RAJENDRA KUMARI vs CHAIRMAN AND MANAGING DIRECTOR, ORIENTAL INSURANCE COMPANY LTD.

THIS complaint under Section 12 of the C.P. Act, 1986 (the ''Act'') by Smt. Rajendra Kumari widow and Km. Khushboo and Master Prashant, minor children of the deceased insured Sri Ratnakar Pratap Singh, arises under the following circumstances :

LATE Sri Ratnakar Pratap Singh, the deceased insured, had obtained a Personal Accident Policy for Rs. 15,00,000/- (Rs. fifteen lakhs) from the respondent Insurance Company (the ''Insurance Company'') on 3.2.1994 for the period from 3.2.1994 to 2.2.1995. This policy covered the risk against permanent partial disablement (Table II) to the extent of Rs. 7,00,000/- and Rs. 3,50,000/- and against temporary total disablement (Table III) to the extent of Rs. 3,00,000/- and Rs. 1,50,000/- of Sri Ratnakar Pratap Singh himself and his wife Smt. Rajendra Kumari Singh (complainant No. 1) respectively. The case of the complainants is that during the period of the currency of the insurance policy late Sri Ratnakar Pratap Singh sustained bodily injuries on 5.3.1994 as a result of fall from staircase in the house. On being x-rayed it was known that he had sustained comminuted fracture of the right side of the pelvis in and around the acetabular cavity and the head of right femur due to which he had to remain confined to bed and under treatment for several months. It was thus alleged that Sri Singh had sustained permanent partial disablement as well as permanent total disablement entitling the complainants to receive total amount of Rs. 10,00,000/- (Rs. 7,00,000/- + Rs. 3,00,000/-) with interest and other benefits under the policy from the opposite party Insurance Company which it did not pay to them despite repeated requests.

It was further averred in para 10 of the complaint that on 3.1.1995 Sri Singh died of consuming some wrong syrup under the mistaken belief that the same was cough syrup.

THE case of the complainants further was that though they had submitted their claim with the Insurance Company for the sum assured amounting to Rs. 10,00,000/- and had further submitted other documents as and when such documents/information were required to be submitted by them yet the O.P. Insurance Company wrongly repudiated their claim on 20.7.1995. THE complainants claimed Rs. 10,00,000/- on account of the sum assured, Rs. 5,00,000/- of account of medical expenses, with appropriate interest and cost of litigation at Rs. 25,000/-. The O.P. Insurance Company, apart from raising some preliminary objection against the adjudication of the complaint by the Commission in a summary way, opposed the complaint mainly on the ground that on investigation of the claim it was known that it was on 1.1.1993 at about 5.00 p.m. near village Padampura, Distt. Itawa (U.P.) that the deceased insured had sustained injuries in a car accident and got himself treated for such injuries at Gem Hospital, Jaipur but he had suppressed the disclosure of such a relevant and material fact relating to his health to the Insurance Company while submitting the proposal form on 3.2.1994. It was submitted that the contract for insurance between the parties stood vitiated and was void ab initio due to deceased insured knowingly suppressing material fact relating to his health from being disclosed upon the O.P. Insurance Company while submitting his proposal. It was thus submitted that the claim of the complainants was rightly repudiated in good faith after conducting thorough investigation into such claim and, therefore, the complaint was liable to be dismissed.

WE heard the learned Counsel for the parties and carefully examined the material on our record. WE entertain no doubt that in the light of the material brought on our record the O.P. Insurance Company had rightly and in good faith repudiated the claim of the complainants as such claim was not at all honest and genuine. Our study of the material placed on our record discloses that late Sri Ratnakar Pratap Singh, the deceased insured, had filed in the proposal form on 30.1.1994 for obtaining the Individual Personal Accident Policy from the O.P. Insurance Company for himself for Rs. 10 lakhs and for his wife, Smt. Rajendra Kumari, complainant No. 1 for Rs. 5 lakhs. He had assigned his interest in sum assured to his wife, in the event of his death during the currency of the policy. In answer to question No. 7 in the proposal form he had specifically denied that he suffered from any physical defect or infirmity, or gout, arthritis, or diabetes, paralysis, fits of any kind or any other chromic disease or any other disability. This proposal form was signed by himself as proposer and by S/Sri Pappu Sharma and Jai Singh r/o Mansarovar, Jaipur as witnesses. On the basis of this proposal form Personal Accident Policy for Rs. 15,00,000/-, covering the risk of permanent partial disablement and total temporary disablement of himself and his wife for the sums, as specified above, was issued by the O.P. on 3.2.1994. The period of currency of this policy was from 3.2.1994 to 2.2.1995. Varying amounts depending upon the nature and extent of the permanent partial disablement and/or temporary total disablement, as specified in the terms and conditions of the policy, or the sum assured in the event of death of the deceased insured and/or his wife was payable on the happening of such event and information in writing to the Company within one calendar month of the happening of such event, was to be given. Now the case of the complainants, as stated in the Para Nos. 4 to 9 of the complaint, is that the deceased insured had fallen down from the staircase in the house and due to the injuries sustained by him by the fall had become handicapped by more than 50% and despite his repeatedly requesting the O.P. Company and submitting all the relevant document, no part of the sum assured was released to him either during his life-time or to complainants after his death on 3.1.1995. This version was sought to be supported with the affidavit of Smt. Rajendra Kumari, complainant No. 1 and a number of documents marked as Annexures I to XI, which mostly include the correspondence exchanged between the parties and some certificates issued by doctors. This evidence is, in our opinion, hopelessly, insufficient to prove the version of the complainant regarding the deceased having sustained any injuries from a fall from staircase.

FROM O.P.''s letter dated 8.6.1994 (Annexure 4) it is gathered that the deceased insured had preferred his claim on 31.3.1994. The O.P. has mentioned in this letter that neither the particulars of the policy in question were given by the deceased in his said letter dated 31.3.1994 nor the address was given. By its letter the O.P. Company had required the deceased to fill up the claim form being sent to him along with the letter, duly supported with the medical report from the doctor attending upon him, and also supply to the O.P. Company the prescription slips, cash memos of medicines purchased, X-ray films, reports, receipts etc. and annual income certificate. Acknowledging the receipt of the above letter of the O.P. Company along with all the enclosures therewith, the deceased, vide his letter dated 25.6.1994 (Annexure 5) had asked the O.P. Company to release weekly compensation to him as all the other requirements would be met at the time of finalising the claim and that the certificate sent by him at earlier point of time clearly informed the Company that he was confined to bed and his condition may be verified at his residence and that the demanded prescription slips, cash memos of the medicines purchased, X-ray films etc. etc. would be supplied at the time of finalisation of the claim. The O.P. Company again repeated their demand for the required information/document through their letter, dated 22.7.1994. By his letter dated 22.9.1994 the deceased informed the O.P. Company that in lieu of medical report, he was submiting permanent disability certificate dated 5.9.1994 issued by Rehabilitation Research Centre, S.M.S. Medical College, Jaipur, photocopy of out patient ticket dated 8.3.1994, money receipt of M/s. G.M. X-Rays dated 8.3.1994, money receipt dated 11.3.1994 from M/s. Sharma X-Ray and Diagnostic Clinic Pvt. Ltd., Jaipur with report of X-Ray money receipt dated 13.3.1994 along with CT Scan Report of M/s. C.T. Scan Centre, Jaipur, certificate from Dr. Mukesh Sharma of S.M.S. Medical College Hospital dated 19.3.1994, prescription from Dr. Ratan Sharma, Udaipur dated 11.4.1994 and certificate of M/s. Dhanawati Rai Nursing Home, Jaipur.

WE have closely studied all the documents as produced by the complainant, and entertain no doubt that none of them mentioned the fact that the deceased had sustained any injury from the alleged fall from a staircase. All the above documents were prepared much after the alleged fall of the deceased from staircase. In fact it was not disclosed even in the complaint, what to speak of these documents, as to on what date the alleged incident of fall from staircase had taken place. Had the alleged incident ever taken place in the manner stated by the complainant, the deceased must have been immediately taken to a doctor for at least first aid and then for hospitalisation looking to the serious injury rendering him disabled for more than 50%. There is absolutely no evidence on record on these points. What the out patient ticket dated 8.3.1994, and G.M. X-rays Slip dated 8.3.1994 say is simply this that X-ray of pelvis including both hips - A.P. view, was advised and done. In fact the certificate issued on 11.3.1994 by M/s. Sharma X-Ray and Diagnostic Clinic Pvt. Ltd. says that deceased''s was a follow-up case of comminuted fracture of the right side of the pelvis in and around the acetabular cavity and the head of right femur with position of the fractured fragments and scanty callus formation around them. The CT Scan report dated 14.3.1994 simply stated that there were multiple fracture of right iliac bone, anterior and posterior column of acetabular cavity and upper part of the femur head, which was deformed. The details of the fractures and the callus formation clearly indicated that it was some old case of the deceased having sustained injury on the pelvis region. The certificate issued by Dr. Mukut Sharma on 19.3.1994 simply stated that for the injury noticed on the person of the deceased on 5.3.1994 skin traction was applied on 16.3.1994 and that due to State-wide strike of employees he was not admitted to hospital and was advised bed rest for three months. This certificate does not say that Dr. Sharma himself had seen any injury on 5.3.1994 and if he had seen it on that day what treatment did he give to the patient and how was it that he could be able to see the patient on 6.3.1994 if there was strike of the employees of the hospital. Similarly the certificate issued by Dhanvantari Nursing Home, Mansoraver, Jaipur dated 5.7.1994 simply says that the deceased had remained under their treatment from 5th May, 1994 till date and during that period he had remained completely confined to bed. It may be mentioned that even if all the documents, as produced by the complainant and as disclosed above, be taken on their face value, they fail to disclose that the deceased had sustained injury after the purchase of the policy by him from the O.P. Company. Those all were prepared subsequent to the purchase of the policy in order to justify a claim for part payment of the sum assured in respect to the bodily injuries sustained by the deceased prior to the contract of insurance between the parties in this case. This conclusion is fully endorsed when the version of the O.P. Company and the evidence in support of such version is considered.

The documents submitted by O.P. Company in support of their version disclose that late Sri Ratnakar Singh, the deceased insured, was the registered owner of Maruti Car No. R.J. 14 C-7974, that on 1.11.1993 the said vehicle was on its way from Jaipur to Allahabad with the deceased and two ladies as occupants thereof and Sri Jitender Pal Singh driver of the vehicle, that near village Padampura in Distt. Etawa (U.P.) Truck No. HR 29 B 2533 had dashed against the Maruti Car of the deceased, causing the fall of the car in a road side pit and injuries to the deceased, the driver and the ladies, that the incident was reported to Police Station, Civil Lines, Etawa (U.P.) whereat a report was written in the General Diary at 11.00 a.m. dated 2.11.1993. The injured persons were removed by one Sri Ramesh Singh r/o Khander Jaswant Nagar, Distt. Etawa to the Govt. Hospital at Etawa where the deceased insured was examined at 6.50 p.m. on 1.11.1993 and he was found having sustained multiple injuries over his body and complaints of pain in right side of chest and hip joints. The doctor had advised X-ray examination of Rt. hip joint and chest region. On X-ray examination at Gem Hospital, Jaipur on 4.11.1993 fracture and dislocation of bones in those areas were confirmed and the deceased had taken treatment at Gem Hospital from 4.11.1993 to 7.11.1993. All these facts, stood fully supported with the copy of the report recorded in the General Diary of Police Station, Civil Lines, Etawa dated 2.11.1993, medical examination report of the deceased at Govt. Hospital, Etawa dated 1.11.1993, report of Sri Devender Kumar, Surveyor and Loss Assessor of New India Assurance Co. Ltd. at Etawa dated 5.11.1993, conducting detailed inspection of the Maruti Car of the deceased insured, X-ray Report dated 4.11.1993 from Gem Hospital, Jaipur and treatment record kept for 5.11.1993, 6.11.1993 and 7.11.1993 at that hospital, report dated 7.10.1994 of Sri Arun Kumar Patni, the investigator appointed by the O.P. Company and who thoroughly investigated the case and rejected the above documents from the police station and hospital at Etawa and report of Gupta Fracture Clinic dated 20.6.1994 which after (sic.) into the X-ray reports, relied upon by the complainants, confirmed that the fracture sustained by the deceased insured was an old one looking to the position of the fusion and callus formation in and around the fractured bones.

THE evidence which has been discussed above affirmatively and conclusively proves that the deceased had sustained injuries on his person in the car accident, which had taken place on 1.11.1993 near village Padampur in Etawa District of Uttar Pradesh and not as a result of any fall of the deceased from the staircase in his house on 5.3.1994 or even near about that. THE complainant had thus preferred a false claim and the O.P. Company was fully justified in repudiating such claim after thorough investigation thereof and on having come to know that the deceased had obtained the policy in question much after his sustaining the injury, which was made basis for submitting a false claim by him subsequently. THE contract of insurance clearly stood vitiated by the act of the deceased of knowingly suppressing the true and natural facts regarding his health at the time of submission of the proposal form. It is really surprising that O.P.''s own agent/Development Field Officer, whosoever had accepted the proposal form, did so without even verifying the state of health of the deceased insured at the relevant time. Such irresponsible act of O.P.''s concerned agent breeds avoidable litigation and we strongly disapprove of such conduct and behaviour of such erring employees/servants/agents of the O.P. Company. In the result, this complaint is found quite baseless and devoid of any merits. It is consequently dismissed as such, but looking to the widow and orphan minors as complainants in this case, with no order as to costs. Complaint dismissed.