Date of filing:14.8.2013
Date of Disposal:6.2.2014
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II::
VIJAYAWADA, KRISHNA DISTRICT.
Present: SRI A. M. L. NARASIMHA RAO, B.SC., B. L., PRESIDENT
SMT N. TRIPURA SUNDARI, B. COM., B. L., MEMBER
SRI S.SREERAM, B.COM., B.A., B.L., MEMBER
THURSDAY, THE 6TH DAY OF FEBRUARY, 2014.
C.C.No.145 OF 2013.
Between :
Mangalapudi Joseph, S/o Appaiah, Hindu, 56 years, Social Worker, R/o Door No.42-39-21, Luna Center, Ajitsingh Nagar, Vijayawada 520 015.
….. Complainant.
And
Life Insurance Corporation of India, Rep., by its Branch Manager, City Branch III, Swarnalok Complex, Governorpet, Vijayawada 520 002
…..Opposite Party.
This complaint is coming before us for final hearing on 22.1.2014 in the presence of Sri D.Ravi Kiran, Counsel for complainant and Sri P.Ramakrishna Paramahamsa , Counsel for opposite party and upon perusing the material available on record, this Forum delivers the following:
O R D E R
(Delivered by Hon’ble Member Sri S.Sreeram)
This is s complaint filed by the complainant under Section 12 of the Consumer Protection Act for a direction to the opposite party to pay a sum of Rs.3,00,000/- towards sum assured along with bonus with interest at 12% per annum from the date of submission of claim till the date of payment, award Rs.50,000/- towards compensation for mental agony, for costs and other reliefs.
The brief facts which lead to filing the present complaint are that:
1. The wife of the complainant by name Singapogu Mary Visrantham who worked as Chief Matron in Railway Hospital, S.C. Railway, Vijayawada had taken insurance policy bearing No.673826102 from the opposite party for a sum assured of Rs.3,00,000/- which is commencing from 13.8.2010. It is submitted that the officials of opposite party people after receiving the proposal from the insured made enquiry regarding age, health condition and paying capacity, issued policy. The complainant is the nominee under the said policy. While so, the wife of complainant complained of cough and throat discomfort and approached Nagarjuna Hospitals, Vijayawada where the doctors diagnosed her as end stage lung disease (Idiopathic Pulmonary Fibrosis) and she expired on 31.3.2012. The complainant being nominee under the said policy submitted claim with all required documents including original policy document and he also submitted the leave particulars of his wife. But the opposite party sent a letter dated 12.4.2013 repudiating the claim of complainant on the ground that “She made deliberate misstatement and withheld material information regarding her sick leave, health and hospitalization at the time of affecting the insurance’. It is further submitted that the repudiation made by the opposite party on the alleged ground is not bonafide and that at the time of taking policy, the deceased was hale and healthy and never complained of any ill treatment. It is further submitted that except the discharge summary, there is no other evidence available or collected regarding the treatment of deceased and that the acts of opposite party amounts to deficiency of service. Hence, the complaint.
2. Denying the material allegations made in the complaint, the opposite party filed version. The opposite party admitted the issuance of policy to the complainant’s wife and also contended that the complainant and his wife committed fraud on LIC and that she has suppressed the material facts and took policy. It is further contended that the complainants wife answered all questions as ‘NO’ in Col.No.11 of Form No.3 and she gave declaration that she has not suppressed anything. It is further contended that after the death of deceased, they caused enquiries which reveals that the deceased was suffered with “Acute Exacerbation of Interstitial Lung Disease for Pulmonale” and that the cause of death is “End Stage Lung Disease”. It is further contended that they also obtained Medical Attendants Certificate dated 21.2.2013 in Form-B issued by Senior Divisional Medical officer, SC Railway, Vijayawada where in it was stated that the deceased has been suffering from the disease for the last five years prior to her death. It is also reveals that the symptoms started in the year 2007 and worsened since 2011. It is further contended that the deceased availed sick leave prior to taking of policy, but she has not mentioned about the same in the personal statement. It is further contended that the declaration given by the deceased while getting policy are false and she suppressed the fact of pre-existing disease and as such there is no deficiency in service on the part of opposite party in repudiating the claim and prayed to dismiss the complaint.
3. The complainant filed his chief affidavit reiterating the contents of his complaint and got marked Ex.A.1 to Ex.A.5. The Legal Manager of Opposite party filed chief affidavit and got marked Ex.B.1 to Ex.B.9 on its behalf. The opposite party filed I.A.No.256/2013 for issuance of summons to Dr.D.Sitaram, Senior Divisional Medical Officer, Railway Hospital, Vijayawada to give evidence and for production of medical treatment documents of deceased and record of absence. The said IA was allowed and Dr.D.Sitaram was examined on behalf of the opposite party and Ex.X.1 and Ex.X.2 are marked through him.
4. Heard both sides and perused the record.
5. Now the points that arise for consideration is:
1. Whether there is any deficiency in service on the part of the opposite party in repudiating the claim of the complainant?
2.If so, whether the complainant is entitled for any relief?
3. To what extent?
POINTS 1 AND 2:-
6. On perusal of the material on record i.e., complaint, version and documents, it is an undisputed fact that the complainant’s wife during her life time had taken policy from the opposite party on 13.8.2010 under Policy No.673826102. According to complainant, the sum assured is Rs.3,00,000/-. Though the complainant has not filed any insurance policy in support of his case, the non denial of said facts by opposite party establishes the issuance of policy and sum assured value etc. On the other hand, the opposite party got marked the policy bond under Ex.B.2. It is also not in dispute that the complainant’s wife was working in S.C. Railway, Vijayawada. It is also not in dispute that the said policy was lapsed and it was renewed. Further it is also not in dispute that the complainant is nominee of deceased.
7. The case of the complainant as seen from complaint is that his wife by name Singapogu Mary Visrantam suddenly complained of cough and throat discomfort and she approached the Nagarjuna Hospitals, Vijayawada where she was diagnosed to have ‘End Stage Lung Disease (Idopathic Pulmonary Fibrosis)’ and that while undergoing treatment, she died on 31.3.2012. Ex.A.5 = Ex.B.4. case summary issued by Nagarjuna Hopsital, Vijayawada discloses the fact of death of deceased Visrantam. Ex.B.3 discharge summary issued by Nagarjuna Hospital discloses the date of admission as 28.2.2012 and discharge as 7.3.2012.
8. It is the further case of the complainant that when the complainant laid claim, it was repudiated by opposite party stating that the wife of complainant suppressed the fact of pre-existing disease and that she made deliberate misstatement and withheld material information regarding her sick leave, health and hospitalization at the time of affecting the insurance, which is no valid and that the deceased never complained of any ailment and the disease which causes for death was affected subsequent to the policy. In this regard, the contention of the opposite party is that the complainant’s wife suppressed the material facts of preexisting disease and took policy and that she gave declaration that she has not suppressed anything and thereby violated the breach of her duty to disclose the correct facts and that the Medical Attendance Certificate of employer, discharge summary issued by nagarjuna Hospitals reveals that the wife of complainant is having ‘Interstitial Lung Disease – 5 years” and as such the complainant is not entitled for any relief.
9. On perusal of the record discloses that, the complainant submitted the proposal form on 17.7.2010 i.e., Ex.B.1 and as per the policy bond i.e., Ex.B.2 the date of commencement of policy is from 13.8.2010. As per complainant version, his wife suffered ill health and she was admitted in Nagarjuna Hospital, Vijayawada and later died on 31.3.2012. Ex.B.3 Discharge Summary of deceased issued by Nagarjuna Hospital, Vijayawada discloses that the wife of complainant by name Visranthamma was admitted in hospital on 28.2.2012 and discharged on 7.3.2012. Further Ex.B.4 = Ex.A.5 case summary discloses that the wife of complainant again joined on 27.3.2012 and died on 31.3.2012. In both Ex.B.3 and Ex.B.4, the doctors diagnosed the deceased as “Acture Exacerbation of Interstitial Lung Disease (IPF) Cor Pulomonale” and “End Stage Lung Disease (Idiopathi Pulmonary Fibrosis) Type – 1 Respiratory failure COR Pulmonale. Further as seen from Ex.B.8 certificate issued by employer of deceased discloses that the deceased was suffering from severe breathlessness for five years and the symptoms started in the year 2007 and worsened since 2011”. Further inCol.No.9 of Ex.B.8, it is mentioned that deceased was treated for interstitial Lung Disease during three years preceding her last illness. As seen from the above documentary evidence, it is clear that the deceased had pas history of illness with regard to breathing problem since 2007. Further the sick leave applied by deceased from the year 2007 till death, which are evident from, Ex.B.7 would also strengthen the case of opposite party that the deceased had past history of illness. Section 45 of the Insurance Act provides that no policy shall be called in question after expiry of two years from the date of which it was issued. In the instance case, the wife of complainant died within two years from the date of proposal and as such the opposite party has got every right to enquire into the matter. Further as seen from record, it is clear that the deceased is an educated person and she subscribed her signatures in the proposal form after having understood all the contents of proposal form given answers to the questions in Col.No.11 under the head PERSONAL INFORMATION as follows:
6. | Have you got treatment for any ill health which required for more than week days | | No. |
| Have you admitted in hospital for the purpose of treatment, surgery etc. | | No. |
| Have you absented for job prior to five years | | No. |
| Have you suffered from any ill health regarding Liver, Stomach, Lungs, Kidneys, Brain and Nerves | | No. |
10. As seen from the documentary evidence marked on behalf of the opposite party and as discussed supra, it is clear that the wife of complainant is a chronic patient of “Lung Disease”. But the complainant’s wife, at the time of filling the proposal form, has not informed about the said ailment, applying of sick leave and as such she has not disclosed the material facts and suppressed the preexisting disease of wife of complainant. Further it is not the contention of complainant that the opposite party people without asking the complainant’s wife and without conducting medical checkup issued the policy. The complainant’s wife being prudent ought to have informed about the ailments, treatments and leave particulars. Further she informed that her health condition is good in the proposal form. It is settled law that the contract of insurance is based on good faith on the part of insured and when information on a specific aspect is asked for in the proposal form, the insured is under the obligation to make a true and full disclosure of information on the subject which is within his knowledge. In this case, though the complainant’s has got knowledge about the ailment, he has not disclosed the same at the time of taking policy. Definitely Section 45 of the Insurance Act is a beneficial legislation and the interest of the insured to be protected. But the fraudulent intention of insured in not disclosing correct facts cannot be entertained.
10. In this regard, it is the contention of complainant is that his wife never complained about any ailment and the disease which cause her death has affected subsequent to policy. To rebut the said contentions, the opposite party examined the Railway Hospital Doctor, Vijayawada by summoning him and got marked Ex.X.1 sick leave particulars of deceased and Ex.X.2 outpatient tickets of deceased from the year 2007. During chief examination, he categorically admitted that the deceased was diagnosed in the year 2011 to have interstitial Lung Disease, which is end stage of disease. The deceased was suffering from the symptoms of Bronchitis from 2007 and that Bronchitis is common symptom in general public, but it may progress to Interstitial Lung Disease and that in the year 2007 the deceased had attack of Bronchitis and the symptoms progress to end stage of lung disease. When this Forum examined the doctor on some aspects, he replied that Interstitial Lung Disease is the end stage of Chronic Pulmonary Disease and to develop the same, the patient must have symptoms for at least four to five years. So as per the evidence of doctor, the deceased had past history of illness from 2007 onwards and it became chronic and came to end stage and died in the year 2012. But as seen from proposal form, which is of the year 2010, it is clear that the complainant suppressed the said fact and taken policy in the year 2010. As such it is clear violation of terms and conditions of policy. Further the admission made by the doctor that for developing Interstitial lung disease, the patient must have symptoms for at least four to five years and Ex.X.1 outpatient tickets of deceased, strengthen the contention of opposite party that the deceased had past history of Lung Disease.
11. The Hon’ble National Commission, New Delhi in a number of cases held that
“that any inaccurate answer will entitle the insurer to repudiate the liability because there is a clear presumption that any information sought for in the proposal form is material for the purpose of entering into contract of insurance” And further held that
Suppression of pre existing disease was deliberate”
In the present case on hand also, the complainant’s wife suppressed the preexisting disease and leave particulars, though it is within her knowledge and thereby suppressed the material fact.
12. The decisions of Hon’ble National Commission, New Delhi relied on by the opposite party i.e.,
(i) Revision Petition No.4875/12 between Usha Rani Gupta Vs. LIC & Others – Wherein it was held that there is no deficiency of service in repudiation by claim by insurer and leave records of the deceased prove that he was under treatment prior to and after hospitalization and he was under obligation to give correct answers pertaining to his health at the time of revival of lapsed policy.
(ii) Revision Petition No.3848/07 between LIC Vs. Kempamma and another – Wherein it was held that claim repudiation is fully justified in a case where the insured is on regular treatment and hence fully aware of his state of health, and statements made in the proposal form are untrue to his knowledge.
(iii) Revision petition No.2314/12 between C.N.Mohan Raj Vs. New India Assurance Co., Ltd.,- Wherein it was held that suppression of material facts in respect of preexisting disease was deliberate.
(iv) Revision petition No.1385/09 between Mrs.Hemalatha Avinash Mhatre Vs. LIC – wherein it was held that the statement made in the proposal form in respect of leave was false, which was material fact, hence LIC was justified in repudiating the claim.
These decisions are squarely applicable to the case on hand as the facts and circumstances are one and the same.
13. In view of the foregoing discussion, we hold that there is no deficiency of service on the part of opposite parties in repudiating the claim. The complaint is devoid of merits and is liable to be dismissed.
14. In the result, the complaint is dismissed, but in the circumstances of the case, there is no order as to costs.
Typewritten by Stenographer K.Sivaram Prasad, corrected by me and pronounced by us in the open Forum, this the 6th day of February, 2014.
PRESIDENT MEMBER MEMBER
APPENDIX OF EVIDENCE
WITNESSES EXAMINED
For the complainant: For the opposite party:-
P.W.1 M.Joseph D.W.1 E.Vidyadhar Complainant Manager (Legal & HPF),
(by affidavit) of the opposite party,
(by affidavit)
DOCUMENTS MARKED
On behalf of the Complainant:
Ex.A.1 12.04.2013 Letter from the opposite party to the complainant along with application for insurance.
Ex.A.2 20.12.2012 Letter from the opposite party to the complainant.
Ex.A.3 23.11.2012 Letter from the complainant to the opposite party.
Ex.A.4 21.11.2012 Photocopy of Certificate issued by Divisional Medical Officer, South Central Railway, Vijayawada.
Ex.A.5 31.03.2012 Photocopy of Case summary issued by Nagarjuna Hospital, Vijayawada.
On behalf of the opposite party:-
Ex.B.1 17.07.2010 Photocopy of application form for insurance.
Ex.B.2 16.08.2010 Attested copy of insurance policy.
Ex.B.3 07.03.2012 Attested copy of Discharge Summary issued by Nagarjuna Hospital, Vijayawada.
Ex.B.4 31.03.2012 Photocopy of Case summary issued by Nagarjuna Hospital,
Ex.B.5 . . Attested copy of Claimant’s Statement.
Ex.B.6 21.11.2012 Photocopy of Certificate issued by Divisional Medical Officer,
South Central Railway, Vijayawada.
Ex.B.7 . . Attested copy of Certificate by Employer.
Ex.B.8 . . Attested copy of Medical Attendant’s Certificate.
Ex.B.9 12.04.2013 Photocopy of letter from the opposite party to the complainant along with application for insurance.
Ex.X.1 30.12.2013 Record of absence from duty of Smt Mary Visrantham,
Matron i.e., the wife of the complainant issued by Chief
Medical Superintendant, Railway Hospital, Vijayawada.
Ex.X.2 . .. Five outpatient tickets of the wife of the complainant.
PRESIDENT
