Life Insurance Corporation of India vs ZAYADA BEGUM

THIS is an appeal against the order dated 4.9.2003 passed by the District Forum, Udham Singh Nagar whereby the complaint of the complainant for recovery of insured amount on death of her husband was allowed.

THE brief facts of the case are that Sh. Sayyad Abid Ali, husband of the complainant had taken a life insurance policy on 28.2.1999 for a sum of Rs. 50,000/- (Rupees fifty thousand). He has been paying premium regularly. On 21st April, 2000, Sh. Sayyad Abid Ali for the first time felt cough and fever and he was shown to T.B. Officer, Pilibhit. He was informed that he was suffering from T.B. from last one year. THE victim was advised to be admitted in T.B. Hospital, Bhawali, where on 13.3.2001 he was admitted. On 24.3.2001 he died. It is alleged that for the first time on 21.4.2000, the complainant or her husband could know that the victim was suffering from T.B. from last one year. It is said that the insured did not know about his illness earlier. After the death of the victim, the complainant lodged the claim with the Insurance Company. It was repudiated on the ground that the victim has knowingly suppressed material fact at the time of taking the policy, therefore, she filed a complaint before the learned Forum. The opposite party filed written statement and admitted the insurance. It is further admitted that the insured died on 24.3.2001. It is stated that it is incorrect to say that the complainant or victim knew about the illness for the first time in March, 2000. He was suffering from the disease before 2 and a half years of taking the policy. It is said that the victim died only after 1 year 11 months and 23 days of taking the policy and Dr. Manoj Upreti of T.B. Hospital, Bhawali has specifically reported that the victim was suffering from this disease before 2 and a half years. This fact has been suppressed, therefore, the claim has rightly been repudiated.

After taking the evidence of the parties and hearing them, the learned Forum held that there was no evidence that the victim was suffering from this disease before 2 and a half years and it has been knowingly suppressed at the time of taking the policy. The learned Forum further held that the papers filed by the doctor cannot be admitted in evidence for want of affidavit by him. It further held that at the time of taking the policy the doctor of the Insurance Company has specifically reported that the insured was healthy. He did not report about any disease. Therefore, the Insurance Company cannot take the shelter that the insured was suffering from any disease. On evidence and merit, the learned Forum allowed the complaint. Against which order the present appeal has been filed.

WE have heard the learned Counsels for the parties and gone through the records. The proposal form is Annexure-A on record. In its column regarding illness, it has been filled in negative. It shows that the victim was not suffering from any disease at the time of taking the policy. The proposal form has been signed by Dr. B.K. Avasthi. He has specifically given a certificate that he certifies that the proposal has been signed in his presence after admitting that all the answers to question No. 10 and onwards of this form have been correctly recorded. The complainant has specifically alleged that the doctor has examined the insured at the time of completion of the formalities. The Insurance Company did not deny this fact. The doctor does not give the certificate casually. He has to make the checkup of the person being insured and it shall be presumed that he has signed after checking. He did not report about any illness. Even otherwise T.B. is a disease which is not ordinarily known. In hill area innocent, ignorant, illiterate people go on coughing, fell ill with fever but when the matter becomes serious prefer to consult doctor otherwise they ordinarily take it a disease of cold and cough and ordinary fever. It is not only that the illness should be there but what is necessary that it should be specifically in knowledge of insured and then alone it should be held that he has suppressed it.

THE certificate of Dr. Manoj Upreti that there was admission that the insured was suffering from disease for the last 2 and a half years is only a hearsay. Who gave this statement, when this statement was given is not clear? It is not he who has earlier examined the victim. In the claim medical declaration form, he has written that he was not a family doctor of the victim. He has only treated him in Bhawali and whatsoever report he has given, he has given on the basis of records. Not only this, in para 6(2), it has specifically been written that if there is an unnatural death, in column (a) the first date on which the disease was for the first time detected, the doctor has reported N.A., not known. THE form has been filled on 9.5.2001. THE doctor has written that detail of his illness was disclosed by the patient himself. How he could know is not clear? THE victim was for the first time admitted in T.B. Hospital, Pilibhit on 21.4.2000 and there is absolutely no paper on record that earlier he has got any treatment before 21.4.2000. Had the victim been a patient of tuberculosis for the last 2 and a half years and the disease was disclosed to him, he must have got some treatment anywhere on earth but the appellant could not produce any paper that anywhere else he has got any treatment, examination, prescription before this date. It is also settled principle of law that mere statement at the time of admission without actual proof is not admissible in evidence and such casual statement cannot form basis of repudiation. In the case of New India Assurance Co. v. P.P. Khanna, reported in II (1997) CPJ 1 (NC), the National Commission has held: "The onus probandi, in cases of fraudulent suppression of material facts rests heavily on party alleging fraud, namely the insurer. The insurer cannot avoid consequences of insurance contract by simply showing inaccuracy or falsity of statement. Burden is cast on the insurer to show that the statement was on a material matter or facts have been suppressed which it was material for the policy holder to disclose. It is further to be proved that the statement was fraudulently made by the policy holder with the knowledge of the falsity of statement or that the suppression was of material facts which had not been disclosed. The Courts will not be satisfied with proof which falls short of showing that intentional misrepresentation was made with the knowledge of perpetrating fraud."

THE mere casual statement, the report of the doctor without formal proof, the absence of affidavit to prove these facts, no concrete evidence who gave that type of statement, all go to prove that such bald allegations cannot form basis of rejection of the claim. At least there is no evidence that the insured had got any treatment, examination, etc. earlier and in the absence of any such evidence to find a way to repudiate the claim cannot be justified.

THE net result is that we do not find any force in this appeal and the appeal is liable to be dismissed. ORDER THE appeal is hereby dismissed. Cost of this appeal shall be easy. Appeal dismissed.