The need for concrete evidence to prove allegations of pre-existing diseases in insurance claims.

ORDER

Piare Lal Garg, Presiding Member - This is an appeal filed by the appellants-LIC (hereinafter called the appellants ) against the order dated 13.6.2008 of the District Consumer Disputes Redressal Forum, Sangrur (hereinafter called the District Forum ) vide which the complaint of the respondent/complainant (hereinafter called the respondent ) was accepted by the District Forum.

2. Brief facts of the complaint are that Mrs. Sonia Sharma, wife of the respondent, was insured for the period of 28.12.2003 to 28.12.2019 for an amount of Rs. 1 lac bearing Jeevan Sathi Policy No 162612220 issued by the appellants. She died on 30.3.2005. The respondent being nominee and husband of the life assured (hereinafter called the LA ) submitted the claim but the same was repudiated by the appellants vide letter dated 31.3.2006 on the ground that the LA was suffering from Peptic Ulcer and this information was not disclosed by the LA at the time of filling the proposal form. Legal notice dated 22.11.2007 was also served and the same was replied by the appellants on 18.12.2007. The complaint was filed with the prayer that the appellant may be directed to pay Rs. 1 lac with interest @ 18% p.a. from the date of death, with Rs. 50,000 as compensation on account of mental pain, agony and harassment as well as Rs. 5,500 as litigation expenses.

3. Upon notice, reply was filed by the appellants taking legal objections that the respondent had not approached the District Forum with clean hands, respondent had no locus standi to file the complaint and the respondent did not fall under the definition of consumer . On merits, it was admitted that the LA was insured for Rs. 1 lac with the appellants, who died on 30.3.2005 and the respondent was nominee in the said policy of LA. It was pleaded that the LA had withheld material information regarding her health at the time of signing the proposal form. She deliberately withheld material information from the appellants at the time of filling the proposal form. The LA died due to peptic ulcer perforation as mentioned by Dr. R.K. Sood of Sood Hospital, Ahmedgarh, District Sangrur. The LA was also treated before death on 30.3.2005, as such, as per the terms and conditions of the policy, the claim of the respondent was rightly repudiated.

4. Rejoinder to the reply of the appellants was also filed by the respondent and it was denied that his wife Sonia Sharma was patient of peptic ulcer and was chronic. The alleged certificates issued by Dr. Mohd. Siddique and Dr. R.K. Sood are wrong and concocted one. The respondent had never made any statement to the appellants or to the investigator as alleged. The LA died suddenly due to heart attack. She was medically examined before the issuance of the policy by Doctor who was on the panel of the appellants. If she was suffering from any disease, it should have come in the knowledge of the Doctor, who medically examined the LA before the issuance of the policy.

5. The District Forum accepted the complaint and directed the appellants to pay Rs. 1 lac with interest @ 9% per annum from 31.3.2006 i.e. from the date of repudiation of the claim as well as Rs. 2,000 as litigation expenses within 60 days from the receipt of copy of the order.

6. The appeal was filed by the appellants on the grounds that the order of the District Forum is based on conjectures and surmises, the order of the District Forum is unsustainable in the eyes of law, the LA deliberately concealed the material facts regarding her health at the time of filling the proposal form and given false answers to the questions put by the Agent to her and played fraud with the appellants, the LA was suffering from peptic ulcer but this fact was not disclosed by the life assured at the time of filling the proposal form, as such, the claim of the respondent was rightly repudiated as per the terms and conditions of the policy but the