Date of filing :08-05-2009
Date of order : 18-01-2011
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
C.C.116/2009
Dated this, the 18th day of January 2011
PRESENT
SRI.K.T.SIDHIQ : PRESIDENT
SMT.P.RAMADEVI : MEMBER
Venugopal.K,
S/o.Late P.Ramavarier,
Vishnumangalam, Haripuram.Po, } Complainant
Anandasharam,
Kanhangad.671531.
(Advs. Mathew .K.L & N. Sudheer, Hosdurg)
1. Branch Manager, LIC of India, } Opposite parties
Kanhangad.
2. LIC of India represented by
Sr. Divisional Manager Kozhikode.
3. Zonal Manager,
LIC of India, Southern Zonal Office,
LIC Building Annasalai, Chennai 670002.
(Adv. A.B. Nair, Kasaragod)
O R D E R
SRI.K.T.SIDHIQ, PRESIDENT
Bereft of unnecessaries the case of complainant is that the opposite party forfeited the premium amount of the policy owned by his deceased wife Swapna since she made deliberate misstatement and withheld matters regarding her health while renewing the policy. According to complainant his wife P.V.Swapna Venugopal had an LIC policy with No.792279193. The policy lapsed once in August 2003. It was subsequently revived on 16-4-2004 for the full sum assured. Later she expired due to breast cancer. When the claim was made it was not honoured for the reason mentioned above. There is no misstatement and concealment of facts as alleged. In fact when she signed the policy revival she was not even aware that she was having breast cancer. Against the rejection of the claim complainant approached insurance Ombudsman. But Ombudsman did not entertain his application since it was submitted after one year of the insurer’s rejection. Therefore the complainant praying for an order against opposite parties to grant full amount covered in the policy.
2. According to opposite party the deceased had LIC policy with proposal dated 21-2-1999 for `50,000/- under plan 90. The premium was `1196/- at half yearly and the term of the policy was 20 years. The policy was under marriage plans and maturity date was 23-2-2019 to the nominee Sree Lakshmi, daughter of the deceased. The deceased Swapna Venugopal did not pay Insurance Premium due on 23-8-2003 to 23-2-2004 and thereafter she paid `2483/- towards arrears of the premium and interests with declaration regarding good health. Hence policy was revived on 16-4-2004 in good faith. As per the claim form ‘A’ dated 12-09-2005 submitted by the complainant the deceased was consulted Dr. Sudheeran Amala Hospital, Thrissur on 7-6-2003. As per the certificate issued by Dr. Sudheeran dated 24-11-2005 the deceased was first seen on 7-6-2003 by Cancer Surgeon with a history of Right Breast Lump of 3 weeks duration, she was admitted on 12-6-2003, and mastectomy was done on 13-6-2003 and discharged on 16-6-2003. As per the result of biopsy, Chemotherapy, Radio Therapy and Hormone Treatment were given to her. She was again admitted on 25-06-2003 for Chemotherapy and discharged on 26-6-2003 thereafter she was an out patient for 3 doses of Chemotherapy and admitted for 4 cycles of Chemotherapy on 19-9-2003, 10-10-2003, 31-10-2003 and 21-11-2003. She had received Radio Therapy as out patient from 8-12-2003 for 5 weeks and thereafter Hormon Therapy till December 2004. The lapsed policy was revived on 16-4-2004 with declaration regarding good health. There was no mention regarding the treatment she had undergone prior to revival of policy. The deceased was a Bcom graduate and hence she was aware about the declaration made by herself for the revival. The opposite parties die not authorize any agent to revive the policy if at all any agent helped her to fill up the revival form the agent will be acting as an agent of the deceased and not that of opposite parties. Because of the misstatement and suppression of facts in the personal statement submitted for the revival of policy the opposite parties repudiated the death claim and the same was intimated to the complainant as per letter dated 28-2-2006. The subsequent premium for the revival is accepted believing the declaration submitted by her that her health condition was good and not taken any treatment and is not hospitalized from the date of lapse to the date or revival of the policy. As per the forfeiture condition of the policy all the money paid consequent to misstatement will stand forfeited by the opposite parties. The opposite parties admitted the claim to the extent of paid up value and accrued bonus under the policy before the date of revival amounting to `11250/- towards paid up value and `15250/- towards accrued bonus and is total `26600/- which is payable only on the date of maturity i.e. on 23-2-2019. There is no immediate death claim payable under the policy since the policy is taken for the benefit of the minor. Hence there is no deficiency in service on the part of opposite parties. The complaint is barred by limitation. Hence the complaint is liable to be dismissed.
3. Complainant filed proof affidavit reiterating the pleadings made in the complaint. Exts A1 to A6 marked on the side of complainant. On behalf of opposite parties Sri.B. Subba Naik, Manager, L&H,PF, LIC of India, Divisional Office, Kozhikode filed counter affidavit. Exts B1 to B6 marked. Both sides heard. Documents carefully perused.
4. Though opposite party had contended in their version that the complaint is barred by limitation no argument advanced to establish this contention. Hence we hold that the complaint is not barred by limitation. Further even according to opposite parties the date of maturity of the policy is 23-2-2019. Hence the complaint is not barred by limitation.
5. On merits, it is the case of complainant that there was no delebrate mis-statements and withholding of material information from LIC regarding her health during the revival of policy. The agent got the letter of revival signed from the assured and the column are filled by agent. Further the deceased was not informed that she was suffering from breast cancer when the application for revival of policy was signed and she was fully hale and healthy when she was discharged from hospital and also during the intermittent periods. The breast cancer is not an incurable disease and doctors told about the seriousness of the disease only in the advanced stage.
6. But the complainant did not made any attempt to examine the concerned LIC agent who is alleged to have filled the revival form to prove the contention that it is filled up by the agent himself and not according to the information passed by the policy holder.
7. Further in Ext.B2 the claimant’s statement submitted by the complainant for the claim, in column No.4 the complainant has made the following statements
8. 4 (a) when did the deceased first complain of being not in usual
good health - Dec. 2004
(b) Name of illness then complained - Body Pain.
9. So according to complainant the deceased complained about body pain only in Dec 2004. But as against this statement in Ext.B5, the letter issued by Dr.P.C. Sudheeran of Amala Cancer Hospital & Research Centre to the manager of LIC OF India, Kozhikode, it is seen reported that the patient/deceased Swapna was first seen on 7-6-2003 by their cancer surgeon with a history of Right Breast Lump of three weeks duration and FNAC report shows malignancy and she was admitted on 12-6-2003 and Mastectomy was done on 13-6-2003 and discharged 16-6-2003.
10. Ext.B5 further details the history of repeated treatments undergone by the patient. This would go to show that the patient/deceased was aware about the malignancy of the cancer affected to her during June 2003 itself. Hence the statement of the complainant made in column 4(a) (b) itself reveals that he was suppressing the material facts even after the death of the policy holder with intention to get the claim honored. That resembles the practice adopted by the policy holder at the time of revival of the policy also.
11. The complainant has no case that Ext.B2 copy of claimant’s statement, Ext.B3 copy of certificate of Hospital Treatment. Ext.B4 copy of Medical Attendant’s certificate. Ext.B5 copy of letter issued by Dr.PC.Sudheeran of Amala Hospital and Ext.B6 the copy of letter rejecting the claim of the complainant are fabricated or concocted for the purpose of the case.
12. In Ext.B5 Dr.P.C. Sudheeran has specifically reported that patient/Swapana has undergone Mastectomy on 13-6-2003 and the FN AC report shows the Malignancy of the disease. Ext.B5 further explain the treatment undergone by the patient during subsequent days. Therefore the case of the complainant that the patient/policy holder had been informed that she was suffering from breast cancer at a later stage and was fully hale and healthy when she discharged from the Hospital and also during intermittent period and breast cancer is not an incurable disease and doctor told the complainant and other relatives about the seriousness of the disease only in the advanced stage are not appears to be true and correct.
13. Therefore the contention of the opposite parties that there is deliberate misstatement and suppression of the facts in the personal statement submitted for the revival of the policy is well founded.
14. The contract of insurance is a contract uberrimae fidei . A person who desires to take or revive a policy must disclose the insurer all the material facts/circumstances because the insurer knows nothing and the assured knows everything. The special facts are commonly in the knowledge of the insured and the insurer trusts the assured’s representations. The insurer proceeds on the belief that the insured has not suppressed any facts and circumstances in his knowledge and induce the insurer to believe that risk doesnot exist. Suppression of such material facts is fraud and therefore the insurer is not liable to honour the claim.
15. The opposite parties in their version has admitted that the nominee of the deceased policy holder i.e her daughter Sreelakshmi is entitled for the paid up value of the policy `11,250/-and the accrued bon us `15,350/- and in total `26,600/-. The said amount is payable on the date of maturity i.e. on 23-2-2019.
Therefore the complaint is allowed to that extent and the opposite parties are directed to pay the said amount of `26,600/- with interest stipulated in the policy. The interest shall be calculated from the date of death of the policy holder i.e. 19-3-2005 to till date of its maturity i.e. 23-2-2019. The payment shall be done on the date of maturity of the policy i.e. on 23-2-2019. There is no order as to costs.
MEMBER PRESIDENT
Exts.
A1. Copy of complaint sent by Venugopal. K. to Zonal Manager, LIC of India, Chennai.
A2. 3-3-2008 letter sent by Venugopal.K. to LIC of India rep.by Sr.Divisional Manager, LIC
of India, Kozhikode, Zonal Manager, LIC of India, Chennai.
A3.30-11-06 letter issued by Sr .Divisional Manager to complainant.
A4. Letter issued by O/o. Insurance Ombudsman to Venugopala.
A5. Copy of death certificate of deceased Swapna.
A6.Photocopy of Marriage Endowment/Educational Annuty Plan with Profits.
B1. Photocopy of Marriage Ednowment/Educational Annuty Plan with Profits.
B2. Claimant’s Statement.
B3. Photocopy of Certificate of Hospital treatment of deceased Swapna
B4. Photocopy of Medical Attendant’s Certificate.
B5.24-11-05 copy of letter issued by Dr.P.C. Sudheeran, Amala Hospital Thrissur to
Manager LIC of India, Kozhikode
B6.Letter issued by OP to complainant.
MEMBER PRESIDENT
Pj/
