Date of filing : 05-09-2008.
Date of order : 01-06-2009.
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.159/08
Dated this, the 1st day of June 2009
PRESENT
SRI.K.T.SIDHIQ : PRESIDENT
SMT.P.RAMADEVI : MEMBER
SMT.P.P.SHYMALADEVI : MEMBER
Nabeesa Hamsa,
W/o. Late P.Hamsa,
R/in Bilal Manzil, Erol Kunnummel, } Complainant
Po.Bare, Hosdurg Taluk, Kasaragod.Dt.
1. Divisional Manager,
Life Insurance Corporation of India, } Opposite parties
Divisional Office, Jeevan Praksh,
P.B.No.177, Kozhikode. 673 001.
2. The Zonal Manager,
Life Insurance Corporation of India,
Southern Zonal office, L.I.C Building,
Annasalai Road, Chennai 600 002.
O R D E R
SMT.P.RAMADEVI, MEMBER
Smt. Nabeesa Hamza filed this complaint through her counsel Mr.Benny Jose alleging deficiency in service against opposite parties.
The facts or the complaint in brief are as follows.
2. That the complainant’s husband Hamza was insured with the opposite parties for a sum of Rs.1,00,000/- on 15-09-1999 with policy No.792578391. The policy was for a term of 20 years with a quarterly premium of Rs.1736/-. The policy was lapsed in March 2005 due to non-payment of premium and the same was revived through the LIC agent on 27-07-06 after paying the premium dues.
3. That on 10-10-07 the complainant’s husband, Hamza died. After his death the complainant placed claim before the opposite parties but it was partly admitted by the LIC stating that while reviving the policy the insured Hamza had suppressed some material facts i.e, his pre-existing disease. Accordingly LIC entertain only paid up sum assured of the policy viz.3500 with the vested bonus of Rs.28,600/- which were secured by the policy on the date of lapse. According to the complainant there was no bonafide mistake or omission on the part of the complainant’s husband Hamza. Hamza was an illiterate person and all the paper works were done by the Corporation agent. The complainant’s husband had not suppressed any material fact at the time of revival of policy. The complainant is entitled to get the insured amount. The rejection of claim amounts to deficiency in service on the side of the opposite parties. Hence this complaint for necessary relief.
4. That the opposite parties served notice and Mr.A.B.Nair appeared for the opposite parties and filed their version.
5. The opposite parties filed version stating that the policy was renewed on the strength of a personal statement regarding the health made by the policy holder, Hamza along with a medical records issued by a Doctor at Sharjah. The revival was accepted by the opposite parties with utmost good faith on the strength of the personal statement regarding the health of the policy holder. The opposite parties further submits that after receiving the application for claim the opposite parties conducted an investigation and it was revealed that policy holder was a chronic patient of high diabetics and hyper tension and also having heart ailment. According to the opposite parties the policy holder had suppressed the above facts while reviving the lapsed policy, hence the opposite parties are not bound to perform their part of the contract. Hence the claim not honoured in full and the paid up value of the policy plus accrued bonus i.e. Rs.32,000/-was paid.
6. After considering the above facts the main question to be raised is whether the repudiation is justifiable or not?
7. The evidence in this case consists of the evidence of PW! The complainant and Exts A1 to A5 and evidence of DW1, the opposite party and Exts B1 to B14.
8. The opposite parties contended that the insured suppressed the fact that he had complaints of hyper tension, diabetics and Heart Ailment. In order to substantiate their contention the opposite parties produced Exts B6 to B11 documents issued by High Land Hospital, Managalore. Ext.B6 shows that one Mr.Hamza aged 41 years had admitted in the High Land ospit
Hospital with a complaint of chest pain on 24-11-03 and discharged on 29-11-2003 and he was treated by Dr.R.L. Kamath. Exts B7 to B11 are the inpatient bill, the diagnostic report and prescriptions. The production of Exts B6 to B11 is not sufficient to prove that the complainant’s husband deceased Hamza had hyper tension, diabetics. The doctor who issued the certificates is not examined as a witness in order to prove Exts B6 to B11. Moreover, the opposite parties have no case that the deceased Hamza had prior knowledge of the disease alleged against him.
9. The Hon’ble National Consumer Disputes Redressal Commission has held in the cases AVIVA and LIC of India v. Joginder Kaur& Ors II (2005)CPJ78(NC) that the allegations of concealment of material facts is not acceptable in the absence of any evidence in support thereof.
10. Here also there is no evidence before this Fora that the deceased Hamza had some preexisting disease and the same was within his knowledge.
11. The further point to be considered in this case is inview of Section 45 of the Insurance At Section 45 stipulates that no policy of life insurance after the expiry of two years from the date on which it was affected will be called in question by insurers on the ground that a statement made in the proposal for insurance or in any report or a medical officer or reference or friend of the insured or in any other document leading to issue of policy was inaccurate or false unless the insurer shows that such statement was on material matter of suppressed facts which it was material to disclose and that it was fraudulently made by the policy holder at the time of making it that the statement was false or suppressed facts which it was material to disclose.
12. In this case the insured had taken the policy on 15-9-1999. The policy was lapsed in the month of March 2005. It was received on 27-7-2006. The alleged preexisting decease was in the year 2003. During that period the policy were in ture.
In view of the above said discussions the Forum is of the opinion that the opposite parties are not able to prove their contentions and we found that the rejection of the part of the claim amounts to deficiency in service. The complainant is entitled to get the entire policy amount after deducting the part payment already made by the opposite parties. Hence the complaint is allowed and the opposite parties are directed to pay Rs.67,900/- with interest @ 9% p.a. from 10-03-08 till the date of payment with cost of Rs.2500/- The time for compliance of the order is 30 days from the date of receipt of the copy of the order.
MEMBER MEMBER PRESIDEN T
Exts.
A1. 14-01-08 letter issued by OP to Branch Manager, Syndicate Bank, Udma.
A2. 16-4-08 letter issued by Regional Manager to complainant.
A3. 28-7-08 letter issued from Sr. Divisional Manager, LIC of India, Kozhikode
A4.10-10-08 Letter issued from Regional Manager (CRM) to Complainant.
A5. Extract of Admission Rtegister of Hamza.M.M. issued by H.M. Udma Islami ALP
School, Udma.
B1. 10-03-08 Receipt.
B2. 14-01-08 letter issued by OP to Branch Manager, Syndicate Bank, Udma.
B3. Medical Attendant’s Certificate.
B4. Certificate of Hospital Treatment
B5.Claim Inquiry Report
B6. Discharge Summary(High Land Hospital, Mangalore)
B7. In Patient bill.
B8. Lab Report
B9. Lab Report
B10.Prescription of Mr. Hamza
B11Prescription of Mr. Hamza.
B12. Medical Examiner’s Confidential Report.
B13.Personal Statement Regarding Health
B14.25-05-06 Renew LIC Policy.
MEMBER MEMBER PRESIDENT
Pj/
Date of filing : 05-09-2008
Date of order : 23 -07-2012
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.159/08
Dated this, the 23rd day of July 2012
PRESENT
SRI.K.T.SIDHIQ : PRESIDENT
SMT.P.RAMADEVI : MEMBER
SMT.K.G.BEENA : MEMBER
Nabeesa Hamsa,
W/o. Late P.Hamsa,
R/in Bilal Manzil, Erol Kunnummel, } Complainant
Po.Bare, Hosdurg Taluk, Kasaragod.Dt.
(Adv.Beeny Jose, Kasaragod)
1. Divisional Manager,
Life Insurance Corporation of India, } Opposite parties
Divisional Office, Jeevan Praksh,
P.B.No.177, Kozhikode. 673 001.
2. The Zonal Manager,
Life Insurance Corporation of India,
Southern Zonal office, L.I.C Building,
Annasalai Road, Chennai 600 002.
(Adv.A.B.Nair, Kasaragod)
O R D E R
SMT.P.RMADEVI, MEMB ER
That this complaint is again came up for hearing before this Forum as per the remand order of the Hon’ble State Commission in appeal No.451/2009 dt.13-07-2010. As per the order the Forum is directed to permit both parties to adduce further evidence in support of their contention and dispose of the matter on merits.
2. The facts of the case in brief is that the complainant’s husband Hamza was insured with the opposite parties for a sum of `1,00,000/- on 15-09-199 with policy No.792578391. The policy is for a term of 20 years with quarterly premium and the same was revived through the LIC agent on 27-07-2006 after paying the premium. On 10-10-2007 the complainant’s husband Hamza died. After his death the complainant placed claim before the opposite parties but it was partly admitted by the LIC stating that while reviving the policy the insured Hamza had suppressed some material facts i.e. his pre-existing disease. Accordingly LIC entertained only paid up sum assured of the policy i.e. `3500/- with the vested bonus of `28,600/- which were secured by the policy on the date of lapse. According to the complainant there was no bonafide mistake or omission on the part of the complainant’s husband Hamza. Hamza was an illiterate person and all the paper works were done by the corporation agent. The complainant’s husband had not suppressed any material facts at the time of renewal of policy. The complainant is entitled to get the insured amount. The rejection of claim amounts to deficiency in service on the part of the opposite parties. Hence the complaint is for necessary relief.
3. The opposite parties filed their version stating that the policy was renewed on the strength of a personal statement regarding the health made by the policy holder, Hamza along with the medical records issued by a doctor at Sharjah. The renewal was accepted by the opposite parties with utmost good faith in the strength of the personal statement regarding the health of the policy holder. The opposite parties further submitted that after receiving the application for claim the opposite parties conducted an investigation and it was revealed that policy holder was a chronic patient of high diabetics and hyper tension and also having heart ailment. According to opposite parties the policy holder suppressed the above facts while reviving the lapsed policy hence the opposite parties are not bound to perform their part of the contract. Hence the claim not honoured in full and the paid up value of the policy plus accrued bonus was paid.
4. After considering the above facts the Forum passed the order infavour of the complainant and against that order the opposite parties approached the Hon’ble State Commission and the Commission after hearing the appeal remanded the case back for fresh disposal. Now the only thing is to be proved is the identity of the life assured, Hamza.
5. Here the PW1 again examined and Exts A6 to A8 marked. On the side of opposite parties DW1 is examined and Ext.B15 and X1 and X2 marked. Heard both sides and documents perused.
6. Here the question is to be answered is whether the person insured is Ext.B6 is the deceased Hamza or not? On perusal of Exts A6 to A8 and Exts.X1 and X2 and the admission made by the complainant in her oral evidence that deceased Hamza and the person mentioned in Ext.B6 are one and the same person. Then the next point is to be considered is that whether deceased Hamza suppressed any material fact before the opposite party at the time of renewal of policy?
7. Ext.X1 is the case sheets of Mr.Hamza. On perusal of Ext.X1 the deceased Hamza was an inpatient in High Land Hospital, Mangalore on 23-11-2003 with a complaint of chest pain and diabetics. Ext.X2 the treatment records of Mr.Hamza from 7-10-2007 to 10-10-2007. It reveals that Mr.Hamza was a known diabetic patient since 5 years. On concluding the above facts Mr.Hamza was a diabetic patient since 2003 and he as hospitalized during the year 2003.
8. Here the only question is to be answered is whether the repudiation of the claim by the opposite parties is justifiable or not. Here while submitting the application for renewal of policy in 1996 Mr.Hamza has not disclosed his previous treatment details or admission to Highland Hospital, Mangalore. There is a specific question in Ext.B12 regarding whether the insured admitted in any hospital. That question was answered by Hamza wrongly which amounts suppression of facts. Contract of insurance is a Uberimae Feddi contract or contract of utmost good faith. Here on suppression of material fact is not justifiable. Here the repudiation of claim of the legal heirs of Hamza by the opposite party is justifiable and the complainant is not entitled to the relief as prayed for.
Hence the complaint is dismissed. No order as to costs.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exts.
A1. 14-01-08 letter issued by OP to Branch Manager, Syndicate Bank, Udma.
A2. 16-4-08 letter issued by Regional Manager to complainant.
A3. 28-7-08 letter issued from Sr. Divisional Manager, LIC of India, Kozhikode
A4.10-10-08 Letter issued from Regional Manager (CRM) to Complainant.
A5. Extract of Admission Register of Hamza.M.M. issued by H.M. Udma Islami ALP
School, Udma.
A6. Death certificate of Hamza.
A7. Passport of Hamza.
A8. Passport of Hamza
B1. 10-03-08 Receipt.
B2. 14-01-08 letter issued by OP to Branch Manager, Syndicate Bank, Udma.
B3. Medical Attendant’s Certificate.
B4. Certificate of Hospital Treatment
B5.Claim Inquiry Report
B6. Discharge Summary(High Land Hospital, Mangalore)
B7. In Patient bill.
B8. Lab Report
B9. Lab Report
B10.Prescription of Mr. Hamza
B11Prescription of Mr. Hamza.
B12. Medical Examiner’s Confidential Report.
B13.Personal Statement Regarding Health
B14.25-05-06 Renew LIC Policy.
B15.Policy deed of assignment
PW1. Nabeesa
DW1. V.P.Gopalan
X1- Admission Record of Hamza,issued by Highland Hospital Mangalore.
X2-Out patient record.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Pj/ Forwarded by Order
SENIOR SUPERINTENDENT
