had been specifically endorsed that patient's renal function impairment had been detected in September, 2000. At the time of discharge, he was advised to have bi-weekly haemodialysis, besides taking other large number of medicines. Medical attendant's certificate (Paper No. 62) prepared and duly endorsed by the medical officer of the main hospital of Bharat Heavy Electricals Limited, Ranipur, Haridwar, where the life insured was employed, has endorsement to the effect that the life insured was admitted in the hospital on 22.04.2003 and expired on 24.04.2003. He was shown to have been suffering from earlier mentioned diseases for 7 the last about five years and for which, he has been receiving treatment from the hospital also during these five years. Certificate of hospital treatment (Paper No. 64) also affirm this fact together with an endorsement that the life insured was suffering from these diseases for the last five years and for nearly five years, he was on haemodialysis. Appellants also placed on record leave record of the life insured (Paper Nos. 46 to 51) for purposes of showing that on number of occasions, the life insured availed medical leave and our attention was also drawn to various dates by the learned counsel for the appellants, to bring home his point of view that in that regard also, deliberate wrong answer has been given in the proposal form by the life insured.
6. On account of above overwhelming evidence, genuineness of which could not be doubted in the absence of any cogent reason put forward on behalf of the complainant, we are persuaded to draw an inference that the life insured was suffering from above-mentioned serious diseases for the last about five years prior to his death and this was the reason that in the discharge summary of Batra Hospital & Medical Research Centre, New Delhi, mentioned above, it had been specifically endorsed that renal function impairment was detected in September, 2000 and that has been the reason that he has been on haemodialysis for the last five years, as has been reiterated in the documents of the life insured's employer's main hospital in Ranipur, Haridwar and whose doctors have made specific endorsements to that effect in medical attendant's certificate as well as certificate of hospital treatment, referred above. Life insured was on the regular cadre of Bharat Heavy Electricals Limited, Ranipur, Haridwar and there can be no doubt that he has been receiving treatment for his ailments as of right from employer's hospital and in a situation like this, the attending doctors and who have also given those certificates, knew very well the medical history of the life insured and have, thus, 8 made specific mention of the above-mentioned serious diseases, with which the life insured had been afflicted for the last five years before his death. There can be no gain saying that the other documents in that regard referred above, fully corroborate this fact and the consistent endorsements of the diseases in the medical records and discharge summaries, also establish that the life insured had renal function impairment since September, 2000, prior to purchasing the policy of insurance in question and that on account of the said disease, the life insured used to be put on haemodialysis for the last five years prior to his death and the disease ultimately turned out to be end stage renal disease. This was also the reason that in the final certificates of the main hospital of Bharat Heavy Electricals Limited, Ranipur, Haridwar, the life insured was reported to have expired on 24.04.2003 due to above-mentioned diseases, including on account of his being a case of renal failure.
7. Having drawn the inference as stated above, we are in a position to safely say that the learned counsel for the appellants rightly urged that the life insured deliberately and fraudulently gave incorrect and false answer to the questions pertaining to the material facts, information on which, was sought from the life insured by way of questions referred above and as contained in the proposal form for purchasing the policy of insurance. In our view, the appellants have been able to discharge the burden, which lay upon them to prove that information, which was on a material fact, was deliberately and fraudulently concealed by the life insured and in view thereof, the policy of insurance, which is issued on the basis of most abundant good faith on either side, stand vitiated in law. We find support to our inference from the decision of the Hon'ble Apex Court in the matter of P.C. Chacko Vs. Chairman, LIC of India; III (2008) CPJ 78 (SC) = (2008) 1 SCC 321.
98. In the face of the facts of the case, we do not find any merit in the argument of the learned counsel for the complainant that the life insured must have innocently made his signatures on the proposal form, which had been filled in by the agent of the insurance company and the practice which the agents usually follow, so as to increase their business and have large number of insurance policies issued to interested persons. Life insured had, in the past, purchased four other insurance policies on four occasions between the period 1994-1997, detail of which has been given by the complainant in her application dated 31.05.2003 (Paper No. 43) and the benefits of those policies have been provided by the Life Insurance Corporation of India to the nominee under those policies on account of their being no dispute about bonafides of the life insured in purchasing those earlier policies. This fact indicate that life insured was not a novice, who could have merely been made to put his signatures on the proposal form for the policy of insurance in question on mere asking of the agent of the insurance company and in a situation like this, the averments of the affidavits of the complainant, her son Sh. Ashok Kumar and another witness Sh. Anand, attention to those has been drawn by the learned counsel for the complainant, would be of no avail to the cause of the complainant in defending the answers given to the questions contained in the proposal form, by claiming that the life insured has innocently made his signatures on the proposal form prepared and filled in by the agent of the insurance company.
9. Further, the fact that the life insured was examined by the panel doctor of the insurance company at the time of purchasing the insurance policy and was then reported to be medically fit, would also make no difference because the panel doctor only make routine 10 check-up, in which the serious diseases, with which the life insured was then suffering, could not easily be detected.
10. In so far as the argument on behalf of the complainant that in the absence of evidence of medical officer in the form of any affidavit, the documentary evidence produced on record by the insurance company can not be considered, was concerned, we may mention to the decision of the Hon'ble National Commission dated 23.01.2006 in the case of Life Insurance Corporation of India Vs. Krishan Chander Sharma (Revision Petition No. 1935 of 1999 - copy of the judgment placed on record by the appellants), in which it has been stressed that non-filing of affidavit and / or non-examination of treating doctor, is not ruinous and the documentary evidence on record could very well be relied upon in support of the contention of the insurance company that the life insured was suffering from diseases regarding which false answer to the questions was knowingly given by the life insured. We also find it advantageous to refer to the decisions of the Hon'ble National Commission in the matter of
1) Bhagwati Prasad Borasi Vs. Life Insurance Corporation of India; II (2009) CPJ 19 (NC), 2) LIC of India and others Vs. K.A. Chandrakala; II (2009) CPJ 167 (NC) and 3) Life Insurance Corporation of India and another Vs. Sunita Hemnani; II (2009) CPJ 172 (NC), where on the basis of the documentary evidence, the policies of insurance were found vitiated due to suppression of material fact as regards the diseases and ailments, with which the life insured were found suffering on the basis of the documents placed on record. The affidavits of the medical officers concerned were not required to be placed on record in those cases.
11. For the reasons aforesaid, we are of the firm view that the insurance company was justified in repudiating the claim under the 11 policy of insurance in question, on the ground that the insured had concealed the material fact that he was suffering from diseases at the time of taking the insurance policy, by deliberately and fraudulently giving false answers to the questions contained in the proposal form and, as such, no deficiency in service in repudiating the claim has been made by the insurance company. The District Forum, therefore, was not at all justified in taking a contrary view, in view of the sufficient reliable evidence on record and, therefore, the order impugned can not legally be maintained and is liable to be set aside. Appeal thus, succeed and is to be allowed accordingly.
12. Appeal is allowed. Order impugned dated 03.04.2007 of the District Forum is set aside and consumer complaint No. 59 / 2006 is dismissed. No order as to costs.
(SMT. KUSUM LATA SHARMA) (JUSTICE IRSHAD HUSSAIN) K