Delhi

East Delhi

CC/1000/2012

GUDDI - Complainant(s)

Versus

L.I.C. - Opp.Party(s)

18 Sep 2017

ORDER

           DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

              CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer complaint no.-   1000/2012

                                                                                                   Date of Institution               06/12/2012

                                                                                                   Order reserved on               18/09/2017        

                                                                                                   Date of Order                        20/09/2017                                                                                     

 

In matter of—

1-Mrs. Guddi, adult   

W/o- Late Jagdish Chand   

2-Ms Neelam, D/o- - Late Jagdish Chand   

3-Ms Preeti, - Late Jagdish Chand   

4-Mst. Akash, Minor, - Late Jagdish Chand   

 

All R/o- C-62, Resettlement Colony

New Gautam Colony

Narela, Delhi……………………….…………………...……………….Complainants

 

                                                                    Vs

The Manager , LIC of India 

Delhi DO II, Scope Minar, North Tower

9^th Floor, District Centre,

Laxmi Nagar, Delhi 110092……….. ……………….……………..Opponent  

 

Quorum   Sh Sukhdev  Singh       President

                  Dr P N Tiwari                Member

                 

Order by Dr P N Tiwari  Member  

 

Brief

This complainant has been filed u/s 12 of C P Act, 1986 against OP for alleged deficiency in their services for rejecting death claim under misrepresentation of facts and non disclosure of facts.

 

Facts of the case                                                                                                

Complainant purchased life insurance policy in 2009 vide policy no. 124618615 for a sum assured Rs 2 lakh. It was stated that complainant got breathlessness and cough so was admitted in Lok Nayak Hospital on 11/05/2011 and expired on 12/05/2011.

Death claim was submitted by the complainant. OP did not pass the claim, but sent a letter dated 10/02/2012 asking for certain documents pertaining to treatment from 08/03/2008 to 11/03/2008 of same treating hospital.

The complainant denied all the facts regarding admission in Lok Nayak Hospital at that time through a letter dated 13/02/2012. Thereafter complainant sent a legal notice dated 25/07/2012 which was replied in frivolous manner on 11/08/2012. Hence, filed this complaint claiming sum assured policy amount and Rs one lakh as compensation with Rs 15,000/-as litigation charges.  

 

OP submitted written statement denying all the allegations of the complainant as wrong and incorrect. It was admitted that deceased /husband of complainant had purchased policy from OP and proposal was accepted on non medical basis where no related medical tests were required as per IRDA guidelines because the age was (42 years) less than required for medical tests.

Policy seeker had not filled required informations correctly in policy proposal (Ex OPW1/1A to D) form clause 11(a) where it was clearly asked as “During the last five years did you consult a medical practitioner for any ailment or required treatment was taken for a week? ”.The deceased husband of complainant had written as “NO”.

Similarly under clause 11(b) it was asked for “Have you ever been admitted to any hospital or nursing home for general checkup, observation, treatment or operation?”. It was replied as “NO”.

It was also asked under clause 11(d) as “Are you suffering from or have you ever suffered from ailment pertaining to liver, stomach, heart, brain or nervous system?” It was replied as “ NO”.

Further it was asked in proposal form under clause 11(i) “your usual status of health? ”. The answer was “Good”.

 It was observed by OP that the policy seeker was under good health and under good faith; the policy was issued on correct informations given by him. Under the contract of Uberrima fides, proposer was under the duty bound to give relevant correct information which he had, but he did not disclose about his ailment related to heart RHD (Rheumatic Heart Disease) and Atrial Septic Defect with their complications for which he remained admitted in Lok Nayak Hospital in 2008 and his policy starts from 2009. The treatment documents were obtained from the hospital (Ex OPW1/1A to D) clearly mentioned about these ailments which were of long duration.  OP also taken a copy of death certificate (Ex OPW1/3) from treating hospital (LNJP). Thus, it amounts to non disclosure of material facts before OP at the time of taking policy. So, repudiation of claim was justified and prayed to dismiss the frivolous claim.

 

Complainant filed her rejoinder and evidences on affidavit where she had affirmed on oath that all her facts and evidences were true and correct. OP had submitted all wrong and incorrect facts on record.  

OP filed their evidences through Mr D K Joshi, Manager Legal at OP office and stated on oath that all the facts pertaining to death claim rejections were based on evidences pertaining to non disclosure of material facts by the husband of complainant, now deceased.

 

Arguments were heard from both the counsels and after perusal of file, order was reserved.

After scrutinizing all the facts and evidences on record, it is to be seen whether complainant was entitled for death claim under policy conditions by considering the following points as under –

1-Whether death claim was genuine by complainant,

2- Whether policy conditions were fulfilled by both the parties,

 

1-Whether death claim was genuine by complainant—

Before discussing for the point 1, we have also gone through the details of ailments he was suffering according to the treatment details (Medical Attendent’s Certificate) taken by OP from treating hospital. It clearly mentioned as the deceased was suffering from multiple congenital heart defects as ASD (Atriel Septal Defect),MS ( Mitral Stenosis) and Rh.HD (Rheumatic Heart Disease). At the time of taking treatment in 2008 and in 2011, deceased had their complications as Pulmonary Hypertension and Congestive Heart Failure.

 

 

At this stage, I would like to clear that Rheumatic Heart Disease starts at the early age of child hood leading to repeated sore throat and recurrent respiratory tract infection. It runs for years despite of taking treatment (unspecific) and ASD which is a internal congenital septal defect. In many new born cases, this defect if present, get healed up usually, but if it fails, precipitates in its complications leading to Pulmonary Hypertension and heart failure known as CHF. When both the conditions (ASD and Rht HD) are present, than symptoms leading to CHF aggravates. All these facts are seen in this treatment document.

 

So, it is clear from medical point of consideration that deceased had intentionally hidden all the symptoms of his diseases and at the time of filling policy proposal form, he did not mention though had clear knowledge of his diseases. So, repudiation of death claim was justified by OP under policy terms and conditions and claim by complainant is not based on correct facts.

 

2- Whether policy conditions were fulfilled by both the parties

It was seen that the complainant took LIC policy from OP which was effective from 15/01/2009 vide policy proposal form inward no. 14439 for a sum assured for Rs 2 lakh under table 179-20-20 and had deposited a premium of Rs 9558/-and it was a yearly paying premium schedule. But scrutinizing the clause 11 of policy proposal form which contains vital informations to be filled at the time of taking policy from OP, has shown that every column was filled as “NO” meaning there by that his health was absolutely in good condition at that time(15/01/2011) and had put his signatures. All the columns were printed in Hindi also as complainant was an eighth pass so it is presumed that he must have read all the columns in Hindi properly before signing the policy proposal form.

OP had also relied on a judgment from NCDRC in Krishna Devi vs LIC of India & others in FA 517/1992 decided on 19/05/1994 where it was laid down that rejection was based on sufficient ground as deceased had suppressed material facts and there was no deficiency on the part of OP.  

 

Thus, we are of the opinion after going through all the facts pertaining to this claim, that complaint has no merit and the same deserves to be dismissed. That being so this complaint is dismissed without cost.  

Copy of this order be sent to the parties as per the Act and file be consigned to Record Room.

 (Dr) P N Tiwari   Member                                         Sukhdev Singh - President