HAJA BEGUM vs Life Insurance Corporation of India

SHORN of details complainant late Bashir Ahmed Bhat was insured with O.P. under three policies bearing Nos. 140320690, dated 6/1991 for Rs. 2 lakhs, 140538045, dated 18.1.1995 for Rs. 2 lakhs and 140538326, dated 21.3.1995 again for Rs. 2 lakhs. Admittedly during the insurance cover Bashir Ahmed Bhat died on 30.7.1995. His nominees who are present complainants raised the claim against all the three policies. First policy was meted out by the O.P. and the nominees, present complainant were paid the claim on 13.10.1997. Now the present dispute between the parties relates to other two policies of January and March, 1995. Complainants have averred in their complaints that the deceased died by Cardiac Arrest. Both the claims were repudiated by the O.P. on the ground that the deceased had suppressed the facts of his earlier disease of diabetes and blood pressure in the proposal forms. In the written version the only ground for resisting the claim under the above said two policies is that the question No. 11E in the proposal form complainant has replied in negative. This question relates as to whether the applicant is suffering from any diseases like diabetes, blood pressure, tuberculosis, etc. etc. (sic). To this query the proposer had written ''No'' O.P. appointed investigator AMS Consultants. AMS Consultants has reported that the proposer was patient of Diabetes and Blood pressure. He has suppressed that fact in the proposal form so complainants are not entitled to any indemnification. Parties have led evidence. Complainants have examined one of the complainants Parveez Bashir. Mr. A.M. Watali Investigator of AMS Consultants investigated LIC Agent besides Dr. Khursheed empanelled with LIC. On the other hand OP has examined Mr. M.Y. Sheikh, Branch Manager.

HEARD learned Counsels for the parties. Learned Counsel for the O.P. has wholly and solely depended on the report of Investigator AMS Consultants and the test reports produced by him. He has contended that the test reports dated 15th January, 1995 and 21st January, 1995 show that the proposal was patient of diabetes and blood pressure. We have gone through the whole record and considered the rival arguments of the parties. In this case both questions of facts and law are involved. It is the O.P. who has agitated that the deceased insured had suppressed the fact which culminates in negation of contract and result thereof is repudiation of the claim. There is no dispute about it that the onus is on the O.P. to prove firstly that the deceased insured was patient of diabetes and blood pressure at the time of filling up of the proposal form for the policy dated 18.1.1995. Secondly, O.P. is saddled with burden to prove that the deceased insured knew about these two diseases and he deliberately suppressed the facts in the proposal form. Thirdly, question arises as to whether the deceased has died of either of the two diseases mentioned hereinabove, if not so what is its effect on the claim petition.

Let us see the evidence which has been placed on the record. The only evidence is the report of Mr. Watali. Mr. Watali states that he has acquired the prescriptions from the claimant complainants from which it appears that the deceased was examined at Sewa Medical Laboratory, New Delhi. From the reports according to Mr. Watali it is apparently clear that the deceased was suffering from diabetes and blood pressure at the time of filling up the proposal form. Learned Counsel for the complainants has rightly challenged the appointment of Mr. Watali as Investigator at their back. Complainants were not associated with the investigation. This is corroborated by the statement of Mr. M.Y. Sheikh, Branch Manager of LIC who has admitted that there is no record to show that the complainants were informed by the O.P. about the appointment of the Investigator. We think this is the sufficient material to believe that the complainants were not associated with the investigation. There is no evidence on the record to show that the complainants were associated excepting the statement of Mr. Watali who says that he got the prescriptions from the complainants. There is no clear proof that Mr. Watali has associated the complainants during the investigation. Our Hon''ble High Court in LIC v. Abdul Aziz Bhat, 1998 SLJ 287, has held that report of Investigator cannot be taken into consideration if it is done at the back of claimants. However, for the sake of arguments if we believe that Mr. Watali has taken the prescriptions from the claimants, the question arises as to whether deceased was patient of diabetes and blood pressure Mr. Watali in his statement has categorically admitted that he never consulted any Doctor or any expert of the Laboratory which has conducted the tests of the patient/deceased. He has admitted that he never sought the opinion of any Medical Expert for interpretation of tests as to whether deceased was a patient of diabetes and blood pressure. So much so Mr. Watali has admitted that he never consulted the Doctor of O.P. Dr. Khursheed Ahmed who is the Doctor empanelled with the O.P. and it is the same Doctor who has examined the deceased at the time of filling up the form dated 19.1.1995 before the policy was issued. Dr. Khursheed is the same Doctor who is not only empanelled with the O.P. but has examined patient. Mr. Khursheed has categorically stated that the deceased was hale and healthy and he was found not the patient of any blood pressure or diabetes. Dr. Khursheed has been examined hereby the complainant. Dr. Khursheed has refuted the allegation that the deceased was having any disease like diabetes or blood pressure. It is very vital to say that the Doctor has in his statement admitted that he checked the pulse rate and Blood Pressure of the deceased just before the acceptance of proposal form and issuance of policy and it was found quite normal. In such circumstances what the O.P. had to do was to examine the Expert who had conducted the test for the Diabetes of the deceased. Expert who has conducted the tests has not been produced nor these tests have been shown to any Medical Expert as to whether the patient was having Diabetes and Blood Pressure. It was necessary for Mr. Watali to refer the prescriptions to a Medical Officer because the word "Diabetes" is not reflected from the Test Report dated 15.1.1995. Rest of the reports will not be material for the disposal of the case because those reports relate to the dates after issuance of the policy. From the report and the statement of Mr. Watali it is not clear as to in what circumstances and in whose presence Mr. Watali got the custody of the prescriptions and tests of the deceased and why those reports were not referred to Medical Officer for opinion so it would not be safe to believe that the deceased was the patient of Diabetes and Blood Pressure especially in the light of the statement of the Doctor Khursheed Ahmed through whom O.P. got the deceased examined fully before issuing the policy. Fourthly it has not been proved that the deceased was knowing that he was patient of Diabetes or Blood Pressure. Not a single witness has been examined by O.P. nor any record has been produced which would reveal that the deceased was knowing that he was a patient of Diabetes or blood pressure. Just three days before the issuance of the policy he was got examined by the O.P. by their own Doctor who is firm in saying that the deceased was quite hale and healthy he had no problem of Diabetes or Blood Pressure.

LEARNED Counsel for O.P. is relying on the judgment of the National Commission, LIC v. Parveen Dingra, in Revision Petition No. 897 of 2001, another LIC of India v. Smt. Veena Kalita, in Revision Petition No. 1167 of 1997, dated 19.3.2002. We have examined both these judgments. In both cases deceased was hospitalized several times either for cancer diseases and in another case for some heart diseases and there was sufficient record to prove that before the issuance of policy the ensured was patient of the diseases, cancer and heart ailment, and he had suppressed the disease while filling up the proposal form. So National Commission, New Delhi held that in both the cases claimants cannot be indemnified because of the suppression of facts. Here in the case in hand factual position is not same. There is no proof that the patient was suffering from disease or he was knowing that he was a patient of diabetes and blood pressure so he cannot be said to have suppressed the facts.

LASTLY, learned Counsel for the complainant has argued that even if for the sake of arguments it is assumed that the deceased was suffering from the disease of diabetes and blood pressure but he was died of cardiac arrest. There is no nexus between the cause of death and the disease suppressed. In that case also complainants cannot be deprived of indemnification. Learned Counsel has relied on : B. Chinama v. LIC, III (1996) CPJ 136 (NC). LIC v. Asha Rani Khanna, II (2000) CPJ 461. LIC v. Smt. Asha Goel, I (2001) SLT 89=AIR 2001 SC 549. LIC v. T. Venkateshwarlu, III (1997) CPJ 147. Here in this case the cause of death is not disputed, by the O.P. They have not disputed that the deceased died due to heart attack. He has not died of diabetes. No proof is on the record. Taking totality of circumstances into consideration we are of the opinion that the complainants have made out a case for indemnification, so we direct the O.P. to indemnify the complainants in both the policies and pay them Rs. 2 lakhs in each policy with 8 per cent interest p.a. for five months after the date of death of the deceased insured. The whole amount be paid to the complainants within a period of 5 weeks. The complaint is disposed of. The original claim file of the O.P. be returned to them through their Counsel. Complaint disposed of.