S.ABITHA vs Life Insurance Corporation of India

THIS is a revision petition arising out of the order of the State Consumer Disputes Redressal Commission. Pondicherry, which had set aside the order of the District Forum and had further directed that the premium recovered by the Life Insurance Corporation of India be refunded together with simple interest at the rate of 10% p.m. The District Forum had gone into the facts of the case and had noticed that the insured had taken a policy No. 732027498. The insured died following an open heart surgery on 19th May, 1995. On a claim being lodged with the LIC it repudiated the claim on the basis of suppression of material facts by the insured, even though the policy had run for three years. Section 45 of the Insurance Act provides as under : 45. Policy not be called in quesiton on ground of mis-statement after two years-No policy of life insurance effected before the commencement of this Act shall after the expiry of two years from the date of commencement of this Act and no policy of life insurance effected after the coming into force of this Act shall after the expiry of two years from the date on which it was effected, be called in question by an insurer on the ground that a statement made in the proposal for insurance or in any report of a medical office, or referee, or friend of the insured, or in any other document leading to the issue of the policy, was inaccurate or false, unless the insurer shows that such statement (was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made) by the policy-holder and that the policy-holder knew at the time of making it that the statement was false (or that it suppressed facts which it was material to disclose) : (Provided that nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to do so and no policy shall be deemed to be called in question merely because the terms of the policy are adjusted on subsequent proof that the age of the life insured was incorrectly stated in the proposal).

THEY have referred to the medical attendant''s certificate obtained by the Insurance Company from the Doctor who had attended on the deceased insured. Column 4-A provides primary cause of death ''Miocardiac failure following open heart surgery''. Secondary cause was ''Rheumatic MS c MR c AR c PHI and it is also recorded against Column 4(c) - ''since childhood''. In the certificate of the hospital treatment against Column 5(a) it is recorded H/O Rheumatic Fever from childhood. A lot of stress has been laid by Mr. Mohinder Singh, learned Counsel for the respondent, on the entry against Column 4(c) which is a certificate of the medical attendant wherein it is stated "since childhood". These two when read together, i.e. certificate of hospital treatment and medical attendant''s certificate, they do not seem to tally whereas against 4(c) of Medical Attendant''s certificate it is recorded since childhood and this is by the medical attendant only. In the certificate of hospital treatment the history recorded at the time of admission mentions rheumatic fever ''in childhood'' and not ''since childhood''. Medical attendant certificate further shows that the rheumatic heart disease is the opinion of the Doctor but the question of ''since childhood'' has been put there, which is not given in the history. At the time of admission there is a discrepancy in the two. Against Column 4-B of the Medical attendant''s certificate, the answer to the question, "Was it ascertained by examination after death or inferred from symptoms and appearance during life ?", ''ascertained'', which means all these statements are based on what they ascertained after the death and these were inferred from the symptoms and appearance during the life of the patient. In the light of the above, we find that there was no warrant for the State Commission to construe these entries against the insured, particularly in the face of the evidence that the rheumatic fever recorded in the hospital was only experienced in the childhood and, thereafter, the insured had led a very active life and had participated in various sporting events like volleyball, hockey, football, kabbadi, baseball, shortput, javelin throw and cricket. For that reason we have no reason to accept that the exception provided under Section 45 is attracted in the present case because the insured had led a very active life involving intense physical activity all along and never suffered any heart-attack except the last occasion before his death when he went to get treatment for his heart ailment. At that time he was admitted to Apollo Hospital which was beyond three years after taking the policy. There is no basis available on record on which the medical attendant has recorded that when the symptoms of illness first observed and in reply he writes, ''4 years ago''. There is no material available to support this and Doctor saw him for the first time on 9th May, 1995 only. The history sheet also does not support any such conclusion. In the face of the above discussion there is no material brought on record wherefrom it can be inferred that there was intentional and fraudulent suppression of facts which would attract the proviso to Section 45. We are, therefore, unable to sustain the impugned order which is set aside and uphold the order passed by the District Forum. Let the opposite party comply with the order, if not already done, within four weeks from the date of receipt of a copy of this order. This revision petition is allowed with costs which are assessed at Rs. 2,000/-. Revision Petition allowed.