KAILASHBEN RAMBHAI PATEL vs Life Insurance Corporation of India

- THE complainant is the widow of the insured who had taken an insurance policy on 13.3.90 for Rs. 25,000/-. It appears that the husband of the complainant (insured) died on 24.7.90 and the last medical attendant''s report submitted by the complainant to the Insurance Company states that the death of the insured was on account of cardio respiratory failure (preliminary cause) and Diabetec coma (secondary cause). Column C para 4 states that C.D.H. Hospital admitted him. THE admission card shows that he was admitted on 16.8.89 for pulmonary koch''s and diabetes mellitius and on 21.7.90 he was admitted for fever, cough and burning...(illegible). In clause (f) it is stated that the patient was under treatment at Bapunagar General Hospital since 21.7.90. Clause 11 states that this repairing is based on the indoor case papers of Rambhai Hargovinddas registration No. 12935 dated 21.7.90 Bapunagar General Hospilal.

THE Insurance Company has repudiated then claim by its letter dated 31.1.1991 staling that the proposal for assurance which was signed by the deceased on 13.3.90 to whom certain questions were asked and he had given incorrect reply i.e. he has made incorrect statement. THE relevant portion reads as under: "We may, however, state that all these answers were false as we hold indisputable proof to show that since about 18 months before he proposed for the above policy, he had suffered from Diabetes Mellitis and Pulmonary Koch''s for which he had consulted a medical man and had taken treatment from him in a hospital. He did not, however, disclose these facts in his proposal personal statement. Instead he gave false answers therein as slated above. It is, therefore, evident that he made incorrect statements and withheld correct information from us regarding his health at the time of effecting the 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 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."

THE Insurance Company in support of their contention has produced several receipts signed by the deceased under which he had been given benefits of his sickness and those receipts show that the deceased has taken sufficient benefit for his sickness e.g., certificate No. 29384 shows that he had taken treatment for Koch''s and diabetes and on that account according to the opinion of Dr. H.M. Desai he was unfit to resume work upto 5.10.88. Similarly the second certificate No. 29389 shows the same disease and he was found unfit to attend the work for the days mentioned therein. This certificate is dated 6.10.88. THE third certificate is in respect of sickness of 15 days for which he was given benefit of Rs. 300/-. THEse benefits were given under E.S.I. Scheme. THEre is another certificate No. 29395 which also shows that he had Koch''s and diabetes signed by the Insurance Medical Officer giving opinion that he was not fit to resume work. One certificate No. 183552 shows that he had Koch''s and diabetes and was in the T.B. hospital for treatment. THEre are more certificates where he has taken benefits and in one certificate it is written that he was admitted for diabetes keto.(illegible) and was an indoor patient from 14.3.89 to 1.4.89 for which he has received Rs. 360/-. Similarly there are other certificates also which we do not reproduce. All these certificates are for the treatment taken before the date of the proposal. It is equally true that the insured has not disclosed these facts in the proposal form and the cause of his death appears to be associated with the diabetic coma and cardio respiratory failure.

Mr. Rajiv Mehta, the learned Counsel appearing on behalf of the complainant states that the very fact that the insured was attending his work in the factory which is a strenuous work clearly shows that he was fit to take the insurance in the year 1990 (March 1990) and all these certificates which have been taken are taken merely to take leave and benefits of E.S.I. scheme. According to Mr. Rajiv Mehta the insured was not actually sick but reported sickness only to avail the benefits of E.S.I. scheme. We are unable to accede to the arguments of Mr. Mehta. Had it been mere certificates issued by non-medical man we might have considered the arguments but all these certificates have been given by a qualified doctor and we do not believe that the doctors issue certificates merely on asking, it is not the case of one certificate but many certificates. Not only that the insured has also taken benefits of his sickness. In these circumstances, though we have all the sympathies for the widow we are unable to accept the argument of Mr. Mehta that these certificates are not good pieces of evidence to come to a conclusion that the insured was suffering from diabetes and koch''s.

HE has taken the policy in March and he actually died on 24.7.90 i.e. within a period of months and 11 to 12 days. HE had paid only one premium. There is no averment before us that he has taken any policy in the past. We are aware of the fact that in this country a man may be suffering from several diseases but he has no money to take treatment and he might not be knowing that he is suffering from a serious disease since he is working till his last days. In this case also the insured was working, he was admitted in the hospital. The widow is very young having children. We have all the sympathies for her. But even then the evidence of the insured itself clearly shows that he was suffering from koch''s and diabetes which he ought to have disclosed to the Insurance Company that takes the insurance relying upon the insured. In this case there was no medical examination.

WE have also considered the plea of Mr. Mehta that the widow is very young and having children and the amount is paltry for the Insurance Company, and, therefore, if the insured has obtained false certificate in order to take the benefits the same cannot be used against him. As stated above these arguments have no merits. However, we feel that in such a case the Insurance Company may make some ex-gratia payment considering the facts and circumstances of the case and that the man has worked till he was admitted in the hospital. With the aforesaid observations we dismiss the complaint. ORDER The complaint is dismissed. In the circumstances there will be no order as to costs. Complaint dismissed.