Before the District Forum :Kurnool

Present Sri K.V.H.Prasad, B. A., LL.B., President

And

Smt C.Preethi, M.A., LL.B., Member

Sri R. Ramachandra Reddy, B.Com., LL.B., Member

Wednesday 21st day of April, 2004

C.D.No 43/2003

Smt.B.Venkatamma,

W/o. Late B.Balaswamy,

H.No.44-86-B-4,

Ashok Nagar,

Kurnool.                                                                                  . . . Complainant represented by his

                                                                                           Counsel Sri K.Kapileswaraiah

 -Vs-

1. Branch Manager,

   Life Insurance Corporation of

   India Ltd,

   Kurnool.

2. Divisional Manager,

   Life Insurance Corporation of

   India Ltd,

   P.B.No.10,

   College Road,

   Cuddapah.                                                                         . . . Opposite party No.1&2 represented

                                                                                                    by his counsel Sri B.Rama Subba Reddy

O R D E R

(As per Sri R.Ramachandra Reddy,Member)

1. This consumer dispute case of the complainant is filed under Sections 11&12 of the C.P.Act of 1986 seeking direction to the opposite parties to pay the policy amount of RS.50,000/- with interest at the rate of 24% per annum from the date of the death of the deceased till the date of realisation,to grant a sum of RS.20,000/- towards mental agony , to grant a sum of RS.2,000/- towards costs and grant any other relief’s as the Hon’ble Forum deems fit and proper in the circumstances of the case.
2. The brief facts of the complainant’s case are that the complainant’s husband B.Balaswamy insured his life on 28,.2.2002 for RS.50,000/- (policy No.652814228). The said policy holder died on 10.7.2002 due to fever.  After the death of the insured i.e. complainant’s husband the complainant submitted the claim form to the opposite parties as the nominee of the above policy.  The opposite parties did not pay the policy claim amount to the complainant even though the complainant represented several times about her claim, but the O.P.No.2 on 16.12.2002 repudiated the claim informing that the complainant’s husband with held the correct information regarding the health at the time of the contract of the Insurance. As mentioned in the repudiation letter, the complainant’s husband never suffered from any diabeties disease, but he died due to fever. As there was no connection with the alleged disease. Thus the opposite parties refusal to pay the insured amount of the policy without any reasonable and lawful cause, amounts to deficiency of service from their part.
3. The complainant besides filing a sworn-affidavit in re-iteration of the complaint averments relies upon the document record which is marked as Ex.A.1 to A.2 for their appreciation.
4. Inpurusance of the receipt of the notice of this case the opposite party No.2 made his appearance and filed its written version. The O.P.No.1 adopted the written version of the O.P.No.2.   The written version of the O.P.No.2 besides denying the justness and the maintainability of the complainant’s case requires strict proof of the complaint averments, which are not admitted by it.  Even though the O.P.No.1 admits the husband of the complainant as policy holder with plan and term 14-15 and adopted to pay premia under quarterly mode and the status of the complainant as his nominee and the demise of the said policy holder on 10.7.2002 and the relevant claim forms have been sent to the nominee (complainant) on her request on 4.9.2002.
5. Since the deceased Bala Swamy died within the short span of time i.e. 4months and 12 days from the date of the commencement of the policy i.e. 28.2.2002 these opposite parties ordered investigation interms of the Insurance Act in order to guard the Corporation from the fraudulent claims and to safe guard the interest of the policy holders as their trustee. The investigation was done thoroughly since the claim was an early one and during the course of investigation it was established that the Life Assured was a diabetes since 5 years and working as watchman in Siri Noble Hospital,Kurnool where he took terminal treatment.  The life assured was admitted into the said Hospital on 9.7.2002 with the complaint of semi-consious guidines with I.P.No.156/203.  The clinical history and finding of the Siri Noble Hospital, Kurnool reveal that the deceased life assured was having past history of known diabetic i.e. the deceased life assured Mr.B.Bala Swamy was not in good health at the time of the taking the policy. Dr.D.V.Ramana of the same Hospital has given. F.No.5152 confirming that the life assured was suffering with diabieties since 5 years which period refers prior to the date of the commencing of the policy. The cause of the death stated in claim Form.A i.e. claimant statement, is Cerebra Vascular Accident and not due to fever as stated in the complaint.  The Medical attendant certificate and the certificate of the Hospital treatment reveal the cause of the death as Cerebra Vascular Accident with secondary cause as diabeties.  So there is nexus between the disease with which the life assured has suffered and the cause of the death.  Hence, it justifies the repudiation of the claim and the un-justness in the complainant’s claim and of her entitleness to any of the claim made and thereby seeks the dismissal of the complaint with costs.
6. The opposite parties taken on reliance on the documentary record which is marked as Ex.B.1 toB.8 for their appreciation without filing their sworn-affidavits.
7. Hence, the point for consideration is whether the complainant has made out any deficiency of service on the part of the opposite parties in settlement of the claim preferred on the policy of her husband consequent to his demise and of his entitleness to the relief’s claimed?:-
8. The Ex.A.1 is an attested xerox copy of the letter dt.16.12.2002 of the Senior Divisional Manager(O.P.No.2) to the complainant in which it was informed that the claiming of the complainant under the said policy on the life of her husband was repudiated on account of the deceased having with held correct information regarding his health at the time of effecting the assurance with O.Ps and further informed that all the answers and the proposals for assurance dt.19.2.2002 the complainant’s husband were false and there was a indisputable proof to show that about 5 years before the deceased proposed for the above policy had suffered from the diabetes for which he has consulted a Medical man and had taken treatment. The Ex.A.2 is the death certificate of the complainant’s husband issued by the Kurnool Muncipal Corporation. The complainant sworn-affidavit also re-iterates all the above facts and the documents.
9. The Ex.B.1 is an attested true copy of the clinical history and finding of the deceased B.Bala Swamy in which it was noted that the said deceased was admitted in the Siri Noble Hospitals on 9.7.2002 at 12.25 P. M and discharged on 10.7.2002 at 6.15 A.M and treated for Semi conscious condition and for vomiting and giddiness and found that the deceased is a diabetic.   The Ex.B.2 is form No.5152 in which the questioner to be completed by a Medical Practitioner who has treated the deceased in the beginning of the last illness who was his last medical attendant which reveals that the date i.e 9.7.2002 at 12.2.25 Pm the deceased consulted Doctor during his last illness and treated for semi consciousness and giddiness for the first time and the deceased was in that condition for one hour and doctor answered for the question No.6 that he w as informed by the deceased son that he was the diabetes on insulin for the last 5years.   But the said doctor for question No.8 has given negative answer. The Ex.B.3 is the claimant statement. The Ex.B.4 is the medical attendant certificate in which it was mentioned that the complainant’s husband died on 10.7.2002 at 6.15 A.M in Siri Noble Hospitals, Kurnool due to Cerebro Vasculor accident with secondary cause diabetes and he was suffering from the said disease for one day and the symptoms of the illness are unconcious with giddiness and the deceased was first consulted on 9.7.2002 at 12.00 noon and that the deceased was under his supervision till his death i.e 10.7.2002 at 6.15 A.M i.e the date of the death.  In the said Ex.B.4 the answer for question No.6.(a) is ‘sober’ and 6(b) is ‘no’.  The Ex.B.5 is the certificate of the Hospital treatment is nothing but the contents of theEx.B.2 and Ex.B.4. The Ex.B.6 is the proposal for insurance on his own life which is medical as per column No.12 which was certified by the L.I.C doctor. The Ex.B.7/Ex.A.1 is the repudiation letter dt.16.12.2002 addressed by the O.P.No.2 to the complainant and the Ex.B.8 is the original Endowment assurance policy (medical) with profits +acc. benefit, where the complainant is the nominee of the policy. 
10. As seen from the Ex.B.1 to Ex.B.6 the said observations, in the said exhibits as to the cause of the death being not based on any clinical investigation, but only on symptamatical investigation and any past record of the patient is there as to his suffering with the said diabetes and his taking treatment for that either in the proceeding period to the taking of the policy or at the time of the taking the policy it cannot be said that the said policy holder B.Bala Swamy being in know of the said disease  conceiled them from releaving in his medical proposal form with an ulterior malafide intention to get a wrongful gain under that policy and there by committed any breech of the conditions forfeiting his claim. Further it is needless to observe that the burden is on the opposite parties to establish that there was suppression of the material facts.  The opposite parties did not adduce any evidence or sworn-affidavits from the doctors who examined the deceased to discharge this burden and also there is no material to show that the opposite parties did not examine any body connected with the case sheet or any doctor of Siri Noble Hospitals, Kurnool or the L.I.C doctor (Ex B.6) examined at the time of obtaining the who proposal form to prove that the deceased was known diabetic patient and that he was aware of the fact that he has a diabetic at the time of the proposal.  Thus the opposite parties failed to establish both these things as to the suppression of the material facts by the complainant’s husband.
11. The complainant in support of her case relied on the judgement of the West Bengal State Consumer Disputes Redressal Commission,Colcutta-III (2003) C.P.J 419 wherein it was observed that the onus is upon the L.I.C to establish the facts there had been suppression of the material facts by the deceased at the time of submitting the proposals. The Medical Officer of the LIC examined the insured and found nothing wrong in the health of the deceased.  The death certificate shows that she died of cardioc failure, claim repudiated after the long lapse of time, the deficiency in service proved and the Company is liable under the policy and in the another judgement of the National Commission, 2003(1) C.P.R. 38 , it was observed that policy could not be called in question by the insurer on the ground that statement made in the proposal form was inaccurate or false unless insurer showed that such information was on material fact and was fraudulently made-Appellant had relied upon two hospitalization certificates both were subsequent to the issue of the policies and no attempt was made to ascertain whether the deceased was treated earlier . Where as the insured had died of the kidney failure.  Commission rightly concluded that the onus which was on LIC had not been discharged.  No interference was warranted in order allowing the claim under the policies and in the another judgement of the National commission 1997 (N.C.J) 33 it was observed that no due or the proper application of the mind by the LIC to the material facts and the circumstances of the case before it proceeded to repudiate the claim. The finding of the District Forum that the repudiation made by the insurer arbitrary and not based on proper application of the mind uphold and the order of the State Commission set-aside.
12. The National Consumer Disputes Reddressal Commission,New Delhi in the LIC of India –Vs- Jasbeer Singh reported in 2003(I) CPR 277(N.C) holds the knowledge of the insured of the deceased with which he was suffering at the time of taking of the policy to hold him liable for the for-feiture for not reveling the said facts in the said proposal form if the said deceased has direct nexus to the death.
13. Therefore, in the result of the above discussion as the complainant is entitle to the policy amount of the deceased B.Bala Swamy on the contingency of his death and the opposite parties by their avoiding conduct put the complainant to the mental agony and also to seek the redressal in this Forum.  The complainant is remaining entitle to the policy amount of RS.50,000/- as the nominee of the deceased policy holder with interest @ 9% per annum from the date of the demise of the policy holder and RS.5,000/- as compensation and RS.500/- as costs. 
14. Therefore, the opposite parties are directed to pay the above awarded amount to the complainant within a month of the receipt of this order, in default the opposite parties shall be liable to pay the said awarded amount @ 12 interest per annum from the date of the said default till the date of the realization.

Dictated to the Stenographer, Typed to the Dictation corrected by us and pronounced in the Open Court, this the 21st day of April,2004.

                                                                       PRESIDENT

                MEMBER                                                                                                   MEMBER