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2006 DIGILAW 699 (ORI)

DIVISIONAL MANAGER, L. I. C. OF INDIA, AND THE BRANCH MANAGER, L. I. C. OF INDIA v. SUSHILA AGARWALLA AND RAJ KISHORE MAHARANA AUTHORISED AGENT OF L. I. C. I

2006-10-10

BASANTI DEVI, SUBASH MAHTAB

body2006
JUDGMENT : 1. Aforesaid each appeal relates to the one and same "Asha Deept Policy" bearing No. E-580479436 dated 28.11.1993 with assured sum of rupees 1,00,000/- (Rupees One Lakh) in favour of Sushila Devi Agrawalla, wife of Nandulal Agrawalla by Life Insurance Corporation of India in short, L.I. C.. C.D. Case No. 43 of 1996 had been filed by the insured Sushila Devi Agrawalla against the L.I. C. represented by its Divisional Manager, Berhampur Ganjam Division, Berhampur, Branch Manager Phulbani, Dist-Kandhamal and Sri R.K. Maharana, the L.I. C. authorised agent At/P.O./Dist.Boudh claiming 50% of the sum assured with interest, etc. due to complete partial disablement. The aforesaid Opposite Parties have filed C.D. Appeal No. 265 of 1997 being aggrieved against the orders dated 21.03.1997 of the District Forum, Boudh in C.D. Case No. 43 of 1996. In the meantime, on 28.08.1999 said Sushila Devi Agrawalla died. Thereafter, her nominee, husband-Nandulal Agrawalla filed C.D. Case No. 34 of 2000 in the same District Forum claiming the balance payment of 50% of the sum assured with other benefits in respect to aforesaid "Asha Deep Policy" against the above mentioned Opposite Parties. Being aggrieved against the orders dated 25.06.2002 of the District Forum, Boudh in C.D. Case No. 34 of 2000, the aforesaid Opposite Parties have filed C.D. Appeal No. 454 of 2002. In view of this state of affairs, both the Appeals were heard in one day one after the other and a common order is being passed for the shake of convenience. 2. The brief admitted facts of both the case are that Sushila Devi Agrawalla, the wife of Nandulal Agrawalla, the complainant of C.D. Case No. 43 of 1996, had taken Asha Deep Policy under Life Insurance Corporation of India (L.I.C.) bearing No. E-580479463 dated 28.11.1993 through L.I.C. authorised agent Sri Rajkishore Maharana (Ext. 1) for an assured sum of rupees 1,00,000/- (Rupees One Lakh). Her husband- Nandulal Agrawalla is her nominee. She had deposited rupees 6477/- on 31.12.1993 and rupees 6744/- on 23.12.1994 as two yearly instalments. 3. The case of the complainant Sushila in C.D. Case No. 43 of 1996 in brief is that in view of the policy condition, she had undergone medical check up including E.C.G. test by the Doctor of the L.I.C.. She had deposited rupees 6477/- on 31.12.1993 and rupees 6744/- on 23.12.1994 as two yearly instalments. 3. The case of the complainant Sushila in C.D. Case No. 43 of 1996 in brief is that in view of the policy condition, she had undergone medical check up including E.C.G. test by the Doctor of the L.I.C.. After through check up and interrogation, in respect to several matter, the L.I.C. Doctor recommended the complainant as a "First Class Life" for taking Asha Deep Policy. Accordingly, the L.I.C. accepted her proposal and issued Asha Deep Policy in her favour. Sushila suffered an attack of paralytic stroke leading to permanent disability of her left leg and hand on 05.12.1994, when the policy was existing. She remained under the treatment of Sri H.K. Mohapatra, M.D. Medicines of the Sub-Divisional Hospital, Boudh from 05.12.1994 and as per the advice of the doctor, she was shifted to Burala and was treated in the Gupta Narsing Home from 11.12.1994 to 15.12.1994. Her husband wrote to the Branch Manager of L.I.C., Opposite Party No. 2 intimating about her paralytic stroke as a result of which the L.I.C., Phulbani Branch issued her favour a claim form on 02.02.1995. Complainant sent the said form duly filled accompanied with the certificates of the treating doctors at Boudh and Burla. But, vide registered letter dated 20.11.1995 the Divisional Manager, L.I.C., Berhampur, Opposite Party No. 1, repudiated the claim under the said policy as the policy is declared as void in view of policy condition due to suppression of material facts in the proposal form about complainant's suffering from diabetic mellitus and hypertension. Therefore, the complainant filed C.D. Case No. 43 of 1996 claiming 50% of sum assured and 10% of sum assured till today with other claim all amounting to rupees 3,05,000/-. 4. The Opposite Party No. 3 was ex parte before the District Forum. Opposite Party Nos. 1 and 2 had filed written version and had contested the aforesaid claim of the complainant. Their case in brief is that the alleged paralytic stroke of the complainant on 05.12.1994 occurred just after one year i.e. on 28-11-1993 of the said policy. Therefore, L.I.C. enquired upon when it received the claim of the complainant. In view of the enquiry report, complainant/assured was having hypertension and diabetes as associated diseased and she had paralytic attack on 05-12-1994. Therefore, L.I.C. enquired upon when it received the claim of the complainant. In view of the enquiry report, complainant/assured was having hypertension and diabetes as associated diseased and she had paralytic attack on 05-12-1994. But complainant did not disclose about suffering from hypertension and diabetes earlier, in the proposal form. Had it been disclosed, the said proposal for policy would not have been accepted or would have been accepted on different terMs. This is how the complainant has suppressed material facts while proposing for taking Asha Deep Policy in violation of the terms and conditions of the policy. Thus the policy is null and void. Therefore, Opposite Party No. 1 vide letter dated 20-11-1995 intimated the complainant about repudiation of claim for the reason of suppression of material facts in respect to suffering from hypertension and diabetic mellitus before which would not have been revealed unless she had disclosed in the proposal form even though medical report had been submitted. The Opposite Party No. 1 intimated that the premium already paid belonged to the L.I.C. due to this reason. This is how Opposite Party Nos. 1 and 2 had claimed for the dismissal of the C.D. case as they have caused no deficiency in service to the complainant. 5. Both the doctors Dr. H.K. Mohapatra, M.D. Asst. Surgeon, S.D. Hospital, Boudh who had treated initially on 05-12-1994 for the stroke as well as Dr. U.K. Murty, M.D. D.M. Associated Professor and H.O. D. Neurology v. S.S. Medical College, Burla who had treated complainant from 11-12-1994 at Gupta Nursing Home, Burla have stated that due to paralytic stroke the left upper and lower lombs of the complainant have been permanently disabled. The reason of stroke according to them is hypertension and diabetes mellitus. Only Dr. U.K. Murty has reported as per his Medical Attendant Certificate dated 21-03-1995 under the claim Form:AD (P.S.)-2 that as per patient's illness history she was suffering from diabetes for 3 years and hypertension for 5 years. Except this no other oral and documentary evidence were available before the District Forum to corroborate history of illness as per the Medical Attendant Certificate. Therefore, the District Forum hold vide orders dated 18-03-1997 that such history, which with all possibility, might have been collected from a third person, is no conclusive to arrive at a finding of suppression of material facts as alleged by the Opposite Parties. Therefore, the District Forum hold vide orders dated 18-03-1997 that such history, which with all possibility, might have been collected from a third person, is no conclusive to arrive at a finding of suppression of material facts as alleged by the Opposite Parties. District Forum accordingly hold that the complainant is a consumer and the action of the Opposite Parties to repudiate complainant is a consumer and the action of the Opposite Parties to repudiate complainant's claim on the ground of suppression of material fact is illegal, the Opposite Parties having accepted the proposal and premium of the policy had completed the agreement. In the circumstances, for complete partial paralysis of left upper and lower limbs, District Forum directed Opposite Parties to pay to the complainant rupees one lakh under the Asha Deep Policy and rupees 5000/- towards legal and other expenses. This finding and order of the District Forum has been assailed by the Opposite Parties in C.D. Appeal No. 265 of 1997. 6. The case of the complainant - Nandulal Agrawalla, the husband and nominee of aforesaid Sushila Devi Agrawalla, against the same Opposite Parties in C.D. Case No. 43 of 2000 is that after the aforesaid orders dated 18-03-1997 in C.D. Case No. 43 of 1996 was passed, the health condition of Sushila gradually detoriated. She was shifted to S.C. B. Medical College Hospital where she died on 25-08-1999. After her death, Nandulal Agrawalla made claim the balance 50% of the sum assured under the policy. But, the Opposite Party Nos. 1 and 2 repudiated his claim. Therefore, Nandulal filed C.D. Case No. 34 of 2000 claiming 50% of the sum assured with other expenses. Only Opposite Party Nos. 1 and 2 had filed written version and had contested the aforesaid claim of Nandulal. Their plea is that as Sushila Devi has suppressed in the proposal Form about her suffering from diabetes for three years and hypertension for five years prior to the policy dated 28-11-1993, the policy has become void. In this respect they had relied upon the Medical Attendant Certificate of Dr. U.K. Murty. Thus they had urged for justification of repudiation of claim of Sushila Devi as well as Nandulal. The Opposite Parties had produced Exhibit A/3, the Bed ticket of Susila Devi where Dr. In this respect they had relied upon the Medical Attendant Certificate of Dr. U.K. Murty. Thus they had urged for justification of repudiation of claim of Sushila Devi as well as Nandulal. The Opposite Parties had produced Exhibit A/3, the Bed ticket of Susila Devi where Dr. V. K. Murty has mentioned about early history of her illness that she was suffering from diabetes since 3 years and hypertension for five years prior to her treatment in Gupta Nursing Home on 11-12-1994. It is not disputed that Sushila Devi suffered from paralytic stroke due in her left uppoer and lower limbs due to diabetic mellitus and hypertension. The District Forum held that as per medical science paralytic stroke can occur at any time without prior suffering from diabetes and hypertension. Even after paralytic stroke, Sushila Devi lived for about 5 years. In the circumstances, she cannot be charged for suppression of material facts as alleged. District Forum also dealt with that the Doctor appointed by L.I.C. for medical check-up of Sushila Devi prior to the policy did not disqualify to enter into Asha Deep Policy on the ground of illness. District Forum did not take into confidence Exhibits A/3 to A/6 and A/9 relied on by the L.I.C. (Opposite Parties) and held that Opposite Party Nos. 1 and 2 have caused deficiency in service in repudiating the claim of the complainant nandulal. Accordingly, vide order dated 25-06-2002 in C.D. Case No. 34 of 2000, the District Forum, Boudh directed Opposite Party No. 2 to pay to Nandulal rupees 1,10,000/- including 50% of the sum assured under said policy, rupees 30,000/- towards 10% of the sum assured from 06-10-1996 till 25-07-1999, Bonus rupees 30,000/- from the date of ailment i.e. 05-12-1994 to the date of death of Sushila Devi on 25-08-1999, with 18% interest per annum from 25-08-1999 till actual payment and in addition rupees 2,000/- towards the cost of litigation. This order has been assailed by the Opposite Party Nos. 1 and 2 in C.D. Appeal No. 454 of 2002. 7. We have heard the Learned Counsels appearing for the Appellants and Respondent No. 1 and perused the xerox copies of documents available in the record. 8. In both the Appeals, it was argued on behalf of the Appellants (the Opposite Party Nos. 1 and 2 in C.D. Appeal No. 454 of 2002. 7. We have heard the Learned Counsels appearing for the Appellants and Respondent No. 1 and perused the xerox copies of documents available in the record. 8. In both the Appeals, it was argued on behalf of the Appellants (the Opposite Party Nos. 1 and 2 of the C.D. cases) that the District Forum has committed gross illegality and gross injustice in not believing and in not taking into confidence the report of Dr. V. K. Murty, the Asst. professor and Head of the Department, Neurology, v. S.S. Medical College, Burla that Sushila Devi was suffering from hypertension and diabetic mellitus 3 to 5 years prior to the said policy when the cause of death of Sushila Devi has direct nexus with the aforesaid ailment. Had the District Forum relied upon the aforesaid part ailment history mentioned by Dr. U.K. Murty mentioned in the Midical Attendant Certificate, the District Forum would have agreed with the Appellants that Sushila Devi had suppressed material facts in respect to her such illness and therefore, said policy is void. The Appellants after necessary investigation and without any malafide intention have repudiated the claim. The Learned Counsel for the Respondent No. 1 in both the Appeals has argued in support of the findings of the District Forum. None appeared for Respondent No. 2 in both the Appeals. 9. Therefore, the points to be decided in the appeal are as to how far the District Forum is justified in not relying upon the aforesaid intimation of Dr. U.K. Murty about the part illness history viz suffering of diabetic mellitus for 3 years and hypertension for 5 years prior to entering into the Asha Deep Policy and whether the Appellants are justified in repudiating the claim of Sushila Devi due to suppression of fact about said earlier sickness which are the cause of her death. 10. In respect to the aforesaid earlier part it may be stated that Sushila Devi has not mentioned in the proposal from about suffering from diabetes and hypertension for any period of time before she entered into the Asha Deep Policy. The Doctor from the side of the L.I.C. has also not stated in the fitness of health certificate of Sushila Devi at the initial stage of starling of policy in respect to suffering from aforesaid ailment by her. Dr. The Doctor from the side of the L.I.C. has also not stated in the fitness of health certificate of Sushila Devi at the initial stage of starling of policy in respect to suffering from aforesaid ailment by her. Dr. H.K. Mohapatra, M.D. Asst. Surgeon S.D. Hospital, Boudh, except stating in his Medical Attendant Certificate dated 10-02-1995 that Sushila Devi was admitted into said hospital on 05-12-1994 and is having permanent paralitical stroke of left side upper limb and lower limb cause being hypertension and Diabetes Mellitus, he denied about early history of alike ailments of Sushila Devi. Undisputedly Sushila Devi was treated by Dr. U.K. Murty in the Gupta Nursing Home at Burla during the period from 11-12-1994 till she was discharged on 15-12-1994. Dr. U.K. Murty has reported on 21-03-1995 in the Medical Attendant Certificate that Sushila Devi is permanently disabled in respect to her left upper and left lower limbs due to paralytical stroke cause being hypertension and diabetes mellitus. In Sl. No. 2(ii) of his said report, Dr. U.K. Murty has stated that she was suffering from diabetes for 3 years and hypertension for 5 years as per the past history of illness. Relying upon this report as well as the confidential enquiry report of the L.I.C., the Appellants allege suppression of past illness of by Sushila Devi while entering into the policy. No other reliable proof or evidence are available to corroborate the aforesaid history of past illness mentioned by Dr. Murty. In said report, Dr. Murty has admitted at the same time that she has not consulted with him nor details of consultation with competent doctors are available with him. Therefore, Dr. Murty has neither personal knowledge nor he has seen any authenticated reports of competent doctors about suffering of diabetic mellitus and hypertension by Sushila Devi for 3 and 5 years respectively. In such circumstance the aforesaid past illness history reported by Dr. U.K. Murty is not at all a proof in respect to suffering of diabetes mellitus and hypertension by Sushila Devi since 3 to 5 years. Therefore, Sushila Devi has not concealed about her past illness when she entered into the contract of Asha Deep Policy. Further, the Appellants have neither produced nor proved the confidential enquiry report in this respect. U.K. Murty is not at all a proof in respect to suffering of diabetes mellitus and hypertension by Sushila Devi since 3 to 5 years. Therefore, Sushila Devi has not concealed about her past illness when she entered into the contract of Asha Deep Policy. Further, the Appellants have neither produced nor proved the confidential enquiry report in this respect. According to Medical Science, diabetes and hypertension may appear suddenly due to various reason and may disappeal if proper tretment is given in time. Therefore, these are casual illness and while entering into L.I.C. policy if assured in the worst case, has not disclosed about temporary suffering of this type of sickness it shall not amount to violation of the term of policy. The Learned Counsel for Respondent No. 1 argued with reference to a decision of the Karnatak State Commission reported in 1996 3 C.P.J.P. 528 that if insured suppressed about suffering from hypertension which is a casual ailment, repudiation of claim due to suppression of this fact would amount to deficiency in service. He has also relied on a decision reported in 1996 1 C.P.R. 129 to the effect that the insured is not required to disclose casual ailment and repudiation of claim by L.I.C. without proving that insured was aware about suffering from cancer, is bad. He has relied upon another decision of the Harayana State Consumer Commission reported in 1996 3 C.P.J. 495 to the effect that Diabetic Mellitus is not a complicated disease in disclosing which L.I.C. will not allow Insurance Policy. A mere fact that insured lived for 31/2 years after getting himself into the Insurance Policy itself enough to prove that the ailment which was suffered by him was neither complicated nor serious one. Even the L.I.C. doctor during check-up has not disqualified the proposer of policy. Therefore, repudiation of claim due to suppression of fact of suffering of Diabetic Mellitus amounts to deficiency in service. However, no materials or evidence are forthcoming about early history of diabetic mellitus and hypertension of Sushila Devi and sushila Devi has suppressed the same while entering into the policy. Though undisputedly Sushila Devi died in the S.C.B. Medical College on 25-08-1999 the day she was admitted there yet the cause of death has not been stated nor it is related with said paralytical stroke of left upper and lower limbs. Though undisputedly Sushila Devi died in the S.C.B. Medical College on 25-08-1999 the day she was admitted there yet the cause of death has not been stated nor it is related with said paralytical stroke of left upper and lower limbs. After the said paralytical stroke, she had lived for about 5 years. Therefore, assuming in the worst case that Sushila Devi had knowingly not disclosed about her earlier suffering from diabetic mellitus and hypertension repudiation of claim on this ground is improper. The authority is the decision of the Hon'ble Apex Court reported in Life Insurance Corporation of India and Others Vs. Smt. Asha Goel and Another, . In view of the analysis made above and the decisions of the State Commissions and the Hon'ble Apex Court referred to above, even if the insured has knowingly suppressed about earlier suffering from diabetic mellitus and hypertension while entering into Asha Deep Policy, repudiation of genuine claim by the L.I.C. is improper. In the present case, the insured has neither concealed nor suppressed about suffering of such illness prior to entering into such policy. It has been proved beyond doubt that insured Sushila Devi became permanently disabled in respect to her left upper and lower limbs due to paralytical stroke during the existence of Asha Deep Policy. Therefore, the repudiation of her insurance claim and after her death, the repudiation of other half of the claim by Nandulal by the Appellants is against the principle of natural justice and illegal. By repudiating their genuine insurance claim, the Appellants have caused deficiency in service. Taking into consideration the above materials, the District Forum, Boudh has passed a reasoned order dated 18-03-1997 in C.D. Case No. 43 of 1996 that the Appellants have caused deficiency in service to the complainant Sushila Devi in refusing to award 50% of the assured amount under the policy. Therefore, we find no justification to interfere with the District Forum's order directing the Respondents to pay a sum of rupees 1,00,000/- along with other expenses of rupees 5,000/-. The District Forum in C.D. Case No. 34 of 2000 has also passed a speaking order that Nandulal, the complainant and husband of Sushila Devi, is entitled to get rest 50% of the sum assured being the nominee and husband of said Sushila Devi after her death on 25-08-1999 with other benefits and cost of litigation. The District Forum in C.D. Case No. 34 of 2000 has also passed a speaking order that Nandulal, the complainant and husband of Sushila Devi, is entitled to get rest 50% of the sum assured being the nominee and husband of said Sushila Devi after her death on 25-08-1999 with other benefits and cost of litigation. The Appellants haveing repudiated balance amount, which is 50% of the sum assured under the said policy, have caused deficiency in service. In these circumstances, we confirm the aforesaid impugned orders of the District Forum in C.D. Case No. 43 of 1996 and C.D. Case No. 34 of 2000. 11. In the result, both the Appeals are dismissed on contest against Respondent No. 1 and on ex parte against Respondent No. 2 without costs. 12. Records received from the District Forum may be sent back forthwith. Subash Mahtab, Member 13. I agree. 14. Appeal dismissed Final Result : Dismissed