Life Insurance Corporation of India vs HARISH JOSHI

THE present appeal has been filed assailing the order dated 9.11.1998, passed by District Forum-I, Tis Hazari, Delhi, in Complaint Case No. 1407/1998 (old) No. 2142/1994) - entitled Shri Harish Joshi v. Life Insurance Corporation of India.

THE relevant facts, in brief are, that the respondent had filed a complaint before the District Forum with the grievance that his claim in respect of insurance policy No. 111445616 for Rs. 50,000/- had been wrongly repudiated by the appellant. The wife of the respondent Smt. Beena Joshi had taken an insurance policy for Rs. 50,000/- commencing from 28.10.1991. However, Smt. Beena Joshi expired in R.B.T.B. Hospital, Kingsway Camp on 2.6.1993 and was diagnosed as suffering from pulmonary tuberculosis. Accordingly the respondent being the nominee in the policy filed a claim with the Insurance Company. The said claim of the respondent was repudiated by the appellant on the ground that the insured had concealed material facts relating to the pre-existing disease i.e. tuberculosis from which the insured was suffering at the time of taking out the policy on 17.10.1991. Accordingly, the respondent filed a complaint before the District Forum for the redressal of his grievance.

The stand of the O.P. in its reply/written version filed before the District Forum was that from the Medical Attendant''s Certificate, as well as, certificate of hospital treatment it was revealed that the assured had been suffering from pulomonary tuberculosis since July, 1988 and the said material fact had been concealed from the appellant at the time of taking the policy and that false answers had been given in the proposal form, especially to questions 17(a) and 18(a) and accordingly the repudiation of the claim of the respondent was justified in the circumstances and there was no deficiency in service in that regard on the part of the appellant.

THE learned District Forum on the basis of the material on record held that the repudiation of the claim of the respondent was not justified and as such directed the appellant to pay the sum assured amounting to Rs. 50,000/- together with interest @ 12% p.a. from the date of repudiation i.e. 20.3.1995 till actual payment together with Rs. 1,000/- as cost of litigation. Aggrieved by the aforesaid order the appellant/LIC has preferred the present appeal before this Commission.

WE have carefully perused the documents/material placed on record, as well as, have deliberated upon the written submissions filed on behalf of both the parties. WE have also heard the arguments advanced on behalf of the respondent as none was present on behalf of the appellant at the stage of arguments. The main thrust of the appellant in the present appeal is that the deceased assured had taken the insurance policy on the basis of statements and answers as well as declarations contained in the proposal form for insurance dated 12.10.1991 and that the said declarations formed the basis of the contract for insurance based on the principle of ''uberrimaa fides'' i.e. utmost good faith. The insured had given false answers in the proposal form to the specific queries in column 17(a) and 18(a) which read as under : 17(a) - What has been your usual state of health ? (a) - Good 18(a) - Have you ever suffered from or are suffering from; persistent cough, asthma bronchitis, pneumonia, pleurisy, spitting of blood, tuberculosis, or any other disease of lungs ? (a) - No. It is contended on behalf of the appellant that the above said statements in the proposal form of insurance policy were false to the knowledge of the appellant as is borne out of the Medical Attendant''s Certificate which was filed by the respondent itself before the District Forum. In answers to Clause 4(c) and (e) it was specifically stated that the respondent was suffering from the tuberculosis since July, 1988 and that the first symptoms of the disease were observed about five years back. Furthermore, the certificate of hospital treatment also disclosed that the assured Smt. Beena Joshi was undergoing treatment for tuberculosis since July, 1988 and the primary cause of her death was also pulmonary tuberculosis. It was, therefore, contended that in the circumstances, there was no deficiency in service on the part of the appellant in repudiating the claim of the respondent vide its letter dated 20.3.1995. So far as the above contention of the appellant is concerned, it has been observed by the learned District Forum vide impugned order that there was discrepancy in the two certificates placed on record i.e. the Medical Attendant''s Certificate and the Certificate of Hospital Treatment inasmuch as the fact that the assured was suffering from tuberculosis since July 1988 was disclosed by the attendant as per the Attendant''s Certificate whereas in the certificate of hospital treatment the said information was given by the patient herself. Furthermore, as has been rightly observed by the learned District Forum that the said observations were hearsay and not based on the medical check-up/diagnosis of the treating doctor himself. Furthermore, in the Attendant''s Certificate the name of the attendant who narrated the history of the patient has not been disclosed. Even otherwise in its letter of repudiation dated 20.3.1995 the appellant had categorically stated that "we hold indisputable proof to show that about three years prior to taking the policy in question the assured was suffering from pulmonary tuberculosis". However, no such proof or corroborative evidence has been placed on record either before the District Forum or before us. Furthermore, before issuing the policy the panel doctor of the LIC of India/appellant must have medically examined the assured Smt. Beena Joshi and in case the assured was suffering from a chronic disease like tuberculosis for the past three years the same would have been detected by the examining doctor. Even as per the documents (mentioned above) relied upon by the appellant it is specifically mentioned that the treating doctor was consulted for the first time on 22.5.1993 as mentioned in Clause 4(f) and (g) of the Medical Attendant''s Certificate. Furthermore, in the Certificate of Hospital Treatment in Clause 4 it is categorically recorded that at the time of admission the assured Smt. Beena Joshi had the symptoms of cough, fever and breathlessness since four months and a oedema in feet for 10 days. Not only that there is no mention of any prior treatment taken or the doctors consulted by the insured for tuberculosis during the preceding period, so as to arrive at the conclusion that the disease in question was pre-existing at the time of taking the policy. Accordingly we are of the opinion that the repudiation of the claim of the respondent was not justified in the circumstances, merely based on the aforementioned documents. We are fortified in our above view by a recent decision of the Hon''ble National Commission in case - entitled The Senior Divisional Manager, LIC of India & Ors. v. Smt. J. Vinaya, reported as 1986-2002 Consumer 6814 (NS). The facts of the above case were similar to the case in hand. The complainant in that case had taken three policies on the life of her deceased husband for Rs. 2,00,000/- and after the death of her husband on 15.11.1994, on account of cardiac arrest, the complainant had filed a claim with the LIC of India, who had repudiated her claim on the ground that material facts relating to the health of the deceased assured had been withheld at the time of affecting the insurance. The matter had come up in appeal before the Hon''ble National Commission. The Hon''ble National Commission placing reliance on a decision of the Hon''ble Supreme Court in case - entitled LIC of India v. Smt. G.M. Chennabasamma, reported as (1991) 1 SCC 357, has held that the LIC of India was not justified in repudiating the complainant''s case merely on the basis of certificate of hospital treatment without any corroborative evidence especially in view of the fact that the burden of proving that the insured had made false representation and suppressed material facts lay on the LIC of India and if the latter failed to discharge the said burden the repudiation of the claim of the policy holder was unjustified and amounted to deficiency in service on the part of the LIC of India. The above said decision of the Hon''ble National Commission clinches the matter finally. We have no hesitation in holding that the repudiation of the claim of the respondent was unjustified and accordingly we uphold the well reasoned decision of the learned District Forum. Accodingly the present appeal, filed by the appellant, being devoid of merit is dismissed. However, in the facts and circumstances of the case there is no order as to cost. The appellant is directed to comply with the impugned order of the learned District Forum within 30 days of the receipt of this order.

THE present appeal, filed by the appellant, stands disposed of in above terms. Appeal disposed of.