State Consumer Disputes Redressal Commission
Life Insurance Corporation Of India, vs Gurmeet Kaur Wife Of Late Sh. Hira Singh ... on 30 January, 2013
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB,
SECTOR 37-A, DAKSHIN MARG, CHANDIGARH
First Appeal No. 720 of 2008
Date of institution : 14.7.2008
Date of Decision : 30.1.2013
1. Life Insurance Corporation of India, Divisional Office, Jeevan Parkash,
Sector 17, Chandigarh.
2. Life Insurance Corporation of India, Branch Office, Railway Road,
Sangrur.
Both the appellants through Authorised Officer Smt. P. Kwatra, Manager
(Legal & HPF), Life Insurance Corporation of India, Divisional Office, 'Jeevan
Parkash', Sector 17, Chandigarh.
....Appellants.
Versus
Gurmeet Kaur wife of Late Sh. Hira Singh Gill son of Sh. Bhagwan Singh, C/o Dr.
Kashmir and sons, Bus Stand Sunam, District Sangrur.
...Respondent.
2nd Appeal
First Appeal No. 721 of 2008
Date of institution : 14.7.2008
1. Life Insurance Corporation of India, Divisional Office, Jeevan Parkash,
Sector 17, Chandigarh.
2. Life Insurance Corporation of India, Branch Office, Railway Road,
Sangrur.
Both the appellants through Authorised Officer Smt. P. Kwatra, Manager
(Legal & HPF), Life Insurance Corporation of India, Divisional Office, 'Jeevan
Parkash', Sector 17, Chandigarh.
....Appellants.
Versus
Gurmeet Kaur wife of Late Sh. Hira Singh Gill son of Sh. Bhagwan Singh, C/o Dr.
Kashmir and sons, Bus Stand Sunam, District Sangrur.
...Respondent.
First Appeals against the order dated 10.6.2008 of
the District Consumer Disputes Redressal Forum,
Sangrur.
Before:-
Shri Piare Lal Garg, Presiding Member.
Shri Jasbir Singh Gill, Member.
Present in F.A. No. 720 of 2008:-
For the appellants : Sh. R.K. Sharma, Advocate For the respondent : Sh. R.S. Dhaliwal, Advocate First Appeal No. 720 of 2008 2 PIARE LAL GARG, PRESIDING MEMBER:
This order will dispose of two appeals i.e. First Appeal No. 720 of 2008 (Life Insurance Corporation of India & another Vs. Gurmeet Kaur) and First Appeal No. 721 of 2008 (Life Insurance Corporation of India & another Vs. Gurmeet Kaur). Both the appeals are against the impugned orders dated 10.6.2008 passed by the District Consumer Disputes Redressal Forum, Sangrur(in short the "District Forum") and are disposed off in a single order as the facts of both the cases are the same.
The facts are taken from 'First Appeal No. 720 of 2008' and the parties would be referred by their status in this appeal.
2. Brief facts of the case are that Hira Singh Gill husband of the respondent/complainant(hereinafter called 'the respondent') got insured himself under two policies No. 162950689 and 162952024 for Rs. 3,00,000/- and Rs. 2,00,000/-, respectively w.e.f. 28.6.2005 and the premiums were paid regularly. It was further submitted that all of a sudden the husband of the respondent died on 13.4.2007 due to brain hemorrhage. The life assured (hereinafter called 'LA') was hale and hearty at the time of purchase of the policies in dispute. She lodged the claims with the appellants/opposite parties (hereinafter called 'the appellants') and also submitted the requisite documents to the appellants but the claims of the respondent were illegally repudiated by the appellants vide letters dated 14.12.2007 on the ground that the LA did not disclose that he was chronic alcoholic and chain smoker at the time of filling the proposal form. The complaints were filed with the prayer that the appellants may be directed to pay the insured amount of Rs.3 lacs and Rs.2 lacs alongwith all the benefits under the policies with interest @ 24% per annum from the date of death till its realization as well as Rs.100000/- on account of mental First Appeal No. 720 of 2008 3 agony, pain and suffering and Rs. 11,000/- as litigation expenses in each of the complaint.
3. Upon notice, the reply was filed by the appellants. The fact of insurance of the LA i.e. husband of the respondent vide two different policies was not denied. The date of death was also admitted but it was pleaded that death of LA was not natural. The claims of the respondent were legally repudiated as on investigation it was found that LA was in the habit of excessive drinking and smoking. It was also proved from Form No. 3816 and as per the history of the LA, he was chronic alcoholic and chain smoker. He was admitted in the hospital as a case of headache, altered sensorium, sudden unconsciouness. He was suffering from alcoholic liver disease and expired on 13.4.2007. At the time of filling the proposal form, the deceased had answered the following questions on 7.7.2005 as under:-
Do you use or have you ever used; Answer
(i) Alcoholic Drinks No
(ii) Narcotics No
(iii) Tabacoo in any form No
The LA had deliberately withheld the material information and made mis- statement at the time of taking the policies. The appellants have also taken the legal objections that the respondent had no cause of action to file the present complaint, complaint was not maintainable, the matter was complicated one, as such, the same be relegated to Civil Court.
4. Learned District Forum after hearing the learned counsel for the parties and going through the record, accepted both the appeals and directed the appellants to pay Rs. 3,00,000/- as well as Rs. 2,00,000/- of both the policies with interest @ 9% per annum from the date of repudiation i.e. 14.12.2007 till realization and to pay Rs. 1,000/- as First Appeal No. 720 of 2008 4 litigation expenses in each complaint to the respondent within 60 days from the receipt of copy of the order.
5. Both the appeals were filed by taking similar grounds that the findings of the District Forum are not correct that the claims were wrongly and illegally repudiated by the appellants, the District Forum has not considered the terms and conditions of the policies as well as the proposal form, the entire approach of the District Forum suffers from material irregularities and illegalities in exercising its jurisdiction, the respondent has not approached the Zonal Manager of the Corporation if she was not satisfied with the decision of the appellants, as such, the orders of the District Forum in both the complaints under appeals are liable to be set- aside.
6. There is no dispute between the parties that the LA was insured with the appellants for an amount of Rs. 3 lacs and Rs. 2 lacs and he was paying the installments regularly. There is also no dispute that the insured died on 13.4.2007 due to brain hemorrhage.
7. The claims of the respondent were repudiated vide separate letters dated 14.12.2007 on the following grounds:-
"RE: Pol. No. 162955024 on the life of Sh. Hira Singh (Decd.) Sum Assured : Rs. 200000/-
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 the deceased having withheld material information regarding his habits at the time of affecting the assurance with us.
In this connection, we have to inform you that in the Proposal for Assurance dated 16.07.2005/personal statement signed by the deceased assured on 22.07.2005 at the time of his medical examination he had answered the following questions, as under noted:
QUESTIONS ANSWERS
11(Ja) Do you use or have you ever used
(i) Alcoholic Drinks NO
(ii) Narcotics NO
(iii) Tobacco in anyform NO
First Appeal No. 720 of 2008 5
We may, however, state that all these answers were false as we have evidence & reason to believe that about 10-15 years before he proposed for the above policy he was a chronic alcoholic and a chain smoker. He did not, however, disclose these facts in his proposal/personal statement. Instead he gave false answers therein as stated above.
It is, therefore, evident that he had made deliberate mis-statements and withheld material information from us regarding his habits at the time of effecting the assistance and hence in terms of the policy contract and the declaration contained in the forms of proposal for Assurance and Personal Statement we hereby repudiate the claim and accordingly, we are not liable for any payment under the above policy and all moneys that have been paid in consequence thereof belong to us."
8. The claim of the respondent qua policy No. 162950689 was also repudiated only on the same grounds.
9. So from the repudiation letters, it is clear that the claims of the respondent were repudiated by the appellants only on the ground that the LA was chronic alcoholic and chain smoker but he did not disclose this fact to the official of the appellants at the time of filling the proposal form. On receipt of the claims, the claims were got investigated/enquired and it was found that the life assured was chronic alcoholic and was chain smoker.
10. We have perused the affidavit of Mrs. Parminder Kwatra, authorized signatory of the appellants in support of its replies in both the complaints before the District Forum as Ex. R-7. Neither in the reply nor in the affidavit, the appellants had disclosed the name of the investigator, who investigated the claims submitted by the respondent with the appellants. The name of the investigator was not disclosed even in the repudiation letters as well as the findings of the Standing Committee dated 19.11.2007 vide which the claims of the respondent were recommended for repudiation. Only in the letters it was mentioned that "our investigator also confirmed the excessive drinking and smoking habits of the deceased/ life assured and recommended the claim under both the policies for repudiation."
First Appeal No. 720 of 2008 6
11. We have also perused the claim inquiry report, which was tendered into evidence as Ex. R-3. Against Column No. 10, which relates to the short history of the last illness of the deceased including the cause of death following questions were put, "what was the date when symptoms were first observed, actual cause of the illness and the doctors, who attended with respective dates, if death due to incident, state the nature of accident No. of the vehicle involved and the name of the Police Station whether the incidents is reported. Is there a suspicion of suicide in case of murder give briefly the circumstances under which he/she was murdered and whether anyone has been arrested? In case of female life where death has occurred due to causes to pregnancy, please state the term of pregnancy at the time of death."
12. Against the said column, it was reported and/or mentioned:-
"During the investigations it was revealed that the DLA used to drink and smoke heavily. Though some persons stated that he used to drink about 10-12 years back, now he was not taking drink and smoke. But Hospital record shows that he was a chronic smoker and alcoholic."
13. So from the report of the Investigator it is proved that some persons also informed him that the life assured was used to take drink and was smoker for the last 10-12 years but now he was not taking drink and was not smoker. The names of the persons, who informed the above facts to the investigator were not disclosed by the Investigator but they must be nears and dears of the LA and there was no reason to give wrong information by the said people to the investigator.
14. We have also perused Form No. 3816 regarding the Certificate of Hospital Treatment. The same is issued by Dr. Prabjot Singh Sibia, MBBS, MD tendered into evidence by the appellant as Ex. R-4. Paras No. 2, 3, 4, 5, 6 & 7 are reproduced:-
First Appeal No. 720 of 2008 7
2. What was the date of his admission into 12.4.07 the Hospital?
Please state his indoor admission No.
3. Under whose treatment was the patient Record not available.
before he was admitted into the Hospital?
If the patient had brought a letter or a note from any doctor at the time of admission kindly furnish us with a certified copy thereof.
4. What at the time of admission, was
a) The nature of his complaint a) Unconscious same day i.e. 12.4.07
b) Duration of the complaint as reported by him?
5 (a) What was the exact history reported by a) Sudden onset unconscious the patient at the time of admission?
(Full history including the dates, duration of the ailments, the symptoms narrated etc. to be given)
b) Was the history reported by the patient b) No himself/herself or by some one else?
c) If not, by whom? Name and relationship of c) by relative the person who reported it) Was the patient present at that time and was he/she conscious?
d) To whom was the history reported & by d) Dr. P.S. Sibia whom it was recorded?
e) Whether the Doctor who reported the e) Yes history is still in your service If not please state his/her present full address Note: Certified copy of the full history may please be furnished
6. What was the diagnosis arrived at in the CVA (illegible) Hospital
7. Was there any other disease or illness No which preceded or co-existed with the ailment at the time of the patient's admission into the hospital? If so what was it? Please give details stating.
a) History Reported a) No
b) Date when such was first observed by b)
patient.
First Appeal No. 720 of 2008 8
c) By whom treated. c) No
d) By whom the history was reported? If not d) No
by the patient himself/herself, please
indicate if it was in his/her presence and to his/her knowledge)
e) Who recorded this history? (If the doctor is e) No not with the hospital at present, please give his/her present address.)
15. Dr. Prabjot Singh Sibia issued Form No. 3816 Ex. R-4 in whose hospital the life assured was immediately admitted on 12.4.2007 and against column No. 4 it was mentioned that at the time of admission, the patient was unconscious and he had referred the LA to DMC Hospital on the same day. Nowhere in columns No. 6 & 7 it was mentioned by Dr. Sibia that the LA was chronic alcoholic and chain smoker.
16. We have also perused Form No. 3816 i.e. Certificate of Hospital Treatment issued by D.M.C. & H, Ludhiana, which is issued on 23.5.2007. The relevant paras of the same are also reproduced:-
2. What was the date of his admission into 12 April 07 the Hospital? 10869 Please state his indoor admission No.
3. Under whose treatment was the patient Not in Record before he was admitted into the Hospital?
If the patient had brought a letter or a note from any doctor at the time of admission kindly furnish us with a certified copy thereof.
4. What at the time of admission, was
a) the nature of his complaint a) Headache Sudden onset unconscious few hrs PTA
b) the duration of the complaint as reported Few Hrs PTA by him?
5 (a) What was the exact history reported by a) Headache the patient at the time of admission? Alt. Sersoriom (Full history including the dates, duration Sudden onset unconscious of the ailments, the symptoms narrated Few Hours PTA etc. to be given)
b) Was the history reported by the patient b) By some one else First Appeal No. 720 of 2008 9 himself/herself or by some one else?
c) If not, by whom? Name and relationship of c) Not in record the person who reported it) Was the patient present at that time and was he/she conscious?
d) To whom was the history reported & by d) Dr. Munish whom it was recorded?
e) Whether the Doctor who reported the e) Yes history is still in your service If not please state his/her present full address Note: Certified copy of the full history may please be furnished
6. What was the diagnosis arrived at in the Chr. Alcoholic, Chr. Smoker Hospital Accoelerated HT T CVA T (L) Parental ICH SAH B/g Blood
7. Was there any other disease or illness Chronic Smoker x 10-15 yr.
which preceded or co-existed with the Chr. Alcoholic ailment at the Time of the patient's admission into the hospital? If so what was it? Please give details stating
a) History Reported a) As above
b) Date when such was first observed by b) Not in Record patient
c) By whom treated. c) Not in Record
d) By whom the history was reported? If not d) Not in Record by the patient himself/herself, please indicate if it was in his/her presence and to his/her knowledge)
e) Who recorded this history? (If the doctor is e) Dr. Munish not with the hospital at present, please give his/her present address.)
17. The appellants on the basis of Form No. 3816 issued by D.M.C. & Hospital repudiated the claims of the respondent as it was reported in paras No. 6 & 7 of Form No. 3816 that the LA was chronic smoker and alcoholic for 10-15 years. In the said Form, it was mentioned against para No. 5 (b) that the history of the patient was reported by someone else but against the column No. 5(c), if not by whom? Name and First Appeal No. 720 of 2008 10 relationship of the person who reported it. (d) Was the patient present at that time and was he/she conscious?
18. From the perusal of Column No. 5, it was reported that the history of the patient was reported by someone else but the name of the person, who reported the history of patient and what was his relationship was not in record of the hospital. It was also mentioned in column No. 5 that the history was recorded by Dr. Munish. But this Form No. 3816 was not signed and issued by Dr. Munish, who was in service of DMC Hospital when Form No. 3816 was issued to the alleged investigator by DMC & Hospital, Ludhiana. But no explanation is given by the appellants that why the history of the LA was not inquired from Dr. Munish, who has recorded the same and was in service of the DMC Hospital.. Neither any Doctor of DMC Hospital, who issued Form No. 3816 was examined nor his affidavit was tendered into evidence. As such, it is proved that Form No. 3816 was procured from the Doctors of D.M.C. & Hospital, who had no concern with the treatment of the LA.
19. In view of the above discussion, we are of the opinion that the appellants have badly failed to prove that the LA was chronic alcoholic and chain smoker. The cause of death mentioned in the report of the Investigator is brain hemorrhage, as such, there is no evidence that the LA was suffering from alcoholic liver disease with cirrhosis of liver.
20. The order passed by the learned District Forum is detailed and speaking one and also legal and valid. There is no infirmity in the same. As such, both the appeals being without any merit are dismissed with costs of Rs. 5,000/- in each appeal. The orders of the District Forum are affirmed and upheld.
21. The arguments in these appeals were heard on 22.1.2013 and the orders were reserved. Now the orders be communicated to the parties. First Appeal No. 720 of 2008 11
22. The appellants in F.A. No. 720 of 2008 had deposited an amount of Rs. 25,000/- with this Commission at the time of filing the appeal and Rs. 1,25,000/- in compliance of the order dated 14.7.2009. These amounts of Rs. 25,000/- and Rs. 1,25,000/- with interest accrued thereon, if any, be remitted by the registry to the respondent by way of a crossed cheque/demand draft after the expiry of 45 days under intimation to the learned District Forum and to the appellants.
23. The appellants in F.A. No. 721 of 2008 had deposited an amount of Rs. 25,000/- with this Commission at the time of filing the appeal and Rs. 75,000/- in compliance of the order dated 14.7.2009. These amounts of Rs. 25,000/- and Rs. 75,000/- with interest accrued thereon, if any, be remitted by the registry to the respondent by way of a crossed cheque/demand draft after the expiry of 45 days under intimation to the learned District Forum and to the appellants.
24. Remaining amount of both the claims shall be paid by the appellants to the respondent with costs and litigation expenses within 30 days from the receipt of the copy of the order.
25. The appeals could not be decided within the statutory period due to heavy pendency of Court cases.
26. Copy of this order be placed on First Appeal No. 721 of 2008 (Life Insurance Corporation of India & another Vs. Gurmeet Kaur).
(Piare Lal Garg)
Presiding Member
January 30, 2013. (Jasbir Singh Gill)
as Member