IN THE CONSUMER DISPUTES REDRESSAL FORUM, KANNUR Present: Sri.K.Gopalan: President Smt.K.P.Preethakumari: Member Smt.M.D.Jessy: Member Dated this, the 17th day of March 2010 C.C.No.53/2006 Leena Ashok, Poyyil House, Near Vankulathuvayal, P.O.Azhikode (Rep. by Adv.M.Govindan Kutty) Complainant 1. The Divisional Manager, Life Insurance Corporation of India, Divisional Office, Jeevan Praksh, P.B.No.177, Kozhikode. (Rep. by Adv.R.Shyam Kumar) 2. Manger, LIC of India, Branch Office, N.2, Fort Road, Kannur (Rep. by Adv.R.Shyam Kumar) 3. C.K.Malathi, LIC Agent, Puliyamkode House, P.O.Valapattanam, Kannur 10. Opposite parties O R D E R Sri.K.Gopalan, President This is a complaint filed under section 12 of consumer protection Act for an order directing the opposite parties to release the claim amount with b onus and to pay Rs.2,00,000/- as compensation to the complainant together with the cost of this proceedings. The facts of the case of the complainant in brief are as follows: The complainant Smt.Leena Ashok is the sister of Mr.N.Ligesh, who has taken the LIC policy vide No.793767443. Mr.Ligesh breathed his last on 16.9.04 from Apollo Hospital, Chennai, where he was admitted on the same day due to certain unexpected ailments like fever and stomach complaints. He has only 26 years of age. The complainant, the nominee of the insured submitted claim in the month of October 2004. But she received only intimation letter of repudiation of claim on 14.3.05 stating that at the time of signing proposal form, the deceased had withheld correct information regarding his health and had given false answers to the questions in the proposal form. Complainant submitted a review before the Zonal office of the opposite party in Chennai on 289.3.05. But that was also rejected. Repudiation of claim is quite arbitrary and without any justification. No false declaration or statement has been given by her brother insured at the time of signing the proposal. Mr.Ligesh had been admitted in Kasthurba Hospital, Manipal on 27.11.2998 due to some abdominal complaints. After thorough check up it was revealed that he had no complex disease and so he was discharged on 1.12.1998 after complete recovery. Thereafter he never had any such complaints or treatment. More over he has reaps excellent track record. In 2001 he completed B Tech Degree in Mechanical Engineering. In 2003 he secured Level 1 certificate in Business English. In 2000 he participated in National Centre for Soft ware Technology Exam and scored high marks. From 1999 December to 2000 January he underwent in plant training in Keltron. He secured 3rd prize in soft ware Development contest. He reaped vista of achievements in and off the campus. In 2001 itself he was placed as a soft ware Engineer in Wipro, Bangalore 3rd opposite party approached him at this stage and explained different schemes and policies and thereby insured for a sum of Rs.5,00,000/-. Three answers given by her brother have been taken as a ground to repudiate the claim. The first question is 11(a) during the last 5 years did you consult a medical practitioner for any ailment requiring treatment for more than a week. The answer was no. There is nothing wrong in this answer, because the treatment in Manipal Hospital was from 27.11.1998 to 1.12.1998. The proposal form was signed on 7.2.04 i.e. after 5years of the receipt of treatment. The second answer is also correct because he never had any such major complaint. The 3rd question 11(i) was “Whether your usual sate of health was good”. That is answered yes. The career and achievements that he had reaped is the best proof to justify this answer. Before effecting the policy insured had undergone a medical examination by Dr.D.P.Mahesh Gopalan of Pallikunnu, Kannur. The answer was recorded by him. In the medical examination the doctor has not found any illness or ill health in the insured. As per claim form B, Medical attendant’s certificate of the doctor of Apollo Hospital has cited in claim 4(a) that the primary cause of death is septic shock/DIC. It has no connection with the one the patient had in 1998. The complainant’s brother had never been under the influence of any recurring or chronic disease. The repudiation of claim is irresponsible, unjustifiable and brutal act of opposite parties. Hence this complaint. In pursuance of notice opposite parties 1 and 2 entered appearance and filed version denying the main averments of complainant. 3rd opposite party remained absent as a whole throughout. Opposite parties case is that the policy was issued to Sri.Ligesh Nelliyotte believing that the information produced through answers in the proposal form dt.7.2.04 to be true. Insurance contract is governed by the principle of utmost good faith and the insuring party is bound to disclose all facts relevant to assess the risk ascertaining his insurability and rate of premium. Inc se the death of the policy holder takes place within two/three years from the date of issue of the policy the claim is treated as early claim and information is sought about the treatment underwent by the party at the time of death and prior to that an investigation also made by the authorized officer of LIC of India to find out if there is any history post illness or any other adverse feature which were suppressed by the insured at the time of proposal. In cases it is revealed that there is suppression of facts, the claim is repudiated and the premiums paid forfeited Mr.Ligesh died on 16.9.04. The medical certificate showed that the insured died due to septic shock DIC, secondary cause being inflammatory bowel disease. It was also stated in the form that CROHN’S Disease was diagnosed in the year 1998 at Manipal Hospital, Mangalore. It was also found from relevant records hat the deceased was admitted to Kasturba Hospital, Manipal on 27.11.1998 and discharged on 1.12.1998. Final diagnosis was CROHN’s Disease. The case sheet pertaining to the treatment showed history of illness as abdominal distension – 2years – paid in epigastria and lumbar regions. Subsequently the claim was repudiated for reasons of withholding correct information. The insured was suffering from CROHN’s disease and he took treatment at KMC Manipal from 27.11.1998 to 1.12.1998 following complaints of abdominal distension – 2 years, loose stools, fever for 6 months etc. the death claim was repudiated on 14.3.2005. The claimant filed review petition and the decision was upheld and confirmed by Zonal Review Committee. It is not true that the deceased was discharged after complete recovery. There were specific questions in the proposal from question 11(a) to (1). To the question 9.11(b) have you ever been admitted to any hospital or nursing home for general check up, observation or treatment or operation, the answer was “No”. These questions rose to elicit information of past hospitalization and it do not related to any period or purpose of hospitalization. The assured could have revealed the information of hospitalization. The answer to their question ii (d) was also untrue and false. The question is thus “Are you suffering from or have-you ever suffered from ailments pertaining to Liver, Stomach, Heart, Lungs, Kidney, Brain or Nervous system? The answer given was untrue. The contract of insurance is nullified for non disclosure suppression etc. of facts. There is no negligence or deficiency in service on the part of opposite parties. Hence to dismiss the complaint. On the above pleadings the following issues have been taken for consideration. 1. Whether there is any deficiency in service on the part of opposite party? 2. Whether the complainant is entitled for the relief as claimed in the complaint? 3. Relief and cost. The evidence consists of the oral testimony of Pw1, DW1, DW2, Exts.A1 to A20, B1 to B22 and Ext.X1. Issue Nos.1 to 3 Admittedly complainant’s brother has taken a Life Insurance policy and the complainant is the nominee. The proposal form was signed on7.2.04. The insured breath his last on 16.9.04, few months after taking the policy. The claim was submitted but rejected on the ground of suppression facts with regard to the health condition of the insured. The case of the complainant, the sister of the deceased inured is that the repudiating of claim is deficiency in service on the part of opposite party. The contention of opposite party that the claim was repudiated on the ground of suppression of facts is quite arbitrary and without any justification. Her brother did not give any false declaration or statement. Her brother, the deceased Ligesh had been admitted in Kasthurba Medical College, Manipal on 27.11.1998 due to some abdominal complaints. After thorough check up it was revealed that he has no complex disease and so he was discharged on 1.12.1998 after compete recovery. Thereafter he never had any such complaint or treatment. The answers given by him had been true and correct and all the entries in the proposal form were bonafide and genuine. Hence the opposite parties are liable to compensate. The case of the opposite parties per contra, that incase of death of policyholder that takes place within two three years from the date of issue of policy the claim is treated ‘as an early claim’ and information is sought about the treatment underwent by the party at the time of death and prior to that and an investigation also made by the authorized officer of LIC of India to find out if there is any history of the past illness. In the case of Ligesh, it is found that he died due to septic shock/DIC secondary cause being inflammatory Bowel Disease. It was also found that the deceased Ligesh was admitted on 27.11.1998 and discharged on 1.12.1998. The final diagnosis was CROHN’s Disease. The case sheet pertaining to the treatment a Kasurba shows the history of illness as abdominal distension – 2 years – pain in epigastricum and lumbar regions. But the insured suppressed these material information regarding his health, which he bound to disclose. He answered the specific questions in the proposal form in the direction that he is in good health and there is no history of ailments suffered by him. Thus the claim was repudiated. The main question to be decided is whether there is any suppression of fact on the part of complainant in respect of his health condition which the complainant bound to disclose. Ext. B1 is the proposal for insurance on own life. Page 3 of Ext.B1 shows that questions 11(a) to (l) is answered by the complainant. Except the answer to the question 11(a) all other questions are seen answered “No” The answer to the second question is no doubt very relevant to be considered. The following is the question – 11(b) “Have you ever been admitted to any hospital or nursing home for general check up, observation, treatment or operation? The answer is” No”. The documents produced and other evidence available unequivocally make it clear the answer is also intend to suppress true facts of the health of insured. It is pertinent to note that this is a case of an early claim. The complainant admitted that her deceased brother Ligesh had been admitted in Kasturba Hospital, Manipal on 27.11.1998 due to some abdominal complaints. No other evidence is necessary other than this admission of the complainant to prove that the answer given by the complainant to the question 11(b) in ext.B1 is false, which against declaration. Discharge of the insured on complete recovery cannot help to justify the false answer given to the question. The complainant’s case is that all the entries in the proposal form Ext.B1 were bonafide and genuine, which are never intended to be false. She added that complainant’s brother never intended to cheat the opposite party by giving false answers and declaration. She has explained the correctness of answers given to questions 11(d), 11(i) etc. but kept silence without giving any explanation of answer given to the question 11(b) in Ext.B1. What is the meaning of this diplomatic silence? Until and unless it is answered complainant does not deserve any consideration to look into other aspects. The learned counsel for the complainants argued elaborately in the most attractive way leaving the above mentioned point, the answer “No” to the question 11(b) of the proposal form Ext.B1. It cannot be ignored the fact that the contract of Insurance is governed by the principle of “Utmost good faith”. Hence we are of opinion that the complainant failed to establish deficiency in service on the part of opposite party in repudiating the claim on the ground of suppression of material facts. It has been established by the answer to the question 11(b) “No”, that the insured had concealed material facts while taking the insurance policy. The regulation defines the word material to mean and include all “important” “essential” and “relevant” information in the context of guiding the insurer to decide whether to undertake the risk or not. It is pointed out by Hon’ble Supreme court in Satwant Kaur Sandhu vs. New India Assurance Company reported in IV(2009) CPJ 8(SC) that “ the upshot of the entire discussion is that in a contract of Insurance, any fact which would influence the mind of a prudent insurer in deciding whether to accept or not to accept the risk is a ‘material fact’. If the proposer has the knowledge of such fact, he is obliged to disclose it particularly while answering questions in the proposal form. Need less to emphasize that any inaccurate answer will entitle the insurer to repudiate his liability because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering in to a contract of Insurance”. There can be hardly be any scope for doubt that the information required in the afore-extracted question 11(b) of the proposal form Ext. B1 was on material fact and answer given to that question was definitely a factor which would have influenced and guided the opposite party insurance company to enter into the contract of insurance with the insured. Judged from any angle, we have no hesitation in coming to the conclusion that the answer given by the insured in the proposal form in respect of 11(b) in untrue to his knowledge. The complainant is not entitled for any remedy as prayed in the complaint. Thus issues 1 to 3 are answered against the complainant. In view of the forgoing discussion, we do not find any merit in this complaint, which is dismissed accordingly but with no order as to costs. Sd/- Sd/- Sd/- President Member Member APPENDIX Exhibits for the complainant A1.Power of attorney A2.copy of the proposal form A3.Death certificate of Ligesh A4.copy of the letter sent to OP A5& 6.Copy of the letter dt.14.3.05 and 23.3.05 sent by OP A7.Copy of the letter dt.28.3.05 sent to LIC Zonal office, Chennai A8.Death summary issued from Apollo Hospital, Chennai A9.copy of Medical attendant’s certificate “ A10.Copy of certificate of Hospital treatment from “ A11. Certificate of B.Tech Degree of Ligesh A12.Certificate for Software Tech Exam of “ A.13.Certificate from College of Engineering Tvm. A14.Certificate issued from Keltron A15. Certificate of Mechanical Engineering Association A16. Level I certificate in Business English A17. Appointment letter from WIPRO A18.Salary offer letter from WIPRO A19.Medical check up letter from WIPRO A20.Confirmatin letter issued from WIPRO Exhibits for the opposite parties B1.Proposal for insurance of Ligesh. B2.Medical examination report of Ligesh B3.Policy of Ligesh B4.Photo copy of Birth certificate of Ligesh B5. Original Death Information letter of Ligesh B6.Death certificate of Ligesh B7.Claimants statements B8.Claim inquiry report B9.Letter of Apollo Hospital B10 to 13. Claim form B, B1,C and E. B14.Vertical illness and premium wavier benefit rider B15.copy of letter sent to complainant B16.Letter sent by complainant B17.Copy of the letter sent to Kasthurba Hospital B18& 19.Letters issued from Kasturba Hospital B20.Copy of discharge summary with history B21.copy of letter sent to complainant B22.AD card Exhibits for the court X1.Certgificate issued from Apollo Hospital Witness examined for the complainant PW1.P.K.K.Nair Witness examined for the opposite parties DW1.Mohammed.A.P DW2.Dr.P.Mahesh Gopalan /forwarded by order/ Senior Superintendent Consumer Disputes Redressal Forum, Kannur
| | HONORABLE PREETHAKUMARI.K.P, Member | HONORABLE GOPALAN.K, PRESIDENT | HONORABLE JESSY.M.D, Member | | 
