State Consumer Disputes Redressal Commission
Sh. Deep Chand Sood & Anr. vs Life Insurance Corporation Of India & ... on 3 June, 2008
H
H.P. STATE
CONSUMER DISPUTES REDRESSAL COMMISSION, SHIMLA
Consumer Complaint No. 03/2005.
Date of Decision 03.06.2008.
1.
Sh. Deep Chand Sood S/o Sh. Devi Prasad Sood,
2.
Ms Ishani Sood (Minor) D/o Sh. Deep Chand Sood,
through
Father-cum-first friend-cum-natural
guardian, Sh. Deep Chand
Sood,
3.
Ms. Sheetal Sood D/o Sh. Deep Chand Sood,
All R/o Friends Colony, Holta,
Palampur,
Tehsil Palampur, Distt. Kangra, HP.
. Complainants.
Versus
1.
The Life Insurance Corporation of India, The
Mall
Shimla through its Senior Divisional
Manager,
2.
The Branch Office, Life Insurance Corporation of India,
Palampur, Tehsil Palampur, Distt. Kangra,
HP
through its Branch
Manager.
. Opposite Parties.
Honble
Mr. Justice Arun Kumar Goel, President.
Honble
Mrs. Saroj Sharma, Member.
Whether Approved
for reporting? Yes.
For the Complainants. Mr. Peeyush Verma, Advocate.
For the Opposite parties. Mr. Varinder Tajta, Advocate with Mr.
Sagar Dev Negi from the office of
Sr. Divisional Manager, Kasumpti,
Shimla.
O R D E R:
Justice Arun Kumar Goel (Retd.) President.
Core question involved in this complaint is, as to whether the 3, (2 new and 1 lapsed got revived) insurance policies which are subject matter of this complaint were obtained by the deceased Smt. Rama Sood, wife and mother respectively of complainant No.1, and complainants No.2 and 3 were the result of suppression of material facts relating to her having obtained medical treatment, her having availed medical leave and also having undergone check up at AIIMS, New Delhi and PGI Chandigarh and above all her having been operated upon by Dr. Mangla Dogra at Chandigarh. In case findings on this issue is recorded in favour of the OPs, then what will be the consequence.
2. Brief facts giving rise to this complaint are, that according to the complainants late Smt. Rama Sood, hereinafter referred to as the insured, was working as a staff nurse in Chaudhary Sarwan Kumar, HP Krishi Vishwa Vidyalaya, Palampur. She had obtained 19 policies according to the complainants, and 18 according to the OPs. Particulars of these 18 policies are given in Chart A, in the reply filed by the OPs. For ready reference this is extracted hereinbelow:-
CHART-A Sr. No. Policy No. Table & Term Sum Assured Proposal Date Remarks Status at Death Last Premia Paid on
1.
130403584 75-20 25,000 22.12.86 Revived on 30.9.03 In force 19.10.04
2. 130405172 75-20 10,000 28.12.87 Revived on 30.03.02 In force 19.10.04
3. 150100344 74-15 50,000 28.07.90 Revived on 30.9.03 In force 30.09.03
4. 152336677 14-20 1,00,000 15.02.96 Not revived In force 28.04.05
5. 152372724 89-15 1,00,000 28.03.99 Not revived In force 28.04.05
6. 150798290 14-15 1,00,000 28.03.2K Revived on 19.10.04 & Repudiated In force 19.10.04
7. 152400755 14-14 2,00,000 28.03.02 Not revived In force 28.04.05
8. 151280124 14-16 1,00,000 28.10.02 Not revived Lapsed 31.10.02
9. 151321656 151-15 5,00,000 15.02.03 Not revived Lapsed 28.02.03
10. 151329959 159-11 2,00,000 22.10.03 Not revived Lapsed 17.11.03
11. 151329994 14-06 1,00,000 22.10.03 Not revived Lapsed 17.11.03
12. 151460678 102-33 5,00,000 7.12.03 Not revived Lapsed 08.12.03
13. 152429832 14-27 5,00,000 15.02.04 Repudiated In force 28.04.05
14. 152411383 149-27 3,00,000 28.02.04 10 Gaps Lapsed 28.04.05
15. 151612717 149-27 18,00,000 18.08.04 Repudiated In force 16.02.05
16. 152365382 14-06 50,000 28.03.97 Matured
17. 130405909 90-15 30,000 12.05.88 Matured
18. 150876629 90-15 1,00,000 28.11.00 Not revived Lapsed Out of these 8 policies have been admittedly paid by the OPs. These are shown in the Chart B, contained in the reply. It is also extracted hereinbelow:-
CHART-B Sr. No. Policy No. Date on which admitted Amount paid
1.
130405172 14.1.2001 12095.00
2. 130403584 14.1.2006 25404.00
3. 150100344 14.1.2006 87951.00
4. 130405909 28.6.2003 34818.00
5. 152365382 28.3.2003 66449.00
6. 152372724 13.7.2005 130306.00
7. 152336677 28.6.2005 123393.00
8. 152400755 28.6.2005 224203.00
3. So far one policy is concerned, at the time of hearing Mr. Verma learned counsel for the complainants stated, that since it pertains to the daughter of the deceased-insured, as such the total insurance policies held by her were
18. Out of these money due of 8 was paid and 6 had lapsed. Therefore according to him, the controversy in this complaint now remains qua 4 policies only.
4. Out of these 4 policies, one at Sr. No. 18 of Chart A above, it was stated on behalf of the OPs that in case this complaint is allowed, its amount will be payable on the date of maturity and not before that without payment of any premium by the complainants as per terms of this policy. Mr. Tajta however stated that his client is neither liable for paying the amount either of this or the other 3 policies which are in dispute and are at Sr. Nos. 6, 13 and 15 of Chart A extracted above. So far policy at Sr. No. 6 which is also in dispute, it was revived on 19.10.2004 and premiums till her death were regularly paid after its revival.
5. So far these 3 disputed policies are concerned those were obtained by the deceased-insured on 28.3.2000, 15.2.2004 and 18.8.2004. Dates in these 3 policies are relevant and would be dealt with appropriately hereafter.
6. After the death of his wife on 20.4.2005, complainant No.1 approached the authorities of the OPs for the payment of admissible amount in respect of these 3 and other policies. Amount of policies at Sr. No. 1, 4 and 5 of Chart B were paid to the insured during her life time, whereas amount of the rest of the policies of this Chart was paid after her death to the complainants is an other admitted fact between the parties.
7. Complainant on 25.10.2005 asked the OPs for release of the payment vide Annexure A-4. In response thereto vide Annexure A-5 he was informed that deceased had visited PGI Chandigarh, AIIMS, New Delhi for her medical check up and was taking treatment there, as such he should provide treatment particulars with OPD slips, discharge slips whatever was available with him, so as to enable them to consider the claim. He replied vide Annexure A-6, that his wife did not visit PGI, Chandigarh and AIIMS, New Delhi nor she was taking treatment from there. He also requested the OPs to please let him know the source i.e. written documentary evidence on the basis of which they have written to him in that behalf.
8. In this case the whole thrust of the case of the OPs is that the contract of insurance being based on utmost good faith and bona fides on the principles of uberrima fides, as such a person like insured before obtaining the insurance policy (s) is duty bound to give full details/particulars of her state of health as to whether she was suffering from any disease and or had undergone any treatment etc., while filling in the proposal form. In this case copy of the proposal forms i.e. Annexure RW-VII is the document giving status report of the health of the insured qua policy No. 150798290. It is dated 11.12.2003.
9. Policy particulars of 3 disputed policies are :-
A) 150798290 in the sum of Rs. 1 lac, it was revived on 19.10.2004 when last premium was received;
B) 152429832 for Rs. 5 lacs this was obtained on 15.2.2004; and C) 151612717 for Rs. 18 lacs it was obtained on 18.4.2004 and last premium in this case was received on 16.2.2005.
10. Another fact that needs to be noted here is that one of the policies was admittedly obtained by the insured after 2001. This is at Sr. No. 8 of Chart-B above. This date assumes significance because this policy was also obtained by the insured after the date when she is alleged to have undergone surgery at the hands of Dr. Mangla Dogra at Chandigarh besides having availed leave for medical check ups at AIIMS New Delhi and PGI Chandigarh. Payment is admittedly made by the OPs to the complainants of this policy. What is its effect will be the other question, we shall examine in this complaint while dealing with rival contentions of the parties.
11. In this background, Mr. Verma urged that even if it be assumed for the sake of argument without conceding what is alleged by the OPs on the basis of Annexures R-IV, V and VI the proposal forms of 3 disputed policies to be correct, still his clients are entitled to the amount of these 3 policies alongwith interest, bonus and other admissible benefits as per law. He buttressed this submission by pointing out that there is no material on record to suggest as to who had filled in these forms. Though he admitted that these forms were signed by the insured.
12. On the other hand to our repeated and pointed query as to who filled in these proposal forms as also Annexure R-VII, answer of Mr. Tajta was that these are signed by the insured, however he did not utter a word as to who had filled in these proposal forms. In this behalf best person(s) to say anything qua filling in of these forms would have been either the agent(s) or the development officer(s) who had done these policies.
13. When the OPs are pleading that this is a case of suppression of true and material facts regarding her state of health etc. as well as deceased having undergone treatment as alleged by them, it was their bounden duty to have come clean by placing reliable as well as acceptable material on record as to who was the agent (s)/development officer(s) who had insured the deceased by placing material on record about filling in Annexures R-IV to R-VII. Reason being that all exclusions are in law required to be proved firstly by the insurance company, and secondly under the Insurance Regulatory and Development Authority (Protection of Policy Holders Interests), Regulation 2002, a duty is enjoined upon the insurer like OPs in the present case, to apprise the insured like deceased regarding all pros and cons, exclusions, terms and conditions of policy subject to which the insurance is undertaken. There is no such evidence and or affidavit placed by the OPs of either the agent(s) or the development officer(s) to the effect that Regulation 3 of Regulations of 2002 (supra), was complied with. Therefore in the absence such evidence, no benefit can be derived by the OPs regarding the alleged suppression of facts in Annexures R-IV to R-VII. In this behalf we rely on a decision of National Commission in the case of National Insurance Co. Ltd. Vs. D.P. Jain, III (2007) CPJ 34 (NC).
14. While placing reliance on the Annexures R-IV to R-VII for the rejection of this complaint, Mr. Tajta learned counsel for the OPs stated that there was hardly any need for the agent(s)/development officer(s) to have explained anything to the deceased, because it was not the first policy she was obtaining. Further according to him, looking to the number of policies held by her in the past, she was very well aware as to what was expected of her to be stated/disclosed in a proposal form while obtaining an insurance policy. Thus it was submitted by him that in these circumstances, it should be presumed to have been duly explained to the insured who was also otherwise well aware, and only then after understanding the same she had appended signatures on Annexure R-IV to R-VII. Per Mr. Tajta requirement of compliance with Regulations of 2002 (supra), is also there in the peculiar circumstances of this case. We do not find any substance in this submission of Mr. Tajta and reject the same.
15. While further advancing the case of his clients, Mr. Tajta referred to statements of 2 witnesses examined in this complaint by him. They are Mrs. Dr. Anjana Tuli, Medical Officer of the University and Dr. K.K. Parmar, Deputy Director (Planning), of the University.
16. Dr. Tuli with reference to original record stated that Ext. R-1 is the form signed by her. This is certificate of the employer and date of death of the insured is mentioned in it. Ext. R-2 contains the detail of earned leave availed by the deceased w.e.f. 1.1.1997 to 20.4.2005. This shows that for 15 days between 27.1.1998 to 10.2.1998 deceased had taken leave to look after the baby. Between 27.3.2000 to 1.4.2000 she had availed 6 days leave for medical investigation at AIIMS, Delhi, again between 6.8.2001 to 10.8.2001 she was on leave for 5 days to attend the marriage, and between 6.1.2003 to 10.1.2003 she availed 5 days leave to attend Satsang at Vias and between 3.3.2003 to 7.3.2003 she availed 5 days leave to look after the child and lastly between 24.3.2003 to 29.3.2003 she availed 6 days leave for investigation/medical check up at Chandigarh.
17. Further according to this witness between 23.9.1998 to 26.10.1998 she was on medical leave due to asthenia, from 16.8.1999 to 19.8.1999 she was on leave for myalgia, from 26.3.2001 to 30.3.2001 she was on leave due to gastroenteritis and from 16.4.2001 to 25.4.2001 she was on leave for 10 days due to osteoarthritis. In the year 2001 she came with the request for medical leave for operation for 25 days from 18.12.2001 to 11.1.2002. In this application she had mentioned to be suffering from ovarian-cyst. Between 16.1.2002 to 19.1.2002 she was suffering from gastroenteritis and myalgia. She had again taken 3 days leave from 13.9.2004 to 15.9.2004 as she was suffering from acute acid peptic disease. In cross-examination this witness stated that Ext. R2 pertains to medical/commuted leave. She also admitted that as per Ext. R-3 ovarian cyst was benign. Deceased joined duty after availing medical leave on furnishing her medical fitness certificate on every occasion. Some of leave applications submitted by the deceased were only signed by her, whereas some were in her own hand. To the knowledge of the witness the deceased never submitted any document for her any chronic disease. However she voluntarily stated that she was having hypothyroid. Insured also submitted medical reimbursement claim for the disease given by her.
18. Dr. K.K. Parmar, Deputy Director has identified the signatures of Sh. Jublani on Exhibits R-1 to R-3, who was working as a Controller and was also acting and Officiating Registrar, whenever the Registrar was on leave.
19. Besides these two statements Mr. Tajta laid emphasis on Ext. RW-1 the Form No. 3816 purported to have been filled by Dr. Mangla Dogra MD (OBS & GYNAE) PGI, Former Associate Professor PGI, C/o Nagpal Nursing Home 8/19A Chandigarh. As per this form deceased was admitted on 19.12.2001 and nature of her complaint was excessive bleeding during periods for 7 months. Patient was discharged on 22.12.2001. In case summary she has stated as under: Pt was having excessive bleeding PIV during periods 7 months was diagnosed (lt) ovarian-cyst at Palampur by Dr. Sushma and LAVH C BSO was done on 20.12.2001 and his histopathology report was non cancerous (Benign). Dr. Mangla Dogra has also sworn affidavit which is Ext. RW/IA. For ready reference the contents of this affidavit are extracted hereinbelow:-
I, Dr. Mangla Dogra, W/o MBBS, MD, (OBS & GYNAE), PGI, Former Associate Professor, PGI Chandigarh, C/o Nagpal Nursing Home and R/o No 8 Sector 19-A Chandigarh, Aged about years, do hereby solemnly affirm and state as under:
1. That I have seen, perused and gone through the certificate of Hospital treatment in Form No. 3816, containing 11 paras in total 4 pages, issued in connection with claim under Policy No. 151612717, Patient Smt. Rama Sood and which is exhibited RW-1.
2. That the said certificate bears my signatures at page 4 in the space inscribed against signature column and is also authored by me, the contents whereof in paras 1 to 11 are true and correct to the best of my personal knowledge and no part of it is false.
Sd/-
Deponent.
Verification: the above named deponent do hereby further verify that the contents of my above affidavit in paras 1 & 2 are true & correct to my personal knowledge and records and nothing material has been concealed there from.
Verified on this day of 16.2.2006.
Sd/-
Deponent.
20. By referring to these documents Mr. Tajta submitted that when the insured obtained 2 new disputed policies and revived the lapsed one, she never mentioned about her having visited Dr. Mangla Dogra and or having obtained any treatment from her. This non disclosure by itself was enough according to him for dismissing the complaint.
21. After having given our thoughtful consideration to these 2 documents i.e. Exts. RW1 and RW1/A, we are of the view that they do not in any manner advance the case of the OPs. Here we would like to again refer to Annexures R-IV to R-VII. Per Mr. Tajta details of few policies are given in R-IV to be precise of 2 policies of the value of Rs 25,000 and Rs. 50,000/-. In Annexure V insured has mentioned of 4 policies obtained by her in the years 2003, 1996 and 1997, whereas in Annexure R-VI she has again mentioned of 4 policies obtained in the years 1986, 1999 and 2003. To our specific query, it was admitted on behalf of the OPs that at the time of getting policies vide Annexures IV to VI, the office which had insured the deceased is fully computerized. Therefore we are of the view that even if the deceased had not given the particulars of all the policies held by her as was urged by Mr. Tajta, it will make no difference. Because in their records OPs had the particulars of all the 18 policies. As such it could have also repudiated the claim due to suppression of other policies. We may also mention here how the OPs were prejudiced on this count nothing could be pointed out by Mr. Tajta.
22. Faced with this situation Mr. Tajta persisted with vehemence that irrespective of this position, the deceased withheld material information with an ulterior motive and obtained policies of substantial value after having undergone surgery as is evident from Exts. RW-1 and RW/1A. Thus he prayed for dismissal of this complaint.
23. Purpose of obtaining information of all the insurance policies according to Mr. Tajta is to see, whether the person getting insured was in a position to pay the premium or is obtaining those with some ulterior motive. In this behalf by referring to policies of Rs. 18 lacs and 5 lacs Mr. Tajta submitted that these were obtained by the insured knowing that her end is fast approaching. This plea appears to be without any basis. Reason being that the policy of Rs. 1 lac was revived and its premium was payable annually. Whereas in the policy of Rs. 18 lacs, premium payable was quarterly and the deceased had paid Rs. 64,566/- without default. Similarly in the policy of Rs. 5 lacs monthly premium was payable and 15 premiums were admittedly paid. In these circumstances argument of Mr. Tajta that after the insured having realized that her end is coming soon, with ulterior motive she obtained two new policies of substantial value and got one old policy revived, is nothing but a surmise of the OPs. Thus this plea is rejected.
24. Here payment of one of the policies which was admittedly obtained after her alleged treatment by Dr. Mangla Dogra at Chandigarh as per the OPs assumes significance. Qua this payment Mr. Tajta submitted, that since the policy had been in force for 3 years as such no enquiry was made, because it had worked for sufficiently long period.
25. This is a very strange argument that is being putforth by the OPs. Reason being that nothing prevented them to have withheld the payment on this policy, though it was obtained after 2001 as mentioned above after she had taken treatment from Dr. Mangla Dogra as per the OPs. Situation in this case is not changed as admittedly policy was also obtained allegedly by suppression of material facts regarding her state of health, her having availed medical leave, as also having gone for medical check up at AIIMS New Delhi, and PGI Chandigarh and above all having been operated upon as per their defence. If this argument of Mr. Tajta is accepted, it will be permitting his client to blow hot and cold in the same breath. They further cannot be allowed to say, that in case of one policy there was no suppression of material facts as alleged by them, whereas in case of other 2 new and one revived policies which are subject matter of dispute in this complaint suppression of material facts etc. as alleged by them is there. Reason given for not holding enquiry in case of this policy is self contradictory and mutually destructive qua the plea set up for 3 policies in dispute, especially when the situation remains the same in case of all the 4 policies, i.e. one paid and the other three which are in dispute. Proposal form of the policy of which the amount has been paid by the OPs is not produced, why could not be explained on behalf of the OPs. And it is not the case of the OPs that full and complete particulars about the state of her health and or the treatment undergone by her was detailed in case of this policy. Similar is the position qua the number of policies held by the insured at the time, when the proposal form in this case was filled in by the deceased. As such we are compelled to draw adverse inference against the OPs for non production of the proposal form of policy obtained in the year 2001 and the amount of which has been admittedly paid by the OPs. Because if all the necessary and required details were given in it by the insured, they would have produced the same. If not, then there is no change of situation in said policy as well as of the two new policies and one that was revived.
26. By making payment of the policy at Sr. No. 8 of Chart-B (supra), particularly when it was also obtained after 2001, as is the situation in case of 2 new and one revived policy, the OPs waived their rights if any based on the alleged suppression of facts. Similarly on what basis it was argued that the insured having realized that her end is coming soon, so she got two new policies of substantial amount, there is nothing on record nor anything could be pointed out by the OPs at the time of hearing to this effect.
27. Another reason not to accept the plea of Mr. Tajta justifying repudiation of the claim of the complainants in this case is, that the deceased had died due to heart failure. So even if it is held that she had ovarian-cyst non cancerous (benign), being there or she had some other Gynae problem, still there is no nexus between the allegedly suppressed medical history, as well as her state of health and the cause of her death. It is also not the case of the OPs that there is any nexus between the cause of death and the suppression of alleged facts. That being the position, no benefit can be derived by the OPs from the alleged suppression of facts. For taking this view reference is being made to a decision of this Commission in the case of Life Insurance Corporation of India and another Vs. Smt. Veena Puri, 2007 CTJ 780 (CP) (SCDRC). Regarding cause of death, un-rebutted affidavit of complainant No.1 is there on the file at page 122 onwards. Whereas the case of the OPs is entirely based on suppression as noted above.
28. With a view to support the case of his client on suppression of material facts Mr. Tajta referred to the decisions in Sabnam Devi & Ors. Vs. LIC of India & Ors, I (2008) CPJ 133 (NC), Life Insurance Corporation of India Vs. Krishan Chander Sharma, II (2007) CPJ 51 (NC), LIC of India & Ors Vs. Roshan Lal Gupta II (2007) CPJ 194 (NC) Goparatnam & Ors. Vs. LIC of India & Ors 1 (2006) CPJ 78 (NC), Vasantiben Haresh Kumar Thakur & Ors. Vs. Life Insurance Corporation of India III (2006) CPJ 440 (NC), Prema & Ors. Vs. Life Insurance Corporation of India Ltd., IV (2006) CPJ 239 (NC) and L.I.C. of India & Ors. Vs. Smt. C.P. Kacheebi, II (2003) CPJ 108 (NC).
29. There may not be necessity of the filing of affidavits in some cases. In this behalf Mr. Tajta referred to the decisions of L.I.C. of India & Anr. Vs. Parveen Dhingra, II (2003) CPJ 70 (NC) and in the case of Life Insurance Corporation of India Vs. Smt. Minu Kalita, III (2002) CPJ 10 (NC). In our opinion filing of the affidavit(s) was necessary, keeping in view the defence of the OPs while repudiating the claim of the complainants.
30. In the face of the above facts, no benefit can be derived by OPs from the decisions relied upon their behalf by Mr. Tajta.
31. No other point is urged.
In view of the aforesaid discussion we are of the view that this complaint deserves to be allowed. Ordered accordingly and as a result of it, the OPs are directed to pay the sum insured in respect of 3 policy Nos. 151612717, 152429832 and 150798290, alongwith other benefits like bonus etc., claim in respect whereof have been repudiated by the OPs. Regarding policy No. 150876629, it is ordered that on the date of its maturity its value alongwith other benefits like bonus etc. accrued thereon will be paid by the OPs and the complainants are not liable to pay premium thereof till that date as this position was not disputed on behalf of the OPs. Since OPs were deficient in rendering service they are also held liable to pay the maturity value and benefits etc. of the aforesaid 3 policies alongwith interest @ 6% per annum w.e.f. 1.11.2005 till the date of payment/deposit whichever is earlier. While fixing 1.11.2005 for payment of interest we have allowed six months time to the OPs for having settled the claim of the complainants. OPs are also held liable to pay compensation on account of deficiency in service as well as for causing harassment to the complainants, besides cost of this litigation, and consolidated sum of Rs. 25,000/- is fixed in this behalf.
Learned counsel for the parties have undertaken to collect the copy of this order from the Reader free of cost.
Shimla.
3rd June, 2008. (Justice Arun Kumar Goel) Retd.
President.
(Saroj Sharma), Member.
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