F.A.No.861 OF 2007 AGAINST C.D.NO.9 OF 2005 DISTRICT CONSUMER FORUM-II KRISHNA AT VIJAYAWADA

Between
1.      The Branch manager,
          LIC of India, Career Agents Unit,
          Vani Niketan Building, Post Box No.326
          Ramachandra Rao Road, Governorpet
          Vijayawada-002

2.      The Senior Divisional Manager,
          Divisional office, LIC of India,
          Kennedy Road, Machilipatnam

                                                                                                                    Appellants/ opposite parties

          A N D

1.   Kolla Santhi W/o late Kolla Durga Prasad
R/o Plot No.G3, Sravya Towers, by the side of
Ravi Neuro Centre, Near Jammichettu,
Mogalarajapuram, Vijayawada Krishna District

2.   Kolla Saranya being rep. by her natural guardian
next friend mother the 2^nd complainant herein,
D/o late Kolla Durga Prasad, R/o Plot No.G3,
Sravya Towers, by the side of
Ravi Neuro Centre, Near Jammichettu,
Mogalarajapuram, Vijayawada Krishna District

Respondents/ complainants

Counsel for the Appellants             Sri N.Krishna Mohan

Counsel for the Respondents         Sri V.Surender Reddy 

QUORUM:      HON’BLE SRI JUSTICE D.APPA RAO, PRESIDENT

                                                      &

                              SRI R.LAKSHMINARSIMHA RAO, MEMBER

                   WEDNESDAY THE THIRTIETH DAY OF DECEMBER                 

                                        TWO THOUSAND NINE

             Oral Order ( As per R.Lakshminarsimha Rao, Member)
                                                          ***

The opposite party is the appellant. This appeal is directed against the order dated 3^rd  day of April,2006 passed by the District Forum-II, Krishna in C.D.No. 9 of 2005    whereby the appellant   was directed to pay the sum assured of Rs, 10 lakhs along with  interest @7.5%, Rs.5,000/- towards damages and Rs.2,000/- towards costs.

Briefly stated the material facts giving rise to the appeal are: The husband of the  1^st complainant obtained insurance policy under ‘Jeevan Anand’ scheme for a sum of Rs.10,00,000/- commencing from 20^th day of August,2003 on quarterly premium payable  Rs.22,731/. The insured paid the 1^st quarterly premium on 30^th September,2003. The policy was issued by the opposite party  after accepting the proposal and after the relevant formalities including the examination of the insured by their  panel doctor were completed.  The first complainant’s husband appointed their daughter, the second complainant as his nominee for the purpose of receiving the benefits conferred by the insurance policy in case he meets an untimely death. The insured died on 8^th November,2003 at Apollo Hospital, Hyderabad. After the death of her husband, the complainant no.1 in the capacity of natural guardian of her daughter submitted claim along with relevant documents on 28^th November,2003. The second opposite party repudiated the claim  on 31^st day March,2004. The 1^st opposite party issued notice to pay the quarterly premium of Rs.22,731/- on or before 20^th March,2004. The repudiation of the claim is on untenable grounds. Therefore, the complainant sought the amount covered under the insurance policy.

          The 1^st opposite party filed counter resisting the claim of the complainant and stating that the deceased submitted the proposal dated 29^th September,2003 by paying an amount of Rs.22,731/- on 30^th September,2003 with a request to date back the policy from 20^th August,2003. After scrutinizing the medical reports submitted by the 1^st complainant’s husband,8^th October,2003 the opposite party no.1 had called for his chest x-ray which was submitted  on 13^th October,2003. After receiving all the requirements, the 1^st opposite party accepted the proposal on 16^th October,2003 dating back the commencement of the policy at the request of the insured to 20^th august,2003 and issued the insurance policy on 18^th day of October,2003 after adjusting the amount paid on 30^th day of September,2003 towards the 1^st premium. As per the declaration made by the insured in the proposal, he agreed to inform the opposite party no.1 any change in  his general health condition and occupation before issuing the 1^st premium receipt. The first premium receipt was issued on 15^th October, 2006.

The 1^st opposite party conducted enquiry into the claim which revealed that the insured took treatment in Apollo Hospital, Hyderabad and died on 8^th November,2003 and prior to the treatment in Apollo Hospital, the deceased took treatment in Arun kidney centre,  and Help Hospitals, Vijayawada. The 1^st complainant submitted claim on 19^th February,2004. The insured was not maintaining good health prior to the date of proposal. The opposite party no.1 collected evidence like case sheet and declaration  of legal representatives. According to the case sheet of the HELP hospital, Vijayawada the insured was shifted from Arun Kidney Centre, Vijayawada on 6^th October,2003 for further management. At the time of admission he was suffering from Status Epilepticus, Essential Hypertension and Diabetes Mellitus. The insured was discharged on 10^th October,2003 and again admitted to Arun Kidney Centre, Vijayawada and Apollo Hospital, Hyderabad and ultimately he died on 8^th November,2003 in Apollo Hospital due to cardio respiratory arrest following Hypo Encophapthy.

Basing on the information from the case sheet the claim was repudiated for suppression of the material facts which were not even disclosed by the insured at the time of submitting the x-ray report on 13^th October,2003. The claim was repudiated  on 31^st March,2004. The date of proposal is 29^th September,2003. Some reports are dated 30^th October,2003 and final x-ray report was submitted on 13^th October,2003 prior to date of acceptance on 15^th Ocotober,2003. The deceased was well aware of the disease which he was suffering from 6^th October,2003 at the time of admission in HELP hospital when he was shifted from Arun kidney Centre. As a general practice, the opposite party no.1 regularly issues machine generated notices to all policy holders about the due premium whether the policy is in force or in lapsed condition. The opposite party no.1 repudiated the claim within 45 days of its submission. There was no deficiency in service on the part of the opposite parties. Hence, prayed to dismiss the complaint.

          The complainant no.1 has filed her affidavit. ExA1 to A6 were marked on their side. The opposite parties got marked documents ExB1 to B7 and RWs1 and 2 were examined on their behalf.

          The District Forum  opined that there was no suppression of material fact in regard to his health by the deceased insured and as such the opposite parties committed deficient service by repudiating the claim of the complainants.

The points for consideration are

1.   Whether there was any suppression of material fact by the first complainant’s husband in submitting the proposal?

2.   Whether the opposite parties committed any deficiency in service?

3.   To what relief?

POINTS NO 1 & 2:   The opposite party no.1 issued Jeevan Anand Policy ,ExB2  with profits and accident benefit. The proposal review slip,ExB3 evidences thorough check up of the deceased by the panel doctor of the opposite parties.  It is the contention of the appellants that the deceased suppressed the fact of his ailment. The appellants placed reliance upon ExB4 to B6. ExB4 is the letter addressed by Doctor S.Bhanu Prabhakar wherein it is stated that the deceased was sent on 6^th October,2003 to the doctor for further management as also that at the time of  admission the deceased was suffering from hypertension and diabetes mellitus. Further, Ex.B4 discloses that the deceased was discharged on 10^th October,2003 within five days of his admission.

          The witnesses examined on behalf of the opposite parties have not supported their case.  Doctor Ammanna Raja, RW1 has stated that he knew the deceased for a long time and the deceased never told him he was suffering from hypertension. He has stated that once the patient complained that he felt giddy. Further, he has stated “ On 6^th October,2003 the patient came to me by walk and he complained me he was feeling giddy, while we were examining through a Fit and became unconscious. Immediately, we resuscitated and shifted him to Help Hospital and recovered in two days. At that time he was not having Hypertension or Diabetes i.e., October,2003.” The witness  has stated that the blood sugar of the deceased read as 430 mgs on 5^th November,2003 was due to the I.V.fluids which were given to the patient at the time of his resuscitation. He has stated that it was mentioned in the case sheet,ExC1 that the deceased was hypertensive and that was stated on information from attendant as the patient was unconscious on 6^th October,2003 when he was shifted to Help Hospital.  In his cross examination RW1 has stated that there is no record to show that patient was hypertensive. The evidence of this witness does not help the case of the appellants.  It supports the version of the complainants.

          The consultant doctor of Help Hospital deposed that when the patient was shifted from Arun Kidney centre to the Help Hospital, as per the case sheet issued by the Kidney centre, the deceased was suffering from Hypertension and Diabetes. He has stated “ As per the history, the patient was not having any hypertension  and Diabetes” During his stay in the hospital, the patient’s B.P. was normal except on one or two occasions and as such he was not prescribed any drugs for Blood Pressure. Further, he has deposed that the patient was treated in Hielp Hospital for Status Epilepticus and Diabetes. In his cross examination  RW2 has stated that he is not competent to speak about Status Epilepticus. He had given treatment as  per the instructions of Doctor Srinivas Reddy , neuro physician. According to the RW2 the reasons for change in sugar level in the blood of the patients vary due to I.V.fluids , food quality and natural causes.

          The evidence of this witness does not corroborate the evidence of the opposite parties.  The witness, RW1 and RW2 and Exs.B1 to B4 does not establish any suppression of material fact by the deceased when he submitted the proposal to the opposite parties.

          Coming to Ex.B5, case sheet issued by Help Hospitals, Vijayawada, it shows that the deceased was admitted on 6^th October 2003 to the hospital with the complaint of giddiness, convulsion and shortlessness of breath .  The deceased was discharged on 10.10.2003.  The deceased diagnosed to have suffered from ‘status epilepticus, essential hypertension and diabetes mellitus’.  Relying upon the admission of the deceased in Help Hospitals on 6.10.2003, the learned counsel for the appellants contends that the deceased had the knowledge of the disease as on 6.10.2003 and suppressed the fact in his proposal.  We do not agree with the learned counsel for the reason that the proposal was submitted on 29.9.2003 while he was admitted in the Help Hospitals on 6.10.2003.  By a perusal of the contents of the Ex.B5 it cannot  be inferred that the deceased was suffering from diabetes and hypertension and that he having knowledge of such diseases inflicting on him, suppressed the fact in his proposal.

          Arun Kidney Centre, Vijayawada issued Ex.B6, discharge summary wherein the reason for admission is mentioned as “unconscious, respiratory distress’ and presenting symptoms are shows as “ a known hypertensive, fell unconscious”.  This document does not establish any suppression of fact by the deceased insured. 

It is pertinent to note that the appellants have got the insured medically examined.  They sought for various reports including chest X-ray and having satisfied with the health and disposition of the deceased, the opposite parties had accepted the proposal and issued the insurance policy in favour of the husband of the first complainant.  The witnesses examined by the appellants did not support their case.  There is no other evidence to come to conclusion that the deceased suffered from diabetes and hypertension earlier to the date of proposal.   Hence we find no merit in the appeal and the appeal is liable to be dismissed.

          In the result the appeal is dismissed confirming the order of the District Forum.  No costs.  Time for compliance four weeks.

                                                                                                                                                                       Sd/-

                                                                                                                                                           PRESIDENT

                                                                                                                                                                     Sd/-                                                                                                                                                                                MEMBER

                                                                                                                                                           30.12.2009

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