TAYYABA SULTANA vs BRANCH MANAGER, LIC OF INDIA

ONE Syed Mohd. Bakar submitted a proposal on 29.7.90 to the L.I.C. of India i.e. opposite party to insure his life for a sum of Rs. 2 lakhs with double accident benefit facility. The proposal was accepted and Endowment Assurance policy with Profits (Accident Benefit) bearing No. 640703551 was issued. He died on 18.11.92 in Princes Esra Hospital, Hyderabad due to chest pain (Miocardia Infraction). His wife i.e. complainant preferred a claim for payment of the amount under the policy. The opposite party by letter dated 15.6.93 repudiated their liability on the ground that the assured in the proposal form suppressed the fact of his suffering from diabetes for about six years before the proposal and also that he had consulted a medical man and had taken treatment in the hospital. Hence the above complaint was filed claiming payment of a sum of Rs. 4 lakhs under the policy with interest at 18% p.a. and compensation of Rs. 1 lakh for inconvenience and mental agony and Rs. 5,000/- towards costs.

IN the complaint, it was stated that the policy issued was medical policy and the complainant''s husband was thoroughly examined by the Panel doctors of INsurance Company before accepting the proposal who certified him to be hale and healthy. Moreover the complainant''s husband died due to chest pain and not due to diabetes and that there is no proof that the complainant''s husband suffered from diabetes for a period of six years prior to the proposal. IN the absence of any material showing that the complainant''s husband suffered from diabetes and was trated for the same prior to the proposal, the repudiation of their lability under the policy is arbitrary and not based on any material and therefore the repudiation of the policy is not valid in law, and the INsurance Company is labile to pay the amount due under the policy. The complainant therefore claimed Rs. 4 lakhs as the policy taken was double accident benefit policy with interest at 18%. In the counter filed by the LIC of India, they reiterated that the life assured, was a diabetic for over 6 years prior to his submitting the proposal for insurance and was also having hypertension prior to the submission of his proposal and underwent treatment for the same. As the assured failed to disclose the same at the time of making of proposal, they rightly repudiated their liability under the policy. It was further stated that the L.I.C. of India found in their investigations that the life assured was suffering from diabetes since about 1984 as mentioned by Dr. V.K. Bhargava of Apollo Hospital, Hyderabad, in the claim form dated 2.2.93. Hence there is no deficiency of service on their part.

No oral evidence was adduced by both the parties. On behalf of the complainant Exs. A- 1 to A-4 were marked. On behalf of the opposite party Exs. B-1 to B-4 were marked.

EX. A-1 is the discharge summary from the Apollo Hospital, Jubilee Hills, Hyderabad which shows that the assured was admitted on 24.10.92 and discharged on 31.10.92 on a complaint of pain in the throat, chest pain, cough, breathlessness and mild fever for seven days. EX. A2 is the death report. EX. A-3 is the certificate of death issued by the Municipal Corporation of Hyderabad and EX. A 4 is letter of repudiation issued by the opposite party. Ex. B 1 is the letter of repudiation corresponding to Ex. A 4. Ex. B 2 is the certificate of Hospital treatment issued by Dr. V.K. Bhargava dated 2.2.93, Ex. B-3 is the proposal and Ex. B-4 is Apollo Hospital Record showing admission of the assured on 24.10.92 and discharge on 31.10.92.

THE only question that arises for consideration is whether there is any material on record which prima facie justifies the repudiation of the liability of the LIC under the policy and whether the repudiation amounts to deficiency of service. The submission of the proposal and issuance of the policy and that the assured was examined by a Penal Doctor of the LIC prior to issuance of the policy were not disputed. The only controversy is whether the assured suffered from diabetes mellitus for a period of six years prior to the proposal and whether he underwent treatment for the same. According to the LIC in answer to question No. 19 i.e. Have you been suspected of diabetes or are you suffering from diabetes or have ever passed sugar, albumin, pus, or blood in the urine ? The assured answered ''No'', and to the question No. 20 i.e. Have you consulted a medical practitioner, within the last five years for any ailments requiring treatment for more than a week? the assured answered ''No''. According to the L.I.C. the assured has been suffering from diabetes for six years prior to the proposal and also he was treated for the same. But he fraudulently suppressed to disclose the same in the proposal form and therefore the policy is vitiated. In support of their case, the opposite party produced Ex. B-2 certificate of hospital treatment dated 2.2.93 signed by Dr. V.K. Bhargava of Apollo Hospital, Hyderabad. In the said certificate it was mentioned that the assured was admitted on 24.10.92 and was discharged on 31.10.92 for pain throat, fever etc. In column 7(a) against History report, it was mentioned that diabetes mellitus, hypertension, obesity from 1984. But in the discharge summary in the column relating to the Past/Personal/Family History it was mentioned that the patient is a known D.M. on oral hypoglycemic drugs. But significantly in the discharge summary, it was not mentioned whether the patient was suffering from diabetes prior to the date of the proposal. Even in the, column relating to the discussion in page 2 of the summary report, it was merely stated that the patient is a known case of HTN and D.M. It was not mentioned that he was suffering from diabetes either from 1984 or for any length of time prior to the proposal. Thus it is evident that in the contemporaneous record i.e. discharge summary, it was not mentioned that the patient was suffering from diabetes from 1984. But in the certificate of hospital treatment issued on 2.2.93, the Doctor mentioned that he suffered from diabetes-mellitus from 1984. It is also evident from the case sheet and the various medicines prescribed by the Apollo Hospital that no medicine was prescribed and the patient was not treated for diabetes.

THE assured died after a period of nearly two years three months from the date of the policy. It might be that on 24.10.92 i.e. nearly two years subsequent to the proposal, it was found that the assured was having diabetes. But that does not establish mat the complainant''s husband was suffering from diabetes-mellitus even prior to the date of the proposal, particularly when he was examined by Penal Doctor at the time of the proposal. As there is no contemporaneous record to show that the assured suffered from diabetes-mellitus prior to the date of the proposal and that he underwent any treatment for the same more than one week prior to the date of the proposal, we are not inclined to place much reliance on the certificate issued by Sri V.K. Bhargava some time in 1993, wherein he mentioned that the patient has been suffering from diabetes from 1984. THE L.I.C. of India did not produce any material to show that the assured underwent treatment for more than a week for any ailment including diabetes under any Doctor and was in the Nursing Home for a week. We have gone through the record produced by the LIC of India. It clearly shows that there is difference of opinion among the Claims Department and the members of DO CRC opined that the evidence available in claim Form B1 (Page 22) is not sufficient to repudiate the claim. But ultimately a decision was taken by higher authorities to repudiate the claim. We are, therefore, satisfied that the repudiation of the liability by the LIC of India is not bonafide and is not based on any contemporaneous material to show that the assured prior to the proposal suffered from diabetes-mellitus for six years and that he underwent treatment for the same for more than a week, in the hospital. Moreover the policy was issued after examination of the assured by a Penal Doctor of LIC. In these circumstances, we are satisfied that the repudiation is arbitrary and is not based on any material and is not bonafide, amounting to deficiency of service.

THE learned Counsel for the complainant drew our attention to the Division Bench decision of A.P. High Court in Life Insurance Corporation of India, South Zone, Madras and Another v. Bhogadi Chandravathamma, AIR 1971 Andhra Pradesh 41, wherein it was held by the Division Bench "the confidential reports submitted by the medical examiners of the Corporation will have to be accepted as true, as ordinarily the presumption is that they submitted the reports only after a thorough and careful examination of the proposers in accordance with the questionnaire is, unless it is shown by the Corporation that either the Medical Examiner who submitted the report, made a false record or that the proposer made a fraudulent suppression of the material facts being aware of the illness from which he was suffering". This observation is relevant as in the instant case also the Panel Doctor examined the assured and gave a report of good health and no evidence was adduced by the LIC of India to show that the Doctor''s report is false. To the similar effect, is the decision of Calcutta High Court in Rameshwar Singh v. LIC of India and Others, AIR 1991 Calcutta 55, wherein it was observed that when the policies issued after full and proper medical examination, the repudiation of the liability under the policy on the ground that the policy holder did not disclose that he had suffered from Asthama cannot be relied, upon particularly when the Insurance Company failed to produce any documents in support of their plea

The complainant claimed a sum of Rs. 4 lakhs in the complaint. But her husband died due to myocardial infraction. It cannot be said that he died in any accident. Therefore the complainant is not entitled for double accident benefit. She is entitled to the policy amount of Rs. 2 lakhs with profits as the policy was Endowment Assurance policy with profits.

IN the result, the complaint is allowed in part and the opposite party is directed to pay to the complainant a sum of Rs. 2 lakhs with profits, with interest @ 15% p.a. from 1st March, 1993 till the date of payment. The opposite party shall pay the amount within a period of two months from today i.e. 3.6.96. There shall be no order as to costs in this complaint. Complaint partly allowed. _____________