K.C. Gupta, President:
1. Briefly stated the facts are that Sh. Mandeep Sharma, husband of Mamta Manu had obtained two policies from Life Insurance Corporation of India bearing Nos. 162286651 and 160953055 dated 14.10.2002 and 15.9.1997 for the amounts of Rs. 5 lacs and Rs. 25,000 respectively. He was a healthy person and was never admitted to any hospital prior to getting these policies issued in his favour.
2. It was next averred that he had honestly disclosed vide Annexure C-1 that he took liquor occasionally. Thereafter, he was thoroughly examined by the doctors of LIC itself and was held to be fit for getting the policies.
3. It was further averred that on 19.1.2003 he complained of weakness and was admitted in the Government Medical College and Hospital, Sector-32, Chandigarh. He was diagnosed suffering from jaundice and after a week i.e. on 27.1.2003 he was discharged vide discharge slip Annexure C-3 and certain medicines were prescribed which he had regularly taken.
4. It was next averred that on 5.2.2003 the condition of Mandeep Sharma deteriorated and he was admitted in the hospital. Unfortunately he expired on the same day. The appellant Smt. Mamta Manu widow of Sh. Mandeep Sharma lodged claim with Life Insurance Corporation in respect of above said two policies but the claim was repudiated vide letter Annexure C-4 on untenable grounds.
5. Alleging deficiency in service, two separate complaints were filed.
6. Opposite parties contested both complaints and stated that the policy of Rs. 25,000 bearing No. 160953055 dated 15.9.1997 had lapsed on account of premium due on December, 2001 to June, 2002 but it was revived on 31.7.2002 on the strength of personal statement regarding health made by him which statement was false and fraudulent as he was a known case of Alcoholic Liver Disease and was a habitual daily drunkard since more than 10 years prior to his death. Moreover, as per death certificate issued by Government Medical College and Hospital, Sector-32, Chandigarh, according to column No. 17 it was mentioned that he was habitual alcoholic for the last 10 years and thus claim was rightly repudiated as he had fraudulently made false statement and withheld material information regarding his health. Thus, they prayed that there was no deficiency on their part and complaint should be dismissed.
7. Complaint No. 804 of 2005 had been filed with regard to policy No. 162286651 for the sum assured of Rs. 5 lacs while complaint No. 805 of 2005 pertained to policy No. 160953055 for the assured sum of Rs. 25,000.
8. The District Consumer Forum-I, U.T. Chandigarh vide order dated 5.4.2007 dismissed both the complaints vide same order as common question law and fact was involved in both the complaints.
9. Aggrieved by the said order, complainant has filed two appeals bearing Nos. 511 of 2007 and 512 of 2007. Since, common question of law and facts is involved in both appeals, so both are decided by same order.
10. We have heard Mr. J.S. Puri, Advocate for appellant, Mr. Gaurav Bhardwaj, Advocate proxy for Mr. B.S. Walia, Advocate for respondents and carefully gone through the file.
11. Annexure C-1 is the proposal form for insurance of his own life which was filled by Sh. Mandeep Sharma on 15.9.1997 in which he stated that he was not suffering from any defect in health but he used to take 1-2 pegs of whisky occasionally. Annexure C-2 is photocopy of insurance policy issued on 29.9.1997 for a sum of Rs. 25,000 which is for fifteen years money back policy with accident benefit. These documents are in complaint case No. 805 of 2005. Similarly in complaint No. 804 of 2005 Annexure C-1 is proposal form filled up by Mandeep Sharma dated 14.10.2002. In it, he had mentioned that he occasionally used to take alcoholic drinks and also occasionally smoke. Otherwise he stated his state of health to be good. Annexure C-2 is insurance policy bearing No.162286651 issued on 21.2.2003 for a sum of Rs. 5 lacs and the date of proposal is 14.10.2002 while the date of last payment was 14.10.2021 and the expiry of term of policy was 14.10.2022.
12. The photocopy of discharge and follow-up card Annexure C-3 bearing C.R. No. 030103278 shows that Mandeep Sharma was admitted on 19.1.2003 in GMCH, Sector-32, Chandigarh and was discharged on 27.1.2003. He was diagnosed as ALD. In the medical note dated 5.2.2003 it is mentioned that jaundice appeared to have deepened i.e. he was having severe jaundice on 5.2.2003. The photocopy of the death report Annexure R2/1 dated 5.2.2003 which is issued by some doctor shows that Mandeep Sharma used to habitually drink alcohol for 10 years. A careful perusal of photocopy shows that originally it was mentioned as 3 years but by overwriting, it was mentioned to be 10 years. It is not signed by any doctor. One does not know who had made the death report. If it is made by Dr. Pankaj then affidavit of Dr. Pankaj has not been placed on file to assert that Mandeep Sharma used to habitually drink alcohol for the last 10 years. It is not known on what basis he had declared that he used to habitually drink alcohol for the last 10 years. There is no evidence on record that before issuance of two policies Mandeep Sharma was ever admitted to any hospital for Alcoholic Liver Disease or cirrhosis disease. It is not mentioned in the death report that who had given history that he was taking liquor for the last 10 years. There is another certificate whose copy is Annexure R/2/3 regarding hospital treatment . It is signed by a doctor, MD medicine and is Senior Resident. The name of doctor has not been mentioned. One does not know which doctor had signed it. His affidavit has not been placed on file. On what basis he had declared that he was chronic patient of Alcoholic Liver Disease is not known. Earlier it was mentioned in the treatment notes that his jaundice had deepened. It is not necessary that he was having jaundice due to excessive use of alcohol. He may have jaundice due to variety of reasons not certainly related to excessive taking of alcoholic. It is not the case that he totally denied that he did not take liquor but he had frankly stated that he occasionally used to take 1-2 pegs of whisky and smoke. This disclosure would have been taken by LIC on its guard and should have thoroughly got medically examined from its doctors. It has been admitted by respondents that Mandeep Sharma was medically examined before getting him insured. That certificate has not been produced on file to prove that he was taking excessive alcohol. There is no evidence that Mandeep Sharma knew earlier that he was suffering from Alcoholic Liver Disease or got treatment from any hospital before taking policy. Hence, it cannot be said that he had deliberately made incorrect statement or had committed fraud with the Life Insurance Corporation of India.
13. Moreover, there are affidavits of Chanan Singh and Niranjan Singh of Chandigarh who knew Mandeep Sharma for the last many years. Both of them had stated that he was not habitual drinker and to their knowledge he was never admitted to any hospital for the last 5 years preceding to his death. Even if it is presumed that he was having problem which was not discovered after diagnose also, then since he was not having any knowledge of the same, so, he could not be penalized for concealment of facts or any other mal practice.
14. There is another aspect of the matter. The documents of the hospital are not definite that he was suffering from ALD because the diagnosis was made on the basis of clinical examination and not by conducting certain tests. Thus the burden to prove that the deceased was suffering from Alcoholic Liver Disease prior to taking policy was on the Life Insurance Corporation which it has miserably failed to prove.
15. It is not necessary that every person who takes alcohol develops ALD. The document Annexure R/2/2 states that only 10-20% alcoholics develop ALD. Thus, there was no occasion of suppression of material facts.
16. The Honble National Commission in LIC of India v. Joginder Kaur and Ors., II (2005) CPJ 78 (NC)=2005 (1) CPC 52, held that reason given for repudiating the claim by the Insurance Company was that the insured had concealed the actual disease at the time of submitting proposal form as it was tried to justify that the insured was a chronic alcoholic for the last 15 years and has also history of jaundice is not justified as no evidence was adduced to prove that any doctor had treated the deceased for the disease and mere allegations are not sufficient. In the present case no affidavit of the doctor who had treated him earlier has been produced on file, nor, there is any piece of material evidence to support the contention that he was suffering from ALD prior to issuance of policy.
17. Therefore, in view of discussion above, we hold that District Consumer Forum had wrongly dismissed the complaints on surmises and flimsy grounds and as such impugned order dated 5.4.2007 is set aside.
18. Consequently both appeals are accepted with costs of Rs. 5,000 each and respondents are directed to pay Rs. 25,000 of one policy and Rs. 5 lacs of another policy with accrued benefits, if any, along with interest @ 9% p.a. from the date of rejection of claim vide repudiation letter dated 16.2.2004 till payment. The amount of interest shall also include compensation for mental agony and harassment, etc.
19. Copies of this order be communicated to the parties, free of charge.