V.Perumalsamy vs BRANCH MANAGER, LIFE INSURANCE CORPORATION OF INDIA

THIS revision petition has been filed by the petitioner against impugned order dated 19 -01 -2007 passed by the learned State Consumer Disputes Redressal Commission, Tamil Nadu (in short, ''the State Commission '') in Appeal No. 646 of 2003 - The Branch Manager, Life Insurance Corporation of India & Anr. Vs Perumalsamy, by which while allowing the appeal, order of the District Forum allowing the complaint was set aside.

BRIEF facts of the case are that complainant/petitioner obtained two policies from opposite party/respondent on 28 -11 -1995 and 28 -09 -1998 respectively each for a sum of Rs. One lakh. As per policies, complainant was eligible to receive medical expenses up to 50% of the amount of policy with bonus. Complainant was admitted at Apollo Hospital, Chennai and he underwent bypass surgery on 11 -12 -2000 and discharged on 18 -12 -2000. Complainant requested opposite party to pay medical claim of the aforesaid two policies and the bonus but as payment was not made, alleging deficiency on the part of the opposite party, complainant filed complaint before District Forum. Opposite parties resisted complaint and submitted that complainant failed to disclose vital information about his health condition and complainant was diabetic for the last eight years, hence complainant was not entitled to receive any claim and prayed for dismissal of complaint. Learned District Forum after hearing both the parties allowed complaint and directed opposite party to pay Rs. One lakh under the two policies and Rs.20,000/ - as bonus amount along with 9% p.a. interest and further awarded cost of Rs.1,000/ -. Appeal filed by the opposite party was allowed by learned State Commission vide impugned order against which this revision petition has been filed. Heard learned Counsel for the parties and perused record.

LEARNED Counsel for the petitioner submitted that as petitioner was not diabetic and has not suppressed any disease in the Proposal Form, learned District Forum rightly allowed complaint but learned State Commission has committed error in dismissing the complaint, hence revision petition be allowed and impugned order be set aside. On the other hand, learned counsel for the Respondent submitted that order passed by learned State Commission is in accordance with law, hence revision petition be dismissed.

IT is not disputed that complainant obtained two policies from respondent with bonus and as per Benefit (B), 50% of the sum assured was payable on open heart bypass surgery along with bonus of 10% of the sum assured. It is also not disputed that in his personal history complainant submitted that his state of health was good and he was not suffering from any disease. The basis of diabetes is only discharge summary given by Apollo Hospital, which reads as under: - - "This 46 years old gentleman, hormotensive, diabetic for 8 years, was admitted with history of class II angina since 2 years for further cardiac evaluation. He was evaluated by cardiac cath and coronary angio which revealed single vessel disease with normal LV function. He was advised CABG surgery. "

RESPONDENT has not placed any documents on record for earlier treatment of diabetes taken by the petitioner. Learned counsel for the petitioner submitted that petitioner never revealed this fact that he was diabetic for 8 years as he was not suffering from diabetes. Merely on the basis of earlier history recorded in the discharge certificate, it cannot be presumed that petitioner was suffering from diabetes since last 8 years.

EVEN if discharge summary is taken to be correct, first policy cannot be called in question on the ground of mis -statement after 2 years as per Section 45 of the Insurance Act. Admittedly, first policy was issued in the year 1995 and petitioner has undergone surgery in December, 2000 meaning thereby after a period of 5 years and respondent has neither pleaded nor proved that inaccurate or false statement about his health was made by the petitioner fraudently at the time of obtaining policy. In such circumstances, petitioner is certainly entitled to get 50% of the sum assured under the first policy, which was issued almost before 5 years. As second policy was issued on 19 -01 -1999 and petitioner has undergone surgery in December, 2000, he may not be allowed to get 50% of the sum assured under the second policy. Learned State Commission has committed error in allowing appeal in toto and dismissing the complaint in toto though petitioner was entitled to receive benefits under the first policy which was issued before 5 years. Consequently, revision petition filed by the petitioner is partly allowed and impugned order dated 19 -01 -2007 passed by learned State Commission in Appeal No. 646 of 2003 - The Branch Manager, Life Insurance Corporation of India and Anr. Vs Perumalsamy is modified and order of the District Forum dated 26 -03 -2003 is also modified and petitioner is held entitled to get Rs.50,000/ - along with Rs.10,000/ - as bonus under the first policy with interest @ 9% p.a. from 18 -12 -2000 till the date of payment. There shall be no order as to costs.