POONAM MAKHIJA Vs. SENIOR DIVISIONAL MANAGER

JUDGEMENT

(1.) Heard Mr. Sukumar Pattjoshi, Sr. Advocate, assisted by Mr. B.S. Sharma, Advocate, for the complainant and Mr. D.N. Goburdhun, Sr. Advocate, assisted by Mr. Rajat Bhalla, Advocate, for opposite party.

(2.) Dr. Poonam Makhija (nominee/heir of the life Insured) has filed above complaint for quashing repudiation letter dtd. 16/12/2017 and directing Life Insurance Corporation of India (the Insurer) to pay (i) all benefits under policies with interest @18% per annum, from 21/1/2016 till actual payment, as the insurance claim; (ii) Rs. one crore, as compensation for mental agony and harassment; (iii) Rs. One lac, as the cost of litigation; and (iv) any other relief which is deemed fit and proper, in the facts and circumstances of the case.

(3.) The complaint stated that Dr. Tilak Raj Makhija (the deceased life Assured) was an ENT Specialist. He used to take insurance policies from Life Insurance Corporation of India (the Insurer), which was a statutory corporation, since 1974 and took 19 policies in his name and 6 policies in the name of his wife (the complainant), time to time. Dr. Tilak Raj Makhija died on 2/12/2016 due to CA oral cavity i.e. tongue cancer. The Insurer honoured 15 life insurance policies of Dr. Tilak Raj Makhija but repudiated the claim under 4 life insurance policies, i.e. "Amulya Jeevan-2" Nos.273958332, 273958335 and 273958337 commenced on 19/3/2014 and No.274093132 commenced on 15/12/2014, giving liberty to send a representation to Zonal Office within 3 months, for which, total premium of Rs. 27.69/- was paid. Dr. Tilak Raj Makhija was diagnosed with cancer i.e. CA Oral Cavity on 30/1/2015. He was admitted to BLK Super Speciality Hospital, New Delhi on 2/2/2015 for treatment, where he was operated on 4/2/2015 and discharged on 12/2/2015. Thereafter, Dr. Tilak Raj Makhija expired on 2/12/2016. The complainant intimated the demise of Dr. Tilak Raj Makhija to the branch office of the Insurer at Saharanpur and lodged insurance claim on 21/1/2017. An officer of the Insurer visited the house of the complainant on 16/2/2017, asked for Biopsy Report dtd. 30/1/2015 of LNJP Hospital, relating to Dr. Tilak Raj Makhija, which was supplied to him by the complainant. Thereafter, the branch office, Saharanpur issued a letter dtd. 28/2/2017, for supply of complete details of treatment of Dr. Tilak Raj Makhija at LNJP Hospital. The complainant, vide letter dtd. 14/3/2017, replied that due to painful ulcer in the tongue, Dr. Tilak Raj Makhija, who was an ENT Specialist, took medicines on his own, for some time. When the ulcer did not heal, in expected period, he consulted his colleague Dr. A. Gulati, Senior ENT Doctor in LNJP Hospital, New Delhi on 29/1/2015. After mutual discussion, he advised for biopsy to diagnose the decease. Biopsy report came on 30/1/2015, in which, CA Oral Cavity was diagnosed. Then he took treatment of Dr.W.V.B.S. Ramalingam, a Senior ENT Onco-Surgeon, in BLK Hospital, New Delhi, who was considered to be best in his field, in north India. He was admitted to BLK Super Speciality Hospital, New Delhi on 2/2/2015 for treatment, where he was operated on 4/2/2015 and discharged on 12/2/2015. Branch Manager, Saharanpur, after quite a long time, again vide letter dtd. 12/7/2017 asked the complainant to supply original papers of OPD treatment at LNJP Hospital, which were supplied on 19/7/2017. The Manager Claims, Divisional Officer, Dehradun vide letter dtd. 9/10/2017, asked for the papers regarding treatment of Hypertension for two years, Diabetes for one year, CAG and PSVT and previous operation of Laparoscopic Cholectectomy. The complainant through email dtd. 23/10/2017, supplied the CAG report and PSVT RF Ablation. Regarding Laparoscopic Cholectectomy, she replied that the papers could not be located as it was done 17 years back and explained about ailments. Thereafter, Divisional Manager repudiated the claim by the letter predating as 16/12/2017 (received on 2/1/2018). Predating is proved from the fact that franking machine impression affixed by LIC on the envelop bears the date 29/12/2017 and dispatched vide speed post No.EV745622738 IN on 30/12/2017. The Branch Manager called for an explanation, attaching the copy of repudiation letter, from the Agent Vineet Mittal, which was received to him on 15/1/2018. The complainant wrote an email dtd. 13/2/2018, asking for the copy of Policy No.273958332, copies of all medical tests and reports as conducted by LIC Doctors, for all the four policies, which were submitted along with claim form through the Agent on 10/12/2016 and received by Branch Office on 21/1/2017. The complainant gave a representation dtd. 26/2/2018 to Zonal Office of the Insurer. Divisional Manager, vide letter dtd. 9/4/2018, informed that the representation of the complainant was rejected by Zonal Office vide letter dtd. 27/3/2018. The complaint filed an appeal to Head Office on 23/4/2018, which was rejected on 10/9/2018 (communicated vide letter dtd. 12/9/2018). Then this complaint has been filed on 9/10/2018, alleging deficiency in service. The complainant stated that the repudiation of the claim on the ground of suppression of material facts in the proposal form by the deceased life assured is illegal inasmuch as the death had occurred on 2/12/2016 due to tongue cancer, while Proposal Forms for the policies were filled up on 26/2/2014, 19/3/2014, 19/3/2014 and 17/10/2014, respectively and there is nothing on record to prove that Dr. Tilak Raj Makhija was suffering from cancer at that time. Sec. -45 of Insurance Act, 1938 prescribed two years limitation for avoiding insurance policy on the ground of suppression of material fact, while in present case two years limitation has expired long before repudiation. The reports relating to CAG, PSVT, RF Ablation, Gallstone relating to Dr. Tilak Raj Makhija were not related deceases, carrying risk to life and not material as per Appendixes VI, VII, VIII of Agents Manual. The Insurer had also obtained medical examination report from its doctor, before issuing the policies and nothing adverse was found.