1. This revision is directed against the order of the State Commission dated 13.12.2012 in FA No.1171/2012 whereby the State Commission, Haryana allowed the appeal preferred by the respondent/opposite party, set aside the order of the District Forum, Jind and dismissed the complaint only on the premise that the deceased insured had obtained the insurance policy by concealment of material fact.
2. We have heard the parties. It is undisputed that the deceased insured purchased a life insurance policy for a sum of Rs.1,50,000/- from the respondent/insurance company on 24.11.2008. The life insured died on 2.4.2010. The petitioner being widow of late Jai Prakash filed insurance claim which was repudiated vide repudiation letter dated 28.6.2010 on the ground that Shri Jai Prakash has obtained the insurance policy by concealing the material facts. Relevant part of the repudiation letter reads as under :-
"This refers to the claim intimation received by us on 7.5.2010, under the above
mentioned policy, in relation to the death of Mr.Jai Prakash.
Please accept our heartfelt condolences for the sad demise of Mr.Jai Prakash on
2.4.2010.
The above policy was issued on the basis of the application for insurance dated
20.11.2008 on the life of Mr.Jai Prakash (the life insured). In the said application
signed by the life insured question no. 5(c) of step 10 were replied in negative. For
your reference we are reproducing below the aforesaid questions and the replies
thereto in the application for insurance.
Step 10 Health Details of life assured and
proposer
Reply
Q 5 Have you ever had any of the following :
(c) Diabetes, thyroid disorders or any other
hormone disorder No
Our investigations have established that the life insured was suffering from
Rheumatoid Arthritis (on wysolone treatment) since prior to the application for
insurance. According to our records, such information was not disclosed in reply to
the specific questions in the application dated 20.11.2008 for the above policy. After
careful evaluation of all facts, documents submitted and circumstances in this case,
we have come to the conclusion that the replies to the aforesaid questions in the
application form are incorrect. Had such information been disclosed, our
underwriting decision(s) would have been different.
Despite making every attempt to consider the claim favourably, the facts regrettably
demonstrate that this is not a valid claim on the above grounds. We, therefore, regret
that we are unable to honour your claim and rescinding the above policy from
inception accordingly. Our inability shall be limited to Rs.22,123.09 i.e. payment of
Account value at the bid price on the next valuation date following the company''s
receipt and approval of notice and due proof of death.
Please find enclosed the claim payout cheque bearing no.000647 dated 23 June, rd
2010 for the sum of Rs.22.123.09 (Rupees twenty two thousand one hundred twenty
three and paise nine only) being full and final settlement of your claim under the
policy. Note that upon encashment of the above-mentioned the company will stand
discharged of all its liabilities under the policy."
3. Being aggrieved of the repudiation of the insurance claim, petitioner Smt.Shanti Devi raised
a consumer dispute which was contested. The District Forum, Jind on consideration of pleadings
and the evidence allowed the complaint and directed the respondent/opposite party as under :-
"Consequently, the opposite party is directed to pay the balance amount of
Rs.1,27,877/- (Rs.1,50,000/- minus Rs.22,123/-) within a period of 30 days from the
order of this case, in case of failure a simple interest @ 9% p.a. will also be paid
w.e.f. the filing of the complaint i.e. 6.12.2011 till full realization. Copies of order be
supplied to the parties under the rule. File be consigned to the record room."
4. Being aggrieved of the order of the District Forum, the respondent/opposite party preferred an appeal. The State Commission after going through the record and hearing the parties was of the view that the deceased insured had obtained the insurance policy by concealing the fact of his previous ailment. The State Commission thus, accepted the appeal, set aside the order of the District Forum and dismissed the complaint. This has led to the filing of revision petition.
5. Learned counsel for petitioner is not present and the proxy counsel has sought adjournment on the ground that he is indisposed. Therefore, we have gone through the record on our own and heard learned counsel for respondent/opposite party.
6. Stand of the petitioner is that the State Commission has failed to appreciate that the insured did not conceal any fact about his previous ailment while obtaining insurance policy. It is also pleaded that the State Commission ignored the fact with late Shri Jai Prakash was an illiterate person and the proposal form was filled by the insurance agent and he appended his signature thereupon without being informed about the contents of the proposal form.
7. Learned Shri Joy Dip Bhattacharya, Advocate for the respondent on the contrary has argued in support of the impugned order. He has contended that the State Commission has rightly relied upon the medical record pertaining to treatment of late insured at Pandit Bhagwat Dayal Sharma, PGIMS, Rohtak, wherein, it is recorded that as per history given by the patient, he was suffering from Rheumatoid Arthritis (joint pain) since long and he was on wysolone tablets, which is a steroid. In order to properly appreciate the contention of the parties, it would be useful to have a look on the repudiation letter 28.6.2010, relevant part of which is reproduced above.
8. On reading of the above, it is clear that the opposite party had repudiated the insurance claim because the life insured in response to the question 5 (c) relating to diabetes, thyroid disorders or any other hormonal disorder replied in the negative. From medical record relied upon by the respondent/opposite party, it is clear that as per history given by the life insured, he was an old patient of Rheumatoid Arthritis which is an auto immune disease and not a hormone disorder. Therefore, by no stretch of imagination, it can be said that the life insured gave a wrong answer to the question 5 (c) of the proposal form detailed in the repudiation letter.
9. Learned Shri Joy Dip Bhattacharya, Advocate submits that as per medical literature, prolonged use of wysolone tablet may result in hormonal disorder causing Cushing disease. In support of his contention, learned counsel for the respondent opposite party has referred to the Investigator Report of Sh. Devender Sharma as also the medical record of insured Pandit Bhagwat Dayal Sharma, PGIMS, Rohtak.
10. In the light of the above, the only issue which needs consideration is whether or not, the respondent opposite party was justified in repudiating the insurance claim filed by the petitioner? As per the repudiation letter, the ground for repudiation is that the insured gave a false answer to the question 5 ( c) in the proposal form calling upon the insured to inform whether he had suffered from any disease relating to diabetes, thyroid disorder or any hormonal disorder, which answer was given in the negative. In order to succeed in its plea, the onus lies heavily on the opposite party to prove that at the time of filling up the proposal form, the insured was aware that he was suffering from Cushing disease which is hormonal disorder. Thus, in order to find answer to this question whether or not the insured gave a false answer to the above noted question, it would be necessary to have a look on the photocopy of the medical record filed before the District Forum, copy of which has been filed today by learned counsel for the petitioner.
11. On perusal of medical record, we find that insured remained under treatment at Pandit Bhagwat Dayal Sharma, PGIMS, Rohtak, initially as an OPD patient and thereafter as an inpatient during the period 17.03.2010 till the date of his death on 02.04.2010. There is nothing in the medical record to show that the insured or his family member gave any history which would lead to the suggestion that the insured was aware that he was suffering from Cushing disease and which is a hormonal disorder and he concealed this fact by giving a wrong answer to question no.5 (c) of the proposal form in the negative. Even the report of the investigator does not point out any evidence which may lead to the conclusion that at the time of submitting proposal form, the insured was aware that he was suffering from Cushing disease. Thus, it cannot be said that the insured obtained the insurance policy by concealing material fact regarding his ailment as a result of hormonal disorder. Thus, in our view the State Commission has committed a grave error in appreciating the facts which has resulted in injustice to the petitioner.
12. In view of the discussion above, we allow the revision petition, set aside the impugned order of the State Commission and restore the order of the District Forum.
