JUDGEMENT
M.THANIKACHALAM, J. -
(1.) The opposite parties are the appellants.
2.The complainant?s husband, Sathasivam had insured his life, in the year
1995, for Rs.1 lakh under policy No.761747798, having paid the premium.
Due to massive heart attack, he died on 4.5.95, and the complainant being
the nominee, claimed the amount, lodged claim, furnishing necessary
particulars, and documents. But the opposite parties, repudiated the
claim, as if the deceased had suppressed the material facts, and
therefore the policy is null and void, which is incorrect. Issuance of
notice also not revoked the opposite parties, to rectify their
deficiency, proceeded by negligence, thereby causing mental agony to the
consumer, and therefore she is constrained to file this case, for the sum
assured with interest, alongwith compensation of Rs.5000/-.
3.The opposite parties, admitting the policy, resisted the case,
contending that because of the early death claim, investigation
conducted, which revealed that the assured had suppressed the material
facts, regarding his health viz. Diabetes mellitus with myocardial
infarction, which was the cause of the death, and based upon this,
revealed fact, which was not disclosed in the proposal, claim was
repudiated justifiably, legally, as well a factually, will not come
within the meaning of negligence, or deficiency, thereby praying for the
dismissal of the complaint.
4.The District Forum, based upon the pleadings, supported by affidavits,
as well as on the basis of the evidence given by a doctor, who had issued
a certificate in favour of the opposite party, came to the conclusion,
that the suppression of material facts, regarding the health alleged, is
not proved and placing merely upon a certificate, it is impossible to
conclude that the opposite party had discharged its burden of proof. In
this view, repelling the defense, based upon admitted policy, directed to
pay the sum assured, with interest, as claimed alongwith compensation of
Rs.5000/-, with cost of Rs.2000/-, as per order dt.24.10.2008, which is
impunged in this appeal.
5.The complainant?s husband, by name Sathasivam, giving Ex.B1 proposal
dt.24.2.1995, had taken an Endowment Life Insurance Policy under
Ex.B2,for the sum assured Rs.1 lakh, w.e.f. 28.2.1995, agreeing to pay
half yearly premium of RS.2836/-, having the maturity period of
28.2.2015. Unfortunately, the assured died on 9.5.1995 i.e., within 3
months, or so, due to heart attack, as disclosed by the death
certificate. The complainant being the nominee of the assured, lodged a
claim, based upon the policy. Because of the early death, the opposite
parties suspecting some fowl play viz. that there should be some
suppression, investigated the matter, which according to them, revealed
suppression of material facts. Therefore, under Ex.A5, communication
dt.11.4.1997, they have repudiated the claim, denying their liability,
labeling the agreement of insurance as void. Thereafter, since the
nominee was unable to get the amount, approached the consumer forum,
obtained a favourable order, which is impugned in this appeal.
6.According to the complainant, her husband died due to massive heart
attack, which is also so reported in the claim form. In the medical
attendance certificate, the complainant has not given any details about
the treatment if any, had taken by the assured. But the opposite party,
purely relying upon a certificate issued, "to whomsoever it may concern"
dt.17.10.1995, have repudiated the claim, on the basis that the deceased
was suffering from diabetes mellitus, with myocardial infarction, as well
known hypertension during 1993-94, which was suppressed in the proposal
form. The proposal form, Ex.B1, does not disclose or the assured has not
disclosed that he was suffering from any disease, and infact for all the
queries, pursuant to the health, as well as to taking treatment, he
reported in negative, certifying his health condition was good. The
doctor, examined the assured also, appears to have certified that the
assured was not suffering from any disease, or any problem, and it is not
the certificate given on oral representation by the assured, whereas it
was the certificate given by the doctor, who was under the pay role of
LIC of India. Thus, it is seen, neither in the proposal nor in the
medical examination, the complainant has informed about his health or
about his taking treatment elsewhere. But as per the certificate,
obtained by the opposite parties on 7.10.1995, Sathasivam was suffering
from Diabetes Mellitus, with myocardial infarction, being known
hypertensive during 1993-94. Proposal is dt.24.2.1995. Ex.B9 does not
disclose that the proposer/assured had taken treatment, as inpatient or
otherwise, continuously, even in the year 1995, at the time of proposal
also. But under the heading Personal History, the first question to be
answered by the assured is the treatment taken if any, during the period
of 5 years, prior to the date of proposal in this case viz. 24.2.1995. If
Ex.B9 is to be taken as correct, then there cannot be any difficulty to
come to the conclusion, that the assured had suppressed the material
facts, since question were framed expecting the answers, that should be
construed as material facts.
7. It is the trait law that the burden is upon the LIC to prove the
suppression of material facts. Except Ex.B9 certificate, they have not
produced anyother documents such as case records, prescription, or
inpatient record etc., indicating Sathasivam was taking treatment, which
he ought to have disclosed at the time of proposal. The doctor, who has
given Ex.B9, has been examined as witness.
8. The learned counsel would contend that Ex.B9, coupled with the
evidence given by the doctor, would suggest positively, that the assured
had suppressed the material facts. Admittedly, after the death of the
assured alone, when claim was lodged, Ex.B9 was obtained, though it is
earlier. Ex.B9 would indicate, that Sathasivam was taking treatment as
OPD in 1993-94. In the absence of any records maintained by the doctor,
it is not known, on what basis doctor has issued Ex.B9. If the doctor had
maintained the case record, and that was produced, then we can say with
certainty that on perusing those records, doctors should have issued
Ex.B9. When the doctor was questioned, he had expressed his inability,
what kind of diagnosis he has made, and what was the prescription given
etc., further confirming, it is also not possible for him to say, how
many times, Sathasivam came to him for treatment. He has also expressed
his inability, to ascertain Ex.B9 treatment, since he deposed he used to
give certificate on verification of records, not otherwise. Admittedly,
no case record has been produced as if CW1 had tested the assured, or
Sathasivam had taken treatment for diabetes or myocardial infarction, or
Hypertension as the case may be. Therefore, we feel, as rightly held by
the District Forum, it may not be possible to accept Ex.B9, as well as
oral evidence of CW1, in order to say with certainty that the assured had
suppressed the material facts, regarding his health. No other
investigation report also produced, as if he was taking treatment
continuously, or he was taking medicine elsewhere etc. Under the above
said circumstances, we are of the considered opinion, the insurance
company failed to discharge its burden of proof, in proving the
suppression of material facts, and therefore the repudiation should be
construed as negligence, followed by deficiency.
9. An attempt was made to say that the claim is barred by limitation. The
death was on 9.5.1995, immediately claim lodged, repudiated on 11.4.1997.
The case came to be filed on 1.10.1997. Till date of repudiation, the
nominee was under the impression that his claim is under process, and she
had no cause of action to proceed before the Consumer forum, though death
had taken place on 9.5.1995. Thus we conclude, the case is in time from
the date of repudiation. The District Forum, considering all the above
facts, has rightly come to the conclusion, in fixing the deficiency, for
which finding, we affix our seal of approval.
10. The complainant had claimed interest @18% p.a, and adding the same,
she had claimed a total sum of RS.1,41,400/-, calculating the rate of
interest @18%, which appears to be not proper. The District Forum,
granting interest @18%, upto the date of filing of the case, then
granting 9% i.e., granting interest on interest, in addition to
compensation also, are all not permissible. Hence the amount should be
modified, according to the assured amount, with reasonable interest of 9%
p.a., from the date of repudiation.
11. In the result, the appeal is allowed in part, modifying the order of
the District Forum in CC.273/1997, dt.24.10.2008, directing the opposite
parties to pay the sum assured under the policy Rs.1 lakh, with interest
thereon at 9% p.a., from the date of repudiation, viz. 11.4.1997, till
realization, with cost of Rs.2000/-. There will be no order as to cost in
this appeal.;