SATNAM SINGH v. AEGON RELIGARE LIFE INSURANCE CO. LTD.
SATNAM SINGH v. AEGON RELIGARE LIFE INSURANCE CO. LTD.
SATNAM SINGH
…Appellant
AEGON RELIGARE LIFE INSURANCE CO. LTD.
…Respondent
Case No: REVISION PETITION NO. 462 OF 2015
Date of Judgement: 06 December 2023
Judges:
DR. INDER JIT SINGH
PRESIDING MEMBER
For Appellant: MR. SIDDHARTH MITTAL, MR. ABHIJIT UARSHNEY, ADVOCATES
For Respondent: MR. PRAVEEN MAHAJAN, MS. VRINDA, MR. KUNAL NEMA, ADVOCATES
Facts:
Arguments: Complainant:
No nexus between death and disease allegedly concealed. Deceased died natural death. Burden on insurance company to prove fraudulent concealment. No treatment records produced. Findings based on assumptions. State Commission wrongly concluded deceased had tumor. Report shows inflammatory granuloma, not tumor. Error in doubting hospital report when compounder examined it.
Insurance Company:
Referred Laws and Sections:
Section 21(b) Consumer Protection Act 1986. Section 45 Insurance Act 1938. Judgments in Sulbha Prakash Motegaonkar vs LIC, Kokilaben Narendrabhai Patel vs LIC, etc.
Case Laws Referred:
No case laws were referred in the order.
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Full Text of Judgment:
1. The present Revision Petition (RP) has been filed by the Petitioner against Respondents as detailed above, under section 21 (b) of Consumer Protection Act 1986, against the order dated 05.09.2014 of the State Consumer Disputes Redressal Commission,Haryana (hereinafter referred to as the ‘State Commission’), in First Appeal (FA) No. 496 of2013 in which order dated 28.02.2013 of Panipat District Consumer Disputes Redressal Forum (here in after referred to as District Forum) in Consumer Complaint (CC) No. 115 of2012 was challenged, inter alia praying for setting aside the impugned judgment and order dated 05.09.2014 passed by the State Commission, Haryana at Panchkula in FA/496/2013 and for calling for the records of the case bearing CC No. 115 of 2012 filed before the District Forum.
3. Brief facts of the case, as emerged from the RP, Order of the State Commission, Orderof the District Forum and other case records are that:-
Palvinder Singh (minor) son of complainant/petitioner herein got insured by the complainant from the agents of Respondent/insurance company on 02.04.2010 vide policy No. 100311723947 for a sum of Rs.6,30,000/- and after thoroughly checkingthe complete body of deceased Palvinder Singh and after being satisfied that thedeceased was quite hale and healthy, the complainant/petitioner here in deposited the premium instalments of Rs.21,000/- on 29.03.2010 and another premium ofRs.21,000/- on 24.04.2011. Palvinder Singh died on 08.07.2011 at Safidon due tonatural death as per medical report submitted by Sairam Clinic Primary Health Centre,Safidon. There was no symptom of any kind of disease at the time of death of deceased Palvinder Singh. Information of death of Palvinder Singh was given by the complainant on 23.08.2011 to the agent of insurance company at Panipat. It was assured by the agents that the entire amount of above insurance policy along with bonus will be paid to the complainant. After some days some officials of the insurancecompany came to the house of the complainant at Safidon and demanded policy papersand premium receipts and assured the complainant that the insurance claim would besettled very soon and disbursed to the complainant. On 22.09.2011 the insurance company repudiated the claim. The insurance company sent an amount of Rs.31,137/-through a cheque dated 24.08.2011 towards the fund value against the insured policyof the deceased. Thereafter the complainant requested the Respondent/insurancecompany to pay the entire claim of the policy but they refused to pay the same. Hence,the complainant filed complaint before the District Forum on 25.04.2012.
4. Vide Order dated 28.02.2013, in the CC 115 of 2012, the District Forum allowed the complaint with a direction to opposite parties to pay Rs.6,30,000/- with interest @8% per annum from the date of filing the complaint till its realization. District Forum also granted Rs. 2200/- towards costs of litigation and granted 30 days’ time from the date of order, to comply with the order.
5. Aggrieved by the said Order dated 28.02.2013 of District Forum, Respondent appealed in State Commission and the State Commission vide order dated 05.09.2014 in FA No.496of 2013 has allowed the appeal and set aside the order dated 28.02.2013 passed by theDistrict Forum.
6. Petitioner has challenged the said Order dated 05.09.2014 of the State Commissionmainly on following grounds:-
i. The order passed by the State Commission is illegal, arbitrary and contrary to well settled principle of law and hence is liable to be set aside. The State Commission failedto consider that there was no nexus between the death and disease which has been allegedly concealed by the Petitioner. The deceased died a natural death which is also certified by the doctor of Sri Ram Hospital. It is for the Respondent-Insurance company to prove fraudulent concealment and suppression of material facts. There is no concealment of material facts proved by the Respondent and they are merely alleging concealment on the basis of a MRI scan which was taken 10 years prior to the deathwhich also does not show or prove any treatment taken for disease and merely shows that there was ring enhancing which could be merely because of a fall. The Respondents are under law required to prove the allegations of fraudulent concealmentand in the absence of the same, the State Commission merely on the letter dated 28.03.2003, erred in allowing the appeal of the Respondent. The State Commission failed to see that there is no concealment of material facts in as much as the Respondent failed to prove that the deceased was ever treated for tumor. The report dated 28.03.2003 being relied upon by the Respondent to show that the Petitioner has not made full disclosure does not in any manner shows that the Petitioner was ever treated for tumor or cancer. The said report merely concluded that inflammatory granuloma right parietal lube was found which could be tuberculoma. It is submitted that wheneveran inflammation occurs, the tissue affected respond producing an inflammatory exudate and a granuloma is formed. A granuloma in the brain is nothing but a localized area of inflammation. It is submitted that it can also be due to tuberculoma orneurocysticercosis but the same cannot be concluded and was not concluded in the report. On the other hand the electroencephalogram report clearly shows that the graphwas normal. It is submitted that in such circumstances the finding recorded by the State Commission are completely based on assumptions and presumptions. The Respondentdid not produce any other documents to suggest that any treatment was taken by the Petitioner and in such circumstances without any evidence the State Commission erredin setting aside a well reasoned order of the District Forum.
7. Heard counsels of both sides. Contentions/pleas of the parties, on various issues raised in the RP, Written Arguments, and Oral Arguments advanced during the hearing, are summedup below.
7.1 Petitioner in addition to repeating what has been stated in para 6 under thegrounds, has contended that apart from MRI report, the Respondent had no other document to allege or plead that there was any non-disclosure by the complainant/petitioner here in. The District Forum while allowing the complaint held that apart from the medical report dated 28.03.2003, there was no evidence to even suggest continued illness of the insured for which he had taken any regular treatment and therefore held that it was not justified to repudiate the police on the ground of non-disclosure or mis-statement. The District Forum also held that the doctor vide itsreport Exhibit C-3 had concluded that the deceased died a natural death. The State Commission without considering the MRI report dated 28.03.2003 seems to conclude that the deceased was suffering from tumor. However, the report only reveals thatthere is a presence of a ring enhancing lesion in the right parietal lobe and that thelesion is surrounded by moderate degree of oedema. In the conclusion it was concluded that the findings are consistent with inflammatory granuloma right parietallobe, tuber culoma and neuro cysticercosis. Merely on the basis of MRI report it cannot be concluded that the deceased was at any time suffering from tuber culoma. The medical literature on diagnosis of intracranial tuber culoma clearly states that CT/MRI diagnosis of tuber culoma is largely presumptive in view of the non-specific appearance. The State Commission erred in shifting the burden on the Petitioner without considering that it was for the Respondent/Insurance Company to provefraudulent concealment and suppression of material facts.
8. We have carefully gone through the orders of the State Commission, District Forum,other relevant records and rival contentions of the parties. In this case OP Insurance Company has repudiated the claim on the grounds of suppression of material facts relating topre-existing ailments. Complainant had argued that he being an illiterate person, did not know the intricacies of the insurance policy, the facts were not explained to him in detail, soit cannot be presumed that he concealed any fact or played any fraud. According tocomplainant even as per averments of Opposite Party, the tumor was detected on 28.03.2003 whereas death took place on 08.07.2011. There was no nexus between the disease and thedeath. As per death certificate, it was a natural death. State Commission disagreeing withthe contentions of the complainant has observed that
“he thumb marked the proposal form atthe time of insurance. He cannot allege that the terms and conditions were not read over tohim because as per this insurance policy he deposited the premium.”
We do not agree withthese observations of the State Commission as it is a normal practice for an illiterate personto put his thumb impression, and in many cases even for an educated person to put hissignatures on proposal form containing detailed terms and conditions running into few pageswithout fully understanding them or reading them, but in good faith based on broadunderstanding as told by the agent/officials of Insurance Companies. Of course, a person whosigns such forms/documents without reading or understanding them, does so at his own risk as he cannot later on say that he did not agree with the contents or terms and conditions ofsuch form/document. State Commission further observed in its order that “as per Exb. R-3the life assured was having a brain tumor. As per clause 6 of proposal form he denied that life assured was having any fumor etc… he was aware of this disease but did not disclose atthe time of insurance. As per certificate Ex. C-3 it cannot be presumed that it was a naturaldeath”. The reason for not accepting is ‘the certificate is not proved by the doctor whoissued it. AW2 claimed himself to be a compounder with the said doctor and proved thecertificate. More so Doctor Ravinder Singh as not a qualified doctor. He was only BAMS and did not conduct any post mortem examination to know the cause of death’. State Commission further observed that:
“…..Palwinder Singh was insured on 02.04.2010 whereas he died on 08.07.2011, just after payment of two instalments. Complainant might have been aware about the Tumour and just to have compensation this policy was obtained. When there is a very short time in between obtaining insurance policy and death, particularly when life assured was having tumour, the complainant is to clear the dust from the scene, otherwise presumption is to go against him.”
We do not agree with these observations of State Commission, ‘might have been aware’,which are based on assumptions rather than any definite evidence before it. Just because death happens within about 1½ years of taking policy and/or payment of two instalments, does not mean that complainant has done so with any malafide intentions. In an insurancecase, insurance companies are liable even if a mishap happens immediately after taking of policy, provided the claim is otherwise admissible under the terms and conditions of the policy.
9. Relying on the judgments of this Commission in Kokilaben Narendrabhai Patel Vs.Life Insurance Corporation of India 2010 CTJ 920 (CP) (NCDRC) and MarketingManager, LIC of India Versus Smt. S. Vijaya, CPC (1995) (10) 341, the State Commissionheld that since Complainant concealed the fact of previous disease at the time of obtaininginsurance policy, District Forum fell in error by allowing the complaint. Complainant on theother hand had placed reliance on the orders of this Commission in LIC Vs. Charanjit Kaur. IV (2011) CPJ 373 (NC), but the State Commission observed that Complainant cannotdeserve any benefit from the cited case law as the same is based on different facts.
10. District Forum in its order has observed as follows:-
“4………In order to discharge his onus opposite parties filed a medical report,copy of which is Ex.P3. This medical report is dated 28.03.2003. This is the report of Palvinder Singh whose examination of brain done when he was at the age of 10 years. It is mentioned in this report that C.T. study reveals the presence of a ringenhancing lesion in the right parietal lobe. It measures 1.35 x 1.01cms in maximumdimension n the axial plane and subcalvarial in position the lesion is surroundedby moderate degree of oedema. The remaining cerebral parenchyma appearsnormal. Rest of the portion in report has been shown as normal and conclusion isgiven C.T. Findings are consistent with inflammatory granuloma right parietallube. Further electroencephalogram (E.E.G.) Report is also placed on file. Exceptthis document nothing has been placed on file by opposite parties to prove thattreatment was continuing and insured was suffering from disease continuouslyform 28.03.2003. Insured died on 8.7.2011 after 8 years of this report. Ex.C3 byWhich doctor confirmed that Palvinder Singh died due to natural death. Ex.C3 wassupported by Affidavit Ex.CW2/B hence there is evidence that insured died in anatural death. Opposite parties did not produce any treatment record or any history of continuing illness of the insured for which he has taken regular treatment till the date of commencement of policy. Counsel of the opposite parties referred citation II (1992) CPJ 493 (NC) case titled Jagdish Prasad Dagar Versus Life Insurance Corporation, III (2008) CPJ Page 78 (SC) and further I(2007) CPJ248 case titled life insurance corporation of India Versus Kasturi Devi. In all these citations it is held that repudiation of policy is justified on account of non-disclosure and mis-statement of fact in proposal form related to material facts.
11. In Sulbha Prakash Motegaonkar and Ors. Vs. LIC of India, Civil Appeal No. 8245of 2015 decided on 05.10.2015, it was held by the Hon’ble Supreme Court that:
“We are of the opinion that the National Commission was in error in denying to the appellants the insurance claim and accepting the repudiation of the claim bythe respondent. The death of the insured due to is chaemic heart disease andmyocardial infarction had nothing to do with his lumbar spondilitis with PID withsciatica. In our considered opinion, since the alleged concealment was not of sucha nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified. Accordingly, we set aside the order passed by the National Commission and allowthe appeal. The respondent will accept the claim made by the appellants within a period of four weeks from today and make the due payment.”
12. In view of the foregoing, we are of the considered view that District Forum has given awell-reasoned order and we tend to agree with its observations and findings. State Commission went wrong in setting aside a well-reasoned order. We agree with the contentions of Petitioner herein that there was no concealment of material facts. Complainant has contended that State Commission went wrong in casting doubt on the report of Hospital on the ground that it has not been issued by the doctor who has issued it without considering that the same was proved by the person who was working as Compounder and doctor issuing the report had died in a road accident on 12.10.2012. In the given facts and circumstances of the case, we hereby set aside the order of the State Commission and restore the order of the District Forum. All payments as per order of District Forum to be paid by the Respondent herein to Petitioner herein within 30 days of this order, failing which, it willcarry interest @12% p.a.
13. The pending IAs in the case, if any, also stand disposed off.