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Judgment
THESE are two appeals, one by the complainant and another by the opposite party.
THE facts of the case are summarily as follows : THE complainant has taken a "Asha Deep" policy from the opposite party for an insured amount of Rs. 1,00,000/- with effect from 28.10.1993. THE complainant has been paying his premium regularly. He developed chest pain in the month of August, 1995 and on medical check up he was found suffering from coronary artery disease. He underwent a bye-pass surgery at Apollo Hospital and paid for that purpose an amount of Rs. 50,000/-. When he claimed the amount from the opposite party the latter informed him that at the time of taking the policy he has stated that he was not having any heart disease, whereas it was found by Apollo Hospital, Madras that he was having symptomatic Angina for the last three years. It was added by the opposite party that there was suppression of material facts regarding his health for which reason the insurance policy has been declared as null and void. The complainant dissatisfied with the decision of the opposite party approached the District Forum with the following prayers : "(a) to pay the policy dues to the complainant or to run the policy as it is as per the terms and conditions thereon till its maturity; (b) direct the opposite party to pay a compensation of Rs. 3,00,000/- (Rupees three lakhs only) to the complainant for deficiency of service and caused mental agony, torture and shock by their letter correspondence; (c) to pay the cost of this petition to the complainant.
The District Forum found that all the statements made by the complainant were true and observed that the opposite party has not shown how it came to the conclusion that the complainant was suffering from symptomatic angina for the past three years prior to 1995. Accordingly it allowed the complaint in the following manner : (1) the opposite party shall continue the policy and receive the quarterly premium from the complainant from the date it has fallen due and pay him the benefits under the policy when he undergoes bye-pass surgery or any major treatment covered under the policy; (2) the opposite party shall pay to the complainant Rs. 2,000/- as compensation and Rs. 200/- towards costs; (3) the opposite party shall report to the Forum regarding the receipt of the premiums from the last payment of the premium and continuation of the policy; (4) the order shall comply within a month from the date of the receipt of this order by the opposite party.
AGAINST this order the complainant has filed an appeal in which he would state that he has already undergone bye-pass surgery and therefore, the first direction of the District Forum should be modified suitably. The opposite party in his appeal would pray for the dismissal of the complaint al together. The learned Counsel for the appellant would first contend that the reports from the Doctors received confidentially from Apollo Hospitals were not made available to the District Forum. He prayed for the acceptance of those documents produced for the first time in appeal. He concluded that the order of the District Forum should be set aside taking into account the entries found in the confidential reports of the Doctors.
THE first question which arises is whether the complainant made wilfully a false statement and whether that statement played an important role in the decision of the opposite party to insure him justifying the course of action taken by the opposite party. In this case we have got three documents. THE first one is the proposal for insurance on own life where in column 11(d) the question is as follows : "Are you suffering from or have you ever suffered from ailments pertaining to liver, stomach, heart, lungs, kidney, brain or nervous system? and the answer is : No."
THE second document is the confidential report of the Doctor of the opposite party which was obtained before admitting the complainant for insurance in which in comumn No. 5 the question is : "Is there any abnormality of the Cardiovascular system? and the answer is : Nil."
THE third set of documents consist of the opinion of two Doctors who took care of the complainant at the Apollo Hospital in a proforma provided by the Life Insurance Corporation of India. In that report they have noted that the complainant was having symptomatic angina since last three years. But none of the reports is dated. One of the reports namely that of Dr. M.P. Girinath bears the stamp of the Life Insurance Corporation of India bearing the date of 30th October, 1995. First it is to be noted that the opposite party does not admit people to insure just upon their declaration. It makes a thorough medical examination by its own Doctors. Therefore, it cannot be said that the decision to admit the complainant for insurance was on the basis of the declaration made by the complainant. The important document which weighed in the mind of the opposite party was the report of its own Doctor. Secondly in the application for insurance called the proposal for insurance on own life in columns 11(d) and (e) almost all the diseases are listed and the applicant is injuncted to answer only yes or no. Heart ailment being one of those serious ailments, it cannot be said that the complainant was really given an opportunity to disclose his ailment, if any. Further that proposal was not filled up by me complainant as it could be gathered from the hand writing, the ink of the entries and the signature. The proposal was filled up by a third party and the complainant was asked to sign. That proposal manifests only the intention of the complainant to get insured. For the rest, it has been reduced to a mere formality. So the entry found in the proposal regarding heart ailment cannot be used against the complainant. Thirdly when the Doctors from Apollo Hospital stated that the complainant was having symptomatic angina since last three years they do not come forward to state that the complainant was aware thereof from that time. To sum up there is nothing to show that the complainant was aware that he was suffering heart ailment, and that he made wilfully a false statement. The statement on record which is the accomplishment of a ritual cannot be acted upon. The opposite party insured the complainant, instead on the basis of the report of its own Doctor.
THE learned Counsel for the opposite party would then contend that the opposite party has not committed any deficiency in service in discontinuing the policy upon hearing that the complainant underwent a heart operation. He would declare that the opposite party was convinced from the reports of the Doctors of the Apollo Hospital that the complainant has given false information. Before discontinuing the policy the opposite party sent a show cause notice to the complainant bringing to his notice the discrepancy between his declaration and the notings of the Apollo Hospital Doctors. This was replied to by the complainant stating that he had not suppressed any facts and that he was not aware of the disease mentioned in the reports of the Doctors and that he had not taken any treatment excepting the last one at Apollo Hospital. Taking into account the report of its own doctors and the perfunctory manner in which the Company gets the proposal filled, the opposite party ought to have accepted the explanation of the complainant. So this contention cannot be accepted.
THE complainant has prayed for a direction to the opposite party to pay the policy dues or alternatively to run the policy. We are of the opinion that the complainant is entitled to the main prayer itself. THErefore, no order is necessary in respect of the alternate prayer. The complainant has also asked Rs. 3,00,000/- as compensation and the District Forum granted Rs. 2,000/-. We find that there is in this case no clear negligence justifying compensation.
In the result, both the appeals are allowed in part. The order of the District Forum is set aside and a fresh order is passed in the following terms : The opposite party shall pay to the complainant an amount of Rs. 50,000/- representing the medical expenses incurred by him. Payment should be made within a period of one month from today, failing which it will carry interest at the rate of 16% p.a. No cost. Appeals partly allowed.