State Consumer Disputes Redressal Commission
Smt. Lalita Chamoli vs Life Insurance Corporation Of India And ... on 4 August, 2006
STATE CONSUMER DISPUTES REDRESSAL COMMISSION UTTARANCHAL - 8 - STATE CONSUMER DISPUTES REDRESSAL COMMISSION UTTARANCHAL DEHRA DUN FIRST APPEAL NO. 52 / 2005 Smt. Lalita Chamoli ......Appellant Versus Life Insurance Corporation of India and another .....Respondents Sh. Anup Kumar Lathar, Learned Counsel for the Appellant Sh. Deepak Ahluwalia, Learned Counsel for the Respondents Coram: Hon'ble Justice Irshad Hussain, President Surendra Kumar, Member Ms. Luxmi Singh, Member Dated: 04.08.2006 ORDER
(Per:
Mr. Justice Irshad Hussain, President):
This is complainant's appeal under Section 15 of the Consumer Protection Act, 1986 against the order dated 18.01.2005 passed by the District Forum, Dehradun dismissing the complaint filed for grant of benefits of the life insurance policy taken by complainant's husband Late Sh. Uma Dutt Chamoli.
2. The controversy involved in the case was whether non-mentioning of the disease "diabetes" in the declaration form by the insured amount to suppression of material facts and fraudulent concealment of the material facts warranting repudiation of the claim under the policy by the insurance company. The claim preferred by the complainant had been repudiated by the insurance company and the District Forum on an appreciation of the material on record held that the insurance company was in the face of the facts of the case fully justified in repudiating the claim of the widow of the insured. The repudiation of claim by the insurance company and the impugned order of the District Forum are, therefore, under challenge in this appeal.
3. We have heard the Learned Counsel for the parties and have carefully considered their submissions in the light of the facts of the case and the legal aspects of the matter in controversy. There is no dispute on the point that on 28.03.1994 a declaration form about the health was filled in by the deceased. In the proposal form, he answered the following questions before the policy was given:
QUESTION ANSWER
(a) During the last five years, did you consult a Medical Practitioner for any ailment requiring treatment for more than a week?
No
(b) Have you remained absent from place of work on grounds of health during the last five years?
No
(c) Are you suffering from or have you ever suffered from diabetes, tuberculosis, high blood pressure, low blood pressure, cancer, epilepsy, hernia, hydrocale, leprosy, or any other disease?
No
(d) What has been your usual state of health?
Good
4. There is also no dispute that the deceased was admitted in PGI, Chandigarh on 07.08.1996 for medical treatment of serious ailments and was discharged on 14.08.1996. LIC obtained the certificate of the treatment from PGI, Chandigarh in connection with the disposal of the claim and the certificate (Paper Nos. 27B/5 to 27B/7 of the record of the District Forum) disclosed following information:
"At the time of admission on 07.08.1996, there was puffiness of face, swelling of feet reported to be for the last five months; shortness of breath and dry cough for the last twenty days and loss of appetite and fatigue for the last one month. History reported by the patient himself (insured) was that he was a known diabetic for the last five years duration; was treated for pulmonary tuberculosis about three years ago; edema feet and face for the last five months and shortness of breath for the last twenty days."
5. History reported was also that the "insured was suffering with diabetes mellitus" for the last five years and he had been receiving treatment locally for his ailment.
6. Case summary recorded in this certificate by the Associate Professor of PGI, Chandigarh was to the effect that the insured had been a known diabetic for the last five years; had presented with history suggestive of renal involvement in the form of pedal edema and facial puffiness for the last five months and history suggestive of congestive heart failure (breathlessness on exertion and even at rest) for the last twenty days.
7. On examination, insured was also found to have features of neuropathy and nephropathy as complications of diabetes and history suggestive of congestive heart failure.
8. There is no dispute that the insured died on 17.01.1997 due to cardio respiratory arrest as the primary cause and hypertension and renal failure as secondary cause as mentioned in medical attendent's certificate (Paper No. 27B/37). This certificate also reveal that the insured was suffering from the said disease for the last about five years approximately before his death. The certificate was prepared and signed by Dr. K.K. Bhardwaj, M.D., Consultant Physician, under whose treatment the insured was before the death. The certificate of hospital treatment (Paper No. 27B/38) issued by the said Physician also reveal that insured was brought to the hospital on 17.01.1997 and breathed his last the same day on account of heart problem and renal failure. Previous history reported was that the insured was a known diabetic for the last five years and was also suffering from hypertension. Certificate of employer (Paper No. 27B/39) issued by the Manager of the bank where the deceased was employed at the time of his death also has endorsement that the deceased was having long kidney problem and had been on sickness leave from time to time since July 1996 while the deceased was having his posting at Rishikesh branch of the bank.
9. From certificate of hospital treatment referred above, it is evident that the insured has had his medical treatment in one of the most reputed Medical Institute of the country namely PGI, Chandigarh and there is absolutely no reason whatsoever to question the veracity of the endorsements made in it by the Associate Professor of the Institute and in our view, the District Forum was fully justified in placing reliance on various entries and endorsements of this certificate to come to a definite conclusion that the insured Late Sh. Uma Dutt Chamoli had been suffering from "diabetes mellitus" for the last about five years at the time of admission in the institute on 07.08.1996. In other words, the insured was suffering from the said disease on 28.03.1994 when the proposal form was submitted for the insurance policy and even for about three years before the submission of the proposal form and making the declaration about his health. As argued by the Learned Counsel for the insurance company, the other certificates referred above also lent credence to the said inference and we see absolutely no merit in the submission of the Learned Counsel for the complainant that the insured was not suffering from the said disease at the time of submission of the proposal form. It is also pertinent to mention that the certificate of employer has endorsement about the period of sickness leave w.e.f. the month of July 1996 till December 1996 as the insured was posted in Rishikesh branch of the bank during that period only and earlier he remained posted at other branches of Punjab National Bank and had in the past also availed sickness leave on good number of occasions from time to time since the year 1990 till the year 1993 as detailed below:
For the period from 14.05.1990 to 14.07.1990 (Paper Nos. 27B/21 to 27B/22) For the period from 10.06.1991 to 22.06.1991 (Paper Nos. 27B/30 to 27B/31) For the period from 24.02.1992 to 28.02.1992 (Paper No. 27B/35) For the period from 14.07.1992 to 29.07.1992 (Paper No. 27B/32) For the period from 23.10.1992 to 07.11.1992 (Paper No. 27B/23) For the period from 09.06.1993 to 14.06.1993 (Paper No. 27B/33) For the period from 12.07.1993 to 17.07.1993 (Paper No. 27B/25) For the period from 26.07.1993 to 31.07.1993 (Paper No. 27B/26) For the period from 11.10.1993 to 16.10.1993 (Paper No. 27B/27)
10. From the above record, which do not admit of any infirmity as regards its veracity and correctness, it is apparently clear that the insured gave false answers to the questions regarding the disease "diabetes"; absence from place of work on grounds of health and also regarding his usual state of health in the declaration form as reproduced above. There can be no doubt that when a specific question was asked to the insured with regard to diabetes, he was bound to disclose that fact. Having not done so, there was suppression of material fact which could otherwise have affected the decision of the insurance company. Not only this, as is evident from the certificate of PGI, Chandigarh, the insured besides being the known case of diabetes mellitus for the last five years (even three years before the submission of the proposal form for insurance cover), he had been treated for pulmonary tuberculosis, which fact was also required to be disclosed when specific question about this disease was also asked to the insured in the declaration form referred above. Considering these aspects of the matter, we do not think that the District Forum fell in error in coming to the conclusion that the insured fraudulently made false representation and suppressed material facts regarding his disease, usual state of health and absence from place of work on grounds of health during the last five years and further that the insurance company had discharged the burden of proving that the insured had made fraudulent suppression of the material facts in order to purchase the policy of life insurance. It is also apparently clear that the cause of death of the insured namely cardio respiratory failure accompanied by hypertension and renal failure was the result of diabetes mellitus with which the insured was suffering for more than five years before his death. In other words, the nexus between diabetes mellitus and heart & renal failure was very well established by the case history of the insured.
11. In the face of the facts of the case, we see no merit in the argument of the Learned Counsel for the complainant that in view of Section 45 of the Insurance Act, the policy cannot be called in question on ground of misstatement after two years. The reason being that the policy can be called in question even after two years if the insurer is able to show that the insured suppressed material facts fraudulently and which facts he knew and was obliged to disclose at the time of purchasing the policy of life insurance and if the burden of prove in that regard is discharged by the insurer by acceptable evidence and material on record. Considering the settled legal import of Section 45 of the Insurance Act, we need not reproduce the full provision of Section 45 here and there can be no gain saying that the material on record fully establish that the statement in the proposal form on material matters was made falsely and suppression of the material facts was made fraudulently by the insured in the proposal form and that the burden of proof was fully discharged by the insurance company. The policy in question was, thus, rightly called into question even though the insured submitted proposal form on 28.03.1994 and he died after expiry of more than two years on 17.01.1997. Considering the facts and circumstances of the case, the two reported decisions of the Hon'ble National Commission pressed into service by the Learned Counsel for the insurer also fortify the above inference. In the case of LIC and Others Vs. Smt. Shashi Bala; (IV) 2003 CPJ 91 (NC), Life Insurance Corporation repudiated the claim on the ground that the insured had suppressed facts regarding suffering from diabetes at the time of taking the policy. The insured had died of heart attack. National Commission held that the nexus between diabetes mellitus and heart attack was too well established by medical literature and the failure to disclose diabetes amounted to suppression of material facts. Therefore, National Commission set aside the order of the State Commission allowing the claim of insured and allowed the appeal preferred by Life Insurance Corporation.
12. In the second reported case in the matter of Life Insurance Corporation of India Vs. Mansa Devi; II (2003) CPJ 135 (NC), policy commenced from 28.04.1993 and insured died after two years on 28.06.1995. The claim preferred by the widow was repudiated by the LIC on the ground that the life assured had intentionally and fraudulently suppressed material facts concerning his health such as diabetes mellitus and treatment undergone for eight years. The insured had a leg amputation after a thorn prick and renal failure which caused death. These were held to be clear indications of long suffering of diabetes and suppression of material facts was held to be proved. It was held to be a valid repudiation of claim by the insurance company. Therefore, the order of the State Commission allowing the appeal was set aside and the order of the District Forum which had dismissed the complaint of the widow was restored.
13. On the face of the facts of the case, the reported decisions in the matter of Chandrabhan Vs. Jagdish Prasad Chauhan; 2005 UAD 498, United India Insurance Co. Ltd. Vs. Jaswant Singh; 2003 Current 511 and Savitri C. Pillai Vs. Life Insurance Corporation of India; 1998 (2) CPR 320 relied upon by the Learned Counsel for the complainant have no bearing on the facts of the case and do not at all help the cause of the complainant.
14. For the reasons aforesaid, we are of the firm view that the Life Insurance Corporation made no deficiency in service in repudiating the claim and the District Forum rightly dismissed the complaint preferred by the widow of the insured. There being no merit in this appeal, the same is liable to be dismissed.
15. Appeal is dismissed. No order as to costs.
(MS.
LUXMI SINGH) (SURENDRA KUMAR) (JUSTICE IRSHAD HUSSAIN)