Life Insurance Corporation Of India vs Kamlesh

V.K. Jain, J

Late Chander Pal, husband of the complainant, obtained Jeevan Saral Policy of the petitioner Corporation. He having died on 16.01.2015, a claim for payment in terms of the said policy was lodged by the complainant/respondent, she being his nominee. The claim was repudiated vide letter dated 01.07.2015 which, to the extent, it is relevant, reads as under:

In this connection we have to inform you that in proposal for Assurance dated 08032013 signed by the deceased assured on 08032013, he had answered the following questions as under noted:

During the last five years, did you consult a medical practitioner for any ailment requiring treatment for more than a week.

NO

Have you ever been admitted to any hospital or nursing home for general check-up, observation, treatment or operation.

NO

Have you remained absent from place of work on grounds of health during last five years.

NO

Are you suffering from or have ever suffered from Diabetes, Tuberculosis, High BP, Low BP, Caner, Epilepsy, Hernia, Leprosy, or any other disease.

NO

Are you suffering from or have ever suffered from ailment for pertaining to liver, stomach, heart, lungs, kidney, brain or nervous system.

NO

We may, however, state that all these answers were false as we hold indisputable proof to show that DLA was having heart disease involving Aortic Volve since birth as per Echo Cardiography report & treatment papers of PGIMS Rohtak. He had concealed material information while taking insurance. He did not however, disclose these facts in his proposal he gave answers therein as stated above.

It is, therefore, evidence that he had made incorrect statements and withheld correct information from us regarding his health at the time of effecting assurance and hence in terms of the policy contract and the declarations contained in the forms of proposal for assurance and personal statement, we hereby repudiate the above 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.

Being aggrieved from the repudiation of the claim, the complainant/respondent approached the concerned District Forum by way of a Consumer Complaint. The complaint was allowed by the District Forum. Being aggrieved from the order passed by the District Forum, the petitioner Corporation approached the concerned State Commission by way of an appeal. By a majority of 2:1, the State Commission dismissed the appeal filed by the petitioner, thereby maintaining the order passed by the District Forum. Being still dissatisfied, the petitioner Corporation is before this Commission.

The only question which arises for consideration in this petition is as to whether the deceased insured was suffering from heart ailment involving aortic valve and was under treatment of PGIMS, Rohtak or not, since, it is not in dispute that no such ailment was disclosed by him while obtaining the insurance policy.

A perusal of the repudiation letter would show that the repudiation was based upon the treatment of the deceased insured at PGIMS, Rohtak and it was clearly conveyed to the complainant that as per the treatment papers of PGIMS, Rohtak, he was suffering from heart ailment involving aortic valve since birth. Despite having received the said repudiation letter, the complainant, while filing the Consumer Complaint, did not even allege that the deceased was not suffering from heart ailment involving aortic valve, though she generally alleged that the claim had been repudiated on false and frivolous grounds and there was no concealment regarding the state of health of the insured. In the Consumer Complaint, the complainant did not even allege that the insured was not treated at PGIMS, Rohtak. In my opinion, once the complainant came to know from the repudiation letter that the Corporation had repudiated the claim solely on the ground that as per the treatment papers of PGIMS, Rohtak, the deceased was suffering from heart ailment involving aortic valve since birth, it was obligatory for her to specifically aver in the Consumer Complaint, if she wanted to refute the ground on which the claim had been repudiated, that the deceased was not suffering from heart ailment involving aortic valve and he had not been under the treatment of PGIMS, Rohtak.

Even after filing the Consumer Complaint, the complainant did not file an affidavit stating that the deceased either was not suffering from heart ailment involving aortic valve and/or that he was not treated at PGIMS, Rohtak. In these circumstances, the OPD Card filed by the petitioner before the District Forum, which shows that as on 07.09.2011, Chander Pal was suffering from aortic stenosis, should not have been rejected by the fora below and the aforesaid document was sufficient to discharge the onus placed upon the insurer to prove that there was concealment of material fact by the insured when he withheld information that he was suffering from aortic stenosis. The answers given by him to the questionnaire contained in the proposal therefore, were false and the said false answers influenced the decision of the insurer on the question as to whether to accept the proposal for insurance cover or not. Had the petitioner Corporation known that the deceased insured was suffering from the decease of aortic valve and had been under the treatment of PGIMS, Rohtak, it might have either rejected the proposal or might have asked the insured to undergo further investigations.

The learned counsel or the petitioner has placed on record a letter sent by the complainant to the Chief Manager, LIC of India stating therein that her husband had expired on 16.01.2015 due to heart attack at home. Therefore, the cause of death of the deceased insured was directly related to the ailments from which he was suffering and for which he was under treatment of PGIMS, Rohtak.

For the reasons stated hereinabove, the orders passed by the fora below cannot be sustained and the same are accordingly set aside. The complaint is consequently dismissed, with no order as to costs.