USHA HAPPA Vs. LIC OF INDIA

JUDGEMENT

(1.) THIS complaint has been filed by Shrimati Usha Happa, the widow of the deceased insured late Naresh Kumar Happa, who was dealing in the business of Pharmaceuticals in Srinagar. At the age of 53, he obtained MEDICO LEGAL INSURANCE POLICY bearing No. 141115674 having insured perils in the sum of Rs. 10 lac. The said policy was of nature as having commenced on 28.2.2002 and had to expire on 28.2.2007, as the Proposal Form had been accepted retrospectively with effect from 30.3.2002. The cause of death of the insured was Cardiac Arrest, which occurred on 25.5.2002. OPs had indemnified the nominee of the deceased insured in respect of two other Insurance Policies detailed in para 6 of the complaint. A different treatment was given to the complainant herein as instead of indemnifying here, the Policy was repudiated after a gap of more than three years from the date of his death on the plea that there was suppression of material fact with regard to the ailments of Diabetes and Hypertension, from which the insured was suffering at the time of issuance of the Insurance Policy in question. The repudiation of the claim was intimated to the complainant through letter dated 22.2.2005 stating therein that on inquiry it had surfaced that the insured was suffering from the diseases of Diabetes and Hypertension but the insured deceased had suppressed them and in a mala fide manner obtained the Insurance Policy. The complainant made representation vide annexure 'D', wherein she denied that insured deceased was a sugar patient. It was also stated that he was not suffering from the ailments pertaining to liver, heart or kidney. It was also denied that he was a known patient suffering from Diabetes and Hypertension. When no action was taken on this representation, the omission amounted to denial of rightful claim and consequently resulting in deficiency for rendering service. In the complaint, the complainant has claimed indemnification of the insured amount in the sum of Rs. 10 lac along with compensation of Rs. 4 lac for mental agony and harassment and litigation expenses are claimed in the sum of Rs. 20,000.

(2.) OPS have contested the complaint and raised the preliminary objection in the written version that the deceased insured had wilfully suppressed the ailment of Diabetes and Hypertension because he expired within a short span of one month and 27 days after taking the Insurance cover. OPs are in possession of indisputable proof that insured was not having good health at the time of filling 'the Proposal Form. The deceased was in the knowledge of being inflicted by the ailments of Diabetes and Hypertension.

(3.) IN support of the complaint, the complainant has led her evidence on affidavit and was cross -examined by the OPs. She has denied that the insured deceased was suffering from Diabetes as well as having Hypertension. She has denied that deceased insured had any major ailment. She, however, admitted that after the mass migration of her minority community members from Kashmir Valley in the year 1990, the insured deceased, who too had migrated with them had gone into psychological/mental depression and remained for some time as an indoor patient in AIIMS, New Delhi. She also examined Dr. N.A. Lone, one of the Panel Doctors of OPs, as her witness. Dr. N.A. Lone has stated that one Insurance Agent of the OPs had introduced the deceased insured to him at the time of issuing the Insurance Policy in question. That as an expert, he conducted all the requisite tests, which were required under norms, and no abnormality was found. Even his Blood Pressure was found normal between the range of 126/82. He has categorically stated: "I do not doubt that the patient/insured was suffering from Diabetes and Hypertension". In his cross -examination, he stated that the record of the tests was in his possession and that insured deceased was not suffering from any disease. He continues to be a Panel Doctor of the OPs. OPs have examined Mr. Mohd. Afzal Bhat Assistant Administrative Officer, as a witness. He has deposed on affidavit that the claim of the insured deceased was raised after two months and 27 days from the commencement of the Insurance Policy. As the claim was very early one, so it had to be got investigated under rules in order to find out the material facts and establish its genuineness. There was sufficient documentary evidence available to establish that insured deceased was a known case of "Diabetes and Hypertension". In cross - examination, he stated that the insured deceased, who had taken the Insurance Policy of a cover of Rs. 10 lac was required to undergo medical tests, like X -Ray, ECG, Blood Tests, Urine Test and physical examination by the Doctor of the Insurance Company. Two Panel Doctors of the OPs namely, Dr. N.A. Lone and Dr. Mir Mohd. Afzal had examined him. He could not produce any record in support of the allegation that insured deceased at that time was suffering from the ailments of "Diabetes and Hypertension".