BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KAITHAL.
Complaint Case No.95 of 2019.
Date of institution: 02.04.2019.
Date of decision:27.01.2020.
Rohtash aged 35 years, son of late Sh. Bhira son of Sheo Nath, resident of Village Roherian, P.O. Chandana, Tehsil and Distt. Kaithal.
…Complainant.
Versus
- LIC of India, Jeevan Bharti Tower-II, 124, Connaught Circus P.B.No.630, New Delhi-110001 through its Zonal Manager.
- LIC Divisional Office, P.O. Box No.106, Jeevan Parkash, 489, Model Town, Karnal-132001 through its Divisional Manager.
- LIC Branch Office near Geeta Bhawan, Kaithal through its Branch Manager.
….Respondents.
Before: Sh. D.N.Arora, President.
Sh. Rajbir Singh, Member.
Smt. Suman Rana, Member.
Present: Sh. Swai Ram, Advocate, for the complainant.
Sh. Naresh Sharma, Advocate for the OPs.
ORDER
D.N.ARORA, PRESIDENT
The complainant has filed the present complaint under Section 12 of Consumer Protection Act, 1986, with the averments that the father of complainant namely Bhira got his life insured with the Ops vide policy No.479364669 dt. 02.05.2017 for the sum of Rs.2,00,000/- and the complainant was appointed as nominee in the said policy. It is alleged that the father of complainant died on 22.12.2017. The complainant being nominee of his father lodged the claim with the Ops and submitted all the necessary documents but the Ops repudiated the claim of complainant vide letter dt. 02.02.2019. The said repudiation of claim is wrong and illegal. So, it is a clear cut case of deficiency in service on the part of Ops and prayed for acceptance of complaint. Hence, this complaint.
2. Upon notice, the OPs appeared before this Forum and contested the complaint by filing their reply raising preliminary objections with regard to locus-standi; maintainability; cause of action; jurisdiction; that the complainant has concealed the true and material facts from this Forum. The true facts are that the insurance policy No.479364669 dt. 12.05.2017, table and term 843/18 for the sum assured of Rs.2,00,000/- was taken by the deceased Bhira. As per record submitted by the complainant, the deceased Bhira, the life assured died on 22.12.2017. The duration of policy was only 7 months 10 days from the commencement of risk. Since the aforesaid policy has not completed three years from the date of commencement of the insurance policy, the claim was examined keeping in view of provisions of Section 45 of Insurance Act, 1938. While examining the claim, it has transpired that the deceased Bhira has given false answers in the proposal form regarding his health at the time of issuance of insurance policy. It is submitted that as per Form 3816 from PGI Chandigarh, the deceased insured was known case of Hepatitis B and Hepatitis C positive. He was also suffering from chronic liver disease, chronic kidney disease, diabetes mellitus type-2 and hypertension. The deceased was taken to Shah Hospital, Kaithal on 22.12.2017 with the history of DM-2 HB Ag reactive HCV and was referred to higher centre for treatment due to critical condition and further was treated in PGI Chandigarh. There is no deficiency in service on the part of Ops. On merits, the objections raised in the preliminary objections are reiterated and so, prayed for dismissal of complaint.
3. The complainant tendered into evidence affidavit Ex.CW1/A and documents Annexure-C1 to Annexure-C6 and thereafter, closed the evidence.
4. On the other hand, the Ops tendered into evidence affidavit Ex.RW1/A and documents Annexure-R1 to Annexure-R31 and thereafter, closed the evidence.
5. We have heard the learned Counsel for both the parties and perused the record carefully.
6. Undisputedly, the father of complainant namely Bhira got his life insured with the Ops vide policy No.479364669 dt. 02.05.2017 for the sum of Rs.2,00,000/- and the complainant was appointed as nominee in the said policy. According to the complainant, the father of complainant died on 22.12.2017 and he being nominee of his father lodged the claim with the Ops and submitted all the necessary documents but the Ops repudiated the claim of complainant vide letter dt. 02.02.2019. Annexure-C3.
On the other hand, the Ops have specifically taken the objection in the written statement that as per record submitted by the complainant, the deceased Bhira, the life assured died on 22.12.2017. The duration of policy was only 7 months 10 days from the commencement of risk. Since the aforesaid policy has not completed three years from the date of commencement of the insurance policy, the claim was examined keeping in view of provisions of Section 45 of Insurance Act, 1938. While examining the claim, it has transpired that the deceased Bhira has given false answers in the proposal form regarding his health at the time of issuance of insurance policy. It is submitted that as per Form 3816 from PGI Chandigarh, the deceased insured was known case of Hepatitis B and Hepatitis C positive. He was also suffering from chronic liver disease, chronic kidney disease, diabetes mellitus type-2 and hypertension.
7. We have considered the rival contentions of both the parties. The moot question arises in this case whether the Ops have rightly repudiated the claim of complainant on the ground that the complainant has concealed the material facts from the Ops regarding the father of complainant was suffering from pre-existing disease. The burden lies upon the Ops. The Ops have relied upon the discharge summary issued by Shah Multispeciality Hospital Annexure-R7 and drawn our attention towards the column diagnosis, wherein it is mentioned that CRF (Chronic Renal Failure), DM-2 SEPTICEMIA pcf c hcv to hm+ve. Ld. Counsel for the Ops also pointed out that as per the medical certificate Annexure-R21 issued by P.G.I. Chandigarh, it is mentioned that the cause of death is mentioned as Refractorsy Septic Shock and Chrnonic Kindeny Disease and Diabetes Mellitus Type-2 and Hypertension. He contended that as per the above-said record, the deceased life assured was suffering with the above-said disease and such type of disease could not occur immediate but it takes the time and in this regard he submitted the literature regarding CRF as-well-as medical definition of DM2, which is as under:-
“The full form of CRF is Chronic Renal Failure. CRF is gradual loss of kidney function, with progressively more renal insufficiency until the stage called chronic irreversible kidney failure or end-stage renal disease. It is also known as Chronic Kidney Disease. In earlier days, there are typically no symptoms but later on, leg swelling, feeling tired, loss of appetite, vomiting or confusion may develop. Complications may include high blood pressure, heart disease, bone disease, or anemia. Any person can get CRF. Some people are more at risk than others. Somethings that increase the risk for CRF include high blood pressure (hypertension), heart disease, diabetes, having a family member with kidney disease, being over 60 years old etc. Chronic Kidney Disease usually gets worse slowly over a period.
Medical Definition of DM2
DM2: Myotonic Dystrophy type 2.
Brief Summary:
Rationale: The global prevalence of diabetes, alongwtih its devastating effects on life expectancy and quality of life, continues to increase. Worldwide, the total number of people with diabetes is projected to rise from about 171 million in 2000 to 336 million in the year 2030. Type 2 diabetes accounts for about 85 percent to 95 percent of all diagnosed cases of diabetes and is associated with a number of serious long-term complications, which are a major cause of morbidity, hospitalization and mortality in diabetic patients. More evidence is becoming available that both lifestyle and clinical intervention in the pre-diabetic condition are effective in slowing down progression of pre-diabetes to overt diabetes.”
Ld. Counsel for the Ops further contended that when the life assured took the policy he was suffering with the chronic renal disease (kidney disease). The Ops have also placed on record certificate of Hospital Treatment i.e. form No.3816 Annexure-R17, wherein it is clearly mentioned that the life assured was admitted in P.G.I. Chandigarh on 22.12.2017. From the perusal of form No.3816, it is not clear that whether the deceased life assured had taken any treatment for kidney problem etc. prior to admission in the P.G.I. Chandigarh. Moreover, the life assured had taken the policy in question on 02.05.2017 i.e. prior to admission in the P.G.I. Chandigarh. So, the enquiry regarding treatment mentioned in the above-said form No.3816 Annexure-R17 is not helpful to the Ops. In view of facts and circumstances of the case, it is clear that the Ops have failed to discharge the duties and not produced any corroborating evidence to connect the disease whether the deceased was taking any treatment from any hospital prior to the taking the policy in question. Mere presumptions and assumptions are not sufficient to prove the pre-existing disease. The contention of Ops is that he produced the literature regarding CRF and it is mentioned in the literature that Chronic Renal Failure is gradual loss of kidney function, with progressively more severe renal insufficiently until the stage called chronic irreversible kidney failure or end-stage renal disease. It means that such type of disease occurred gradually, it might be possible that the complainant was not having the knowledge of kidney disease, so, the said contention of ld. Counsel for the Ops has no force. Therefore, the contention of Ops that the life assured has not disclosed the medical history in the proposal form has no force. Ld. Counsel for the complainant contended that the proposal form Annexure-R4 is typed in English, whereas the deceased life assured has put the thumb marked on the above-said proposal form being an illiterate person and there is no signature of any independent person in which presence the same may be read over to him. He further contended that this proposal form has not been explained to the deceased and he was no knowledge about the contents of proposal form. It is clear that the Ops have failed to prove that they had explained the terms and conditions to the life assured while taking the policy in question. From the above-said discussion and facts and circumstances of the case, we are of the considered view that the Ops have wrongly repudiated the claim of complainant and this act of Ops amounts to gross deficiency in service on their part and they have adopted the unfair trade practice.
8. Thus, as a sequel of above discussion, we allow the complaint and direct the Ops to pay the insured amount of Rs.2,00,000/- to the complainant alongwith interest @ 9% p.a. from the date of filing of present complaint till its realization and further to pay Rs.5,000/- as lump sum compensation on account of harassment, mental agony and costs of litigation charges. Let the order be complied with within 30 days from the date of preparation of copy of this order. A copy of said order be supplied to the parties free of costs. File be consigned to record-room after due compliance.
Announced in open court:
Dt.:27.01.2020.
(D.N.Arora)
President.
(Suman Rana), (Rajbir Singh)
Member Member.
