Life Insurance Corporation Of India, Through Its Secretary Legal Petitioner(S) v. Manish Gupta (S).

Deepa Sharma, Member (Presiding):—

I.A. No. 20304/2017 (condonation of delay)

The respondent states that application be allowed with heavy cost.

In view of this objection, I.A. No. 20304/2017 is hereby allowed on payment of cost of Rs.10,000/- to be paid to the respondent.

R.P. No. 3894/2017

The present revision petition has been filed against the order of the State Commission dated 09.08.2017 passed in Appeal No. 731/2016. This appeal was filed by the petitioner challenging the order dated 14.06.2016 of the District Forum in C.C. No. 369/10/2015 filed by the respondent.

2. The admitted facts of the case are that the respondent had purchased Health Plus Plan Policy dated 25.06.2008 from the petitioner. He suffered from Rheumatic Heart Disease and was admitted in Fortis Hospital, Mohali with this condition on 12.07.2009 and remained admitted till 22.07.2009. He spent about 2,21,990/- on his treatment. After his discharge, he submitted his claim with the petitioner which was repudiated on the ground that respondent had pre-existing disease and he had concealed this fact at the time of taking the policy.

3. After recording evidences on record and dealing with the contentions and arguments of the rival parties the District Forum issued the following directions:

7. In view of the facts discussed above, we are of the confirmed view that he OPs have wrongly repudiated the claim of the complainant, as such, the complaint of the complainant is allowed and the OPs are directed to comply with the following directions within thirty days from the communication of this order:

To pay a sum of Rs. 2,21,990/- to the complainant along with simple interest @9% per annum from the date of repudiation of claim i.e. 29.10.2009 to till the date order.

Also to pay a sum of Rs. 10,000/- on account of compensation qua causing mental harassment etc.

And to pay a sum of Rs. 10,000/- on account of costs of litigation etc. incurred by the complainant.”

4. In the appeal filed by the petitioner, the State Commission while dismissing the appeal confirmed the order of the District Forum.

5. This order has been impugned before me on the ground that medical treatment record of the respondent clearly shows against the column ‘past history’ that he was suffering from Rheumatic Heart Disease since childhood. It is submitted that this fact had been concealed by the respondent while submitting the proposal form and taking the policy. It is submitted that this fact is sufficient to repudiate the policy.

6. It is however argued by the respondent in person that he was not aware of such disease and that he never took any treatment for the said disease and that his disease was diagnosed for the first time after his admission in the hospital and he never had any symptoms of the said disease.

7. I have heard the arguments and perused the relevant records.

8. The only issue before this Forum is whether the respondent had concealed the fact from the knowledge of the petitioner at the time of taking the policy and thus, the petitioner had rightly repudiated the claim and that the finding of facts of both the Fora below that the respondent had no such knowledge, is contrary to the facts proved on record. There is no dispute to the settled preposition of law as laid down in several pronouncements that the burden of proof that insured had suppressed material facts is on the petitioner as held by the Hon'ble Supreme Court in the case of Life Insurance Corporation Of India v. Smt G.M Channabasamma.. Chamaba, AIR 1991 SC 392 and also in Life Insurance Corporation of India v. Asha Goel, (2001) 2 SCC 160. In the case of Life Insurance Corporation of India v. Badri Nageshwaramma - II, (2005) CPJ 9 (NC), this Commission has clearly stated that not only the burden is upon the Corporation to prove that the insured had made a false representation and suppressed material fact, it has to be proved by producing cogent evidence. In that case, this Commission rejected the contention of the Corporation that the insured had concealed the material fact on the ground that the Corporation had failed to examine the medical officer. In that case, the Corporation had relied upon a letter written by the doctor to Branch Manager of LIC that deceased used to attend his clinic as outpatient for getting injection Neurobion as advised by Santosham Chest Hospital of Madras and that he was a known diabetic. The Commission held that such a certificate without any affidavit of the doctor in support of it cannot be the basis for repudiating the claim. In another matter i.e. Life Insurance Corporation of India v. Joginder Kaur - II, (2005) CPJ 78 (NC), this Commission has held that

“unproved case history recorded by some person on the date of admission of Shri Bachan Singh, the deceased, would not be cogent and convincing evidence to repudiate the claim unless it was coupled with medical report for the treatment prior to submission of the proposal form.”

9. The Commission has further held in the said case that:

“it has also not been proved that patient has brought any letter from any doctor at the time of admission and that the doctor was examined to prove his previous ailment to justify the submission that wrong statement was made by the deceased.”

10. In another matter Life Insurance Corporation of India v. Dr. P.S. Aggarwal - I, (2005) CPJ 41 (NC) this Commission held as under:—

“3. The onus to prove that there was material concealment of any disease, which directly proved fatal, was on the petitioner-insurance company. In addition to above, the petitioner was supposed to prove that at the time of taking policy, the person who gave the information, knew about such a disease and he withheld it with an intention to defraud the insurance company.

4. In the present case, it is evident that the information collected from the records of Apollo Hospital is not primary piece of evidence but the primary evidence would be of the doctors who recorded the information in Discharge Summary. The doctor who prepared the Discharge Summary has not been produced.”

11. In the case of Life Insurance Corporation v. P.R. Sumangala - III, (2018) CPJ 106 (NC), this Commission has held as under:—

“it was pointed out by the learned counsel that the responsibility to prove the suppression of fact of pre-existing diseases lies solely on the insurance company. In the present case, no treatment record or any other evidence has been produced by the petitioner that the insured was getting treatment for diabetes prior to filling of the proposal form. All the treatment records filed by the petitioner/opposite party relate to his treatment when the policy holder was admitted in the hospital where he finally died.”

12. In the present case, in order to prove that the respondent has concealed the material information of existence of a pre-existing disease prior to filling proposal form, the petitioner has relied on the treatment record of the respondent after he was admitted in the hospital for his treatment. Therein, doctor had recorded against the ‘past history’ column “K/C/O Rheumatic heart disease since childhood”. It is apparent that the doctor has not been examined in order to prove as to how the said information has been recorded by the doctor in his report. This noting also does not show that this has been recorded on the basis of information given by the patient. Moreover, on the same document against the column ‘diagnosis’ three different diagnosis for the present history of ailment for which the respondent was admitted in hospital has been given. This has a wide range of diagnosis starting from ‘Rheumatic Heart Disease’, ‘mild mitral stenosis’, ‘severe mitral regurgitation’, ‘concentric left ventricular hypertrophy’, ‘severe pulmonary arterial hypertension’, ‘severe tricuspid regurgitation’, this diagnosis certainly is based on the investigation into the condition of the respondent done earlier in June 2009 on his admission in the hospital. Except this document, no evidence has been produced by the petitioner to prove that respondent was aware of existence of his disease and he was taking treatment for this disease.

13. Thus, it is clear that petitioner has failed to discharge the burden placed upon it. There exists no ground to set aside the impugned order. There is no illegality and perversity in the impugned order.

14. The Revision Petition No. 3894/2017 has no merit and is, dismissed with no order as to costs.