Late Shri Inderpal Singh husband of the complainant/respondent obtained an insurance policy from the petitioner company in his lifetime. He having died on 25.03.2009, about four months after obtaining the policy, the complainant/respondent, she being her nominee, submitted a claim for payment of the benefit in terms of the insurance policy taken by her husband. The claim was repudiated vide letter dated 15.06.2009 which to the extent, it is relevant, reads as under:
'This has reference to the claim dated 25th May 2009 submitted by you for the benefits under the policy. The above policy was issued on the basis of an application for insurance dated 30th November 2008 by Mr. Inderpal Singh (the 'Life Assured') on his own life. In the said application for insurance, the Life Assured had replied in the negative to question No. (IX) (A) 5 (a), (D) 2 (a), (b), (c) and 3 (e). For your ready reference, we are reproducing below the aforesaid question and the reply thereto in the application for insurance:
(IX) Medical and Personal History of the Life to be Insured.
1. Lifestyle information
5 (a) Do you consume alcohol? ........................ No.
(D) MEDICAL INFORMATION
2 (a) Consulted any doctor or other health practitioner except for common cold, influenza lasting less than 4 days?................ No.
(b) Submitted to ECG, X-rays, blood test or other tests? ......... No.
(c) Attended or been admitted/advised to be admitted to any hospital or other medical facility? ................... No.
3 (e) Ulcer, colitis, chronic diarrhea, hepatitis or jaundice or other liver or digestive disorders? ............................ No.
Further, in the Medical Examiner’s Report dated 11th December 2008 (the 'MER'), in connection with the aforesaid application for insurance dated 30th November 2008, the Life Assured had replied in negative to the following questions:
3. (Of Part 1) within the past five years have you:
(a) Consulted any doctor or other health practitioner? ............... No.
(b) Submitted ECG, X-rays, blood test or other tests? ................No.
(c) Attended or been admitted to any hospital or other medical facility ................ No.
4. Have you ever had a or sought advice for
(e) Ulcer, Colitis, Chronic Diarrhoea, Hepatitis or Jaundice or other liver or digestive disorder? ........................................................... No.
7. (a) Indicate your average weekly consumption of alcohol ......... No.
(b) Have you ever been advised to stop drinking alcohol or to drink less? ............................ No.
However, our investigations have established that the Life Assured was a known alcoholic since long and that he was diagnosed of Alcoholic Liver Disease and its complication for which he was admitted and treated in Hospital much prior to the application for insurance. We also note that he died due to the complications of the same. Hence, the replies to the aforesaid questions in the application as well as MER are false.
If the true and correct facts pertaining to Life Assured’s Medical condition and personal history were disclosed at the proposal stage, the company would not have issued the policy at all.
We are, therefore, hereby repudiating out liability under the Policy; forfeiting the premium paid thereunder.'
2. Being aggrieved from the rejection of the claim, the complainant approached the concerned District Forum by way of a Consumer Complaint. Vide order dated 03.05.2010, the District Forum allowed the complaint and directed the insurer to pay an amount of Rs.15,10,250/- alongwith interest @ 9% per annum and cost of litigation quantified at Rs.11,000/-. Being aggrieved from the order passed by the District Forum, the insurer approached the concerned State Commission by way of an appeal. The said appeal having been dismissed, the insurer is before this Commission by way of this revision petition.3. The whole case of the petitioner company is that the insured was an alcoholic and was diagnosed with alcohol lever disease and its complications. The aforesaid plea of the insurer is based upon certain photocopies of the record purporting to be a Government Medical College & Hospital, Chandigarh in respect of the deceased. It is an admitted position that no doctor who may have treated or examined the insured in Government Medical College & Hospital, Chandigarh was produced before the District Forum to prove that the deceased was an alcoholic and was diagnosed with alcohol lever disease and its complications. Admittedly, no official from the aforesaid hospital was produced to prove that the photocopies filed by the insurer were supplied by the said hospital and were true and correct copies of the record of treatment of the deceased insured. In fact, as noticed by the State Commission, the photocopies produced by the petitioner company were not even authenticated or certified by any official of the hospital. It was also noticed by the State Commission in this regard that even the affidavit of the person who allegedly collected these photocopies from the hospital was not filed. In my view, since the complainant had denied the alleged alcoholism and ailment of the insured, it was obligatory for the insurer to either produce the doctor who had allegedly treated him in the hospital or to file his affidavit. Alternatively, it could have examined an official of the hospital to prove the authenticity of the photocopies which the petitioner company filed before the District Forum in support of its case. In the absence of any such evidence, mere production of some unattested, unverified and unauthenticated photocopies, could not have been the basis of holding that the deceased was an alcoholic and was diagnosed with alcohol lever disease and its complications. No application for producing additional evidence was filed by the petitioner before the State Commission, despite losing before the District Forum. No such application is filed with this Revision Petition. The concurrent findings of the fora below therefore, do not call for any interference by this Commission in exercise of its revisional jurisdiction.4. During the course of arguments, it was pointed out by the learned counsel for the petitioner company that the sum assured was only Rs.13,75,000/- but the District Forum has directed payment of Rs.15,10,250/- with interest on that amount. The contention of the learned counsel for the complainant in this regard is that not only the sum assured but some bon
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uses etc. were also payable in terms of the insurance policy. It is made clear that if as per the terms of the insurance policy, a sum of Rs.13,75,000/- was payable in the event of death of the insured, the petitioner company will pay only the said amount @ 9% per annum from the date of filing of the complaint and the cost of litigation quantified by the District Forum and upheld by the State Commission. If however, a higher amount was payable in the event of the death of the insured, that amount shall be paid alongwith interest on that amount at the same rate of interest alongwith compensation and cost of litigation. The payment in terms of the order shall be made within four weeks from today. The revision petition stands disposed of.