STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA
Date of Institution: 21.03.2018
Date of final hearing: 04.08.2023
Date of pronouncement: 27.09.2023
First Appeal No.349 of 2018
IN THE MATTER OF:-
- Shree Bhagwan S/o Sh. Ram Mehar
- Hem Lata W/o Late Sh. Sunil Kumar S/o Ram Mehar
- Anshika D/o Late Sh. Sunil Kumar
- Harsh Sharma S/o Late Sh. Sunil Kumar
All residents of village: Chadiya, Tehsil: Samalkha, District: Panipat. The appellant No.3 and 4 are minors, so they are through their mother Smt. Hem Lata i.e. appellant No.2.
....Appellants
Versus
Life Insurance Company of India-II, 382-L, Idgah Road, Model Town, Panipat, through its Branch Manager. …..Respondent
CORAM: Naresh Katyal, Judicial Member
Argued by:- Sh. Gagandeep Singh proxy counsel for Sh. J.S. Saneta, counsel for the appellants.
Sh. S.S. Sidhu, counsel for respondent.
ORDER
NARESH KATYAL, JUDICIAL MEMBER:
Challenge in this appeal No.349 of 2018 has been invited by unsuccessful complainants-Shree Bhagwan and others, to the legality of order dated 12.02.2018 passed by District Consumer Disputes Redressal Forum-Panipat (In short “District Consumer Commission”) in complaint case No.169 of 2016, vide which their complaint has been dismissed.
2. Complainant’s brother-Sunil Kumar was insured with OPs for sum of Rs. Ten Lacs vide four insurance policies No.178361721, 178361722, 178361723 and 178361724, on 04.09.2013. At the time of issuance of insurance policies; officials of OP enquired about health of life assured. Life assured died on 25.09.2014 due to silent attack-a natural death. Complainant/Shree Bhagwan was nominee in said policies. Complainants, after death of life assured informed OP and submitted documents for payment of claim, but OP failed to pay claim to complainants, despite requests and service of legal notice, which amounted to deficiency in services of OP. Thus, complainants’ filed complaint praying for payment of claim along with compensation for mental harassment caused and litigation expenses.
3. Upon notice, OP in its defence, in preliminary objections thereof has pleaded that: complaint is not maintainable; complainants have no locus standi to file complaint; they have concealed true and material facts and has no cause of action. On merits, issuance of insurance policy and death of life assured has been admitted. It is pleaded that OP-LIC received intimation dated 12.01.2015 that life assured-Sunil Kumar had died due to ‘sugar’ on 25.09.2014. Death claim of life assured was processed, investigated and it was found that life assured was suffering from IDDM (Insuline Dependent Diabetes Melititus), prior to date of proposal and remain admitted from 01.08.2013 to 03.08.2013 in Hyderabadi General Hospital and Nursing Home-Panipat. Death summary of deceased was collected from All India Institute of Medical Sciences-New Delhi and it was found that deceased life assured was cronic alcoholic, cronic smoker and suffering from Type-2 diabetes. Certificate dated 24.01.2015 issued by Senior Resident, Department of Medicine, AIIMS revealed that deceased life assured was suffering from Diabetes Melititus, two years back, which goes prior to date of proposal. Thus, as per plea, life assured was not keeping good health before taking insurance and these facts were not disclosed by him in proposal form dated 01.09.2013. It is pleaded that life assured had not disclosed about pre-existing disease at the time of obtaining of insurance policies and claim has rightly been repudiated and its intimation has been sent to complainants. Other allegations have been denied specifically by OP by asserting that there was no deficiency in services on its part.
4. Parties to this lis led evidence, oral as well as documentary.
5. On subjectively analyzing the same; learned District Consumer Commission-Panipat vide order dated 12.02.2018 has dismissed the complaint thereby giving rise to filing of this appeal by complainants.
6. Learned counsel for parties have been heard at length. With their able assistance; record too has been perused.
7. On behalf of complainants/appellants, it is contended that impugned order dated 12.02.2018 is erroneous on all fronts. Life assured did not have any past medical history of any ailment/disease. There was no concealment of any material fact in the proposal form, filled as such while obtaining insurance policies. It is asserted that officials of OP had enquired about health of life assured at that time, when he was examined by empanelled doctor of OP. Life assured was not suffering from any life threatening disease. There being no pre-existing disease/ailment confronting deceased life assured; repudiation of claim by insurer was legally unjustified. It is urged that impugned order dated 12.02.2018 has no legs to stand.
8. Per contra, learned counsel appearing for OP/respondent-insurer has supported the impugned order dated 12.02.2018 and urged that learned District Consumer Commission has meticulously analyzed all facets of this case and its decision dated 12.02.2018 does not call for any interference in this appeal.
9. This Commission has critically analyzed the rival submissions. The poser before this Commission is: “as to whether OP-insurer has rightly repudiated the claim of Rs.10.00 lacs submitted by complainants or not”? Admittedly, OP issued four policies in the name of deceased life assured-Sunil Kumar. As per case set up by complainants, he (Sunil Kumar) suffered natural death due to silent cardiac arrest and died on 25.09.2014. To refute this claim, OP has come forward with an express plea that deceased was suffering from pre-existing ailment/disease viz. IDDM (Insuline Dependent Diabetes Melititus) prior to date of proposal and remain admitted from 01.08.2013 to 03.08.2013 in Hyderabadi General Hospital and Nursing Home-Panipat.
10. Ex.C-1 to Ex.C-4 are the four Life Insurance Policies. In all these insurance policies; Shri Bhagwan-brother of deceased (Sunil Kumar) is nominee. Date of commencement of risk and proposal date in all these policies is 04.09.2013. Ex.C-13 to Ex.C-19 are premium payment receipts. Life assured had died on 25.09.2014. Death Certificate Ex.C-9 reflects as such. OP has repudiated the claim by repudiation letter dated 15.04.2015 (Ex.R-6) on the premises that in the proposal for insurance dated 01.09.2013 and personal statement signed by deceased life assured on 04.09.2013 at the time of medical examination he answered following questions as under:-
“11(e) Are you suffering from or have you ever suffered from or have you ever suffered from Diabetes, Tuberculosis, High Blood Pressure, Low Blood Pressure, Cancer, Epilepsy, Hernia, Hydrocele, Leprosy or any other disease? NO
11 (i) What has been your usual state of health? GOOD.”
11. In firm opinion of this Commission, OP-insurer has rightly justified its repudiation. Ratio of law laid down by Hon’ble Supreme Court in case titled as “Anil Rishi Versus Gurbax Singh” 2006(2) PLR 775 is attracted to the factual scenario of this case. In this case it has been held as under:-
“there is an essential distinction between the concept 'burden of proof and onus of proof'. Burden of proof lay upon a person, who has to prove the fact and which never shifts, whereas, onus of proof shifts. Such a shifting of onus is a continuous process in the evaluation of evidence. The elementary rule of Section 101 of Evidence Act is inflexible. In terms of Section 102 of the Evidence Act; the initial burden is always on plaintiff. If the plaintiff discharge that onus and makes out a case, which entitles him to relief, then onus shifts upon the defendant to prove those circumstances, which would dis-entitle the plaintiff to the same.”
12. Medical Attendant’s Certificate Ex.R-8 dated 24.01.2015 signed by Senior Resident, Unit-III, Department of Medicines AIIMS-New Delhi expressly recites that: Diabetic Melititus 2 concerning deceased life assured is having history relating back to two years. Two years prior to 24.01.2015 would be 24.01.2013. Proposal for insurance is dated 01.09.2013 and personal statement of deceased is dated 04.09.2013. Meaning thereby, on the date of filling proposal and making personal statement; deceased-life assured had a prior history of Diabetic Melititus 2 and he has conveniently concealed this fact. Ex.R-14 is document of Hyderabadi General Hospital and Nursing Home-Panipat. This documents also recites that deceased was admitted in this hospital on 01.08.2013 and discharged on 03.08.2013. He was diagnosed as suffering from IDDM (Insuline Dependent Diabetes Melititus). This material fact too had been concealed by deceased life assured at the time of filling proposal for insurance on 01.09.2013 and at the time of making personal statement on 04.09.2013 in course of his medical examination.
13. Deceased-life assured has given answer ‘No’ to question 11 (e) and given answer ‘GOOD’ to question 11 (i) so reproduced above and thus landed himself to be guilty of concealment/suppression of material facts regarding pre-existing ailments. It would disentitle the complainants from any equitable relief. OP-insurer has succeeded in proving circumstance which would disentitle complainants to the relief claimed. Legal position on above facts and evidence is no more res-integra. Hon’ble Apex Court in case titled as “Satwant Kaur Sandu Vs. New India Assurance Company Ltd.”, Civil Appeal No. 2776 of 2002 decided on 10.07.2009 has held as under in Para 12 of its judgment:-
- “There is no dispute that Section 45 of the Insurance Act, 1938 (for short “the Act”), which places restrictions on the right of the insurer to call in question a life insurance policy on the ground of mis-statement after a particular period, has no application on facts at hand, inasmuch as the said provision applies only in a case of life insurance policy. The present case relates to a mediclaim policy, which is entirely different from a life insurance policy. A mediclaim policy is a non-life insurance policy meant to assure the policy holder in respect of certain expenses pertaining to injury, accidents or hospitalizations. Nonetheless, it is a contract of insurance falling in the category of contract uberrimae fidei, meaning a contract of utmost good faith on the part of the assured. Thus, it needs little emphasis that when an information on a specific aspect is asked for in the proposal form, an assured is under a solemn obligation to make a true and full disclosure of the information on the subject which is within his knowledge. It is not for the proposer to determine whether the information sought for is material for the purpose of the policy or not. Of course, obligation to disclose extends only to facts which are known to the applicant and not to what he ought to have known. The obligation to disclose necessarily depends upon the knowledge one possesses. His opinion of the materiality of that knowledge is of no moment. (See: Joel Vs. Law Union & Crown Ins. Co.1 )
Hon’ble Apex Court in this judgment has also observed that: the expression “material fact” is to be understood in general terms to mean as any fact which would influence the judgment of a prudent Insurer, in deciding whether to accept the risk or not. If the proposer has knowledge of such fact, he is obliged to disclose it particularly while answering questions in the proposal form. Any inaccurate answer will entitle the Insurer to repudiate their liability because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering into a contract of insurance, which is based on the principle of utmost faith-uberrima fides. Good faith forbids either party from non-disclosure of the facts which the party privately knows, to draw the other into a bargain, from his ignorance of that fact and his believing the contrary.”
14. Having given anxious consideration to the material/evidence available on record of this appeal, in the light of above cited pronouncements; this Commission is of opinion that: answer given by deceased-life assured in the proposal form, as well as, in his statement so made at the time of his medical examination, was untrue to his knowledge. There was clear suppression of material fact in regard to health of insured. It was not for the insured to determine, whether information sought for through questionnaire was material for the purpose of obtaining insurance policies. At any rate, statement made by him was untrue and incorrect.
15. Thus, the answer to the poser put across to this Commission in this appeal is that: insurance company (OP) has successfully proved its exclusion from policies and rightly repudiated the claim vide letter dated 15.04.2015 (Ex.R-6). It is more than clear from the evidence that information about past medical history of deceased life assured should have been supplied by him. Had, it been so supplied, then insurer/OP might not had issued four insurance policies on 04.09.2013. However, deceased-life assured (Sunil Kumar) in his wisdom had withheld material information regarding his past medical history on 01.09.2013 and 04.09.2013 in the proposal for insurance and in his personal statement respectively from of OP/insurer. Hence, on that pedestal, complainants/appellants herein have been rightly non-suited by learned District Consumer Commission through its order dated 12.02.2018 (impugned in this appeal). This order dated 12.02.2018 does not carry any manifest error, legal or factual. It is accordingly affirmed and maintained. Present appeal, being devoid of merits, is hereby dismissed.
16. Application(s) pending, if any stand disposed of in terms of the aforesaid judgment.
17. A copy of this judgment be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986/2019. The judgment be uploaded forthwith on the website of the Commission for the perusal of the parties.
18. File be consigned to record room.
Date of pronouncement: 27th September, 2023
Naresh Katyal
Judicial Member
Addl. Bench-II
