Date of filing: 09.03.2017                                                                      Date of disposal: 07.12.2017.

Complainant: Monalisha Karfa, D/o. Sri Tushar Karfa, resident of Bahir Sarbamangala Para,

                          G.T. Road, P.O., P.S. & Dist.-Burdwan, Pin-713101.

-VERSUS-

Opposite Party: 1. Life Insurance Corporation of India, having its Branch Office at Burdwan,

                                   Branch-III, Sundaram Building, near Parbirhata, P.O.-Sripally, P.S. & Dist.-

                                   Burdwan, Pin-713103, represented by its Branch Manager.

                            2.  The Divisional Manager, Life Insurance Corporation of India, Burdwan

                                    Divisional Office at Gopal Nagar, Ghourdour Chati, P.O.-Sripally, P.S. &

                                    Dist.-Burdwan, Pin-713103.

Present: Hon’ble President: Smt.Jayanti Maitra(Ray).

    Hon’ble Member:  Miss Nivedita Ghosh.

Appeared for the Complainant       :Ld. Advocate, Debdas Rudra.

Appeared for the Opposite Parties: Ld. Advocate, Sourabh Dey.

JUDGEMENT

This is a case U/s.  12  of the C.P.  Act for an award  directing the O.Ps.  to pay Rs.1,10,000/- towards death claim of the insured, to pay Rs.1,00,000/- towards compensation for mental pain, agony and harassment and to pay  litigation cost of Rs.20,000/- to the complainant.

The complainant’s short case in hand is that the mother of the complainant namely, Kakali Karfa, since deceased, was insured under LIC’s New Jeevan Anand Policy bearing No.489975249 issued by LICI.  The said policy was commenced on and from 22.8.2014 and the date of maturity was 22.8.2035.  The basic sum assured amount of the said new Jeevan Anand Policy was Rs.1,10,000/- and the payment of the premium was yearly mode and the premium amount was Rs.7,045/-.  The complainant was the nominee of the said policy.  The mother of the complainant during her life time had already paid the first premium including service charges amounting to Rs.7,155/-  on 22.8.2015. 

On 11.3.2016 the mother of the complainant(insured) was suffering from illness and immediately she was admitted to the Sun Hospital, Super Specialty Hospital, Burdwan on that day.  She was treated under Dr. Arnab Maji.  But ultimately the insured was expired on 12.3.2016 at 9.50 A.M. due to sudden cardio respiratory failure in a case of sepsis.

The complainant intimated the said fact to the O.Ps. on 11.5.2016 and after receiving the letter the O.Ps. sent a letter stating the that the O.Ps. are sending Claim Forms-A,B, C & E and requested to return the said claim from duly filled up along with some documents as per their requirement.  After filled up all the Forms the complainant submitted the same along with other documents before the O.Ps. for reimbursement.  The O.ps. received the same with their seal and signature.  As per request of the O.Ps. the complainant submitted the bank details and the O.Ps. assured the complainant that the death claim amount will be made through NEFT.  On 26.8.2016 the O.Ps. sent a letter requesting to send all the previous treatment papers and all diagnostic report of the insured, Kakali Karfa.  On 13.9.2016 the complainant sent a letter before the O.Ps. stating the fact that his mother was not suffering from any disease and as such there is no question of previous treatment papers as claimed by the O.Ps.  The complainant also intimated that the mother of the complainant was died due to cardio respiratory failure and it would be evident from the certificate of death issued  by the doctor of Sun Hospital.

Inspite of receiving the said letter and getting the information of non-availability of the of the previous treatment papers of the insured the O.Ps. again sent another letter requesting to submit previous treatment papers of the insured, Kakali Karfa on 22.2.2017.  The complainant sent a letter stating that he is not in a position to submit the same.  The complainant went to the office of the O.ps. several times and requested them to settle the death claim as early as possible but O.Ps. did not bother to make any single response.  Finding no other alternatives the complainant filed this case before this Forum for relief as stated above.

The O.P. No.1& 2 jointly contested this case by filing written version and stating that one Kakali karfa purchased a policy being No.489975249 from the O.P. No.1 with the date of commencement from 22.8.2014 having basic sum assured Rs.1,10,000/- under Table No.815.  Be it mentioned that in said policy Monalisha Karfa, daughter of the life assured  was the nominee of the said policy.  Be it also mentioned that two yearly premium of the said policy have adjusted on record.  After death of the insured (Kakali Karfa) the complainant(nominee) death intimation of life assured on 11.5.2016 and thereafter the LICI issued claim form to the complainant.  After scrutiny of the documents these O.Ps. found that life assured, Kakali Karfa was admitted at Sun Hospital, Burdwan on 11.3.2016 and expired on 12.3.2016.  In Form No.3748 the primary cause of death has mentioned Cardio Respiratory Failure and Secondary cause of death mentioned Sepsis with Chronic Kidney disease.  In the said Form No.3748, it was also mentioned that the life assured had been suffering from illness before  the death of admission on 11.3.2016 and the symptom of illness were Respiratory Distress, Fever, Palpitation, Olliguria.  In the said form the husband of the life assured stated at Sun Hospital that the life assured was a patient of Chronic Kidney Disease with Type-II Diabetes Mellitus and she was treated by local doctors.  These O.ps. also observed in Form No.16  that the life assured was under treatment of Dr.S.D. Mishra before admission in the said Hospital and the history of the patient was reported by her husband.  The diagnosis arrived at the Hospital was Cardio Problems (Ventricular Tachycardia), Sepsis, Type-II Diabetic mellitus, Hyperkalermia).  The treatment sheet of Sun Hospital shows a clear picture  that the life assured was a known Type-II diabetic mellitus and Chronic Kidney Disease (Stage-V) patient as on date of admission on 11.3.2016.  On same day the attending physician mentioned ‘patient needs urgent Haemodialysis’.  It was also found in Form No.3783 that the complainant stated herself that the life assured, Kakali Karfa suffering from last illness for the period of six months before the date of admission in Hospital and as such it is evident from the documents submitted by the complainant that life assured was suffering from illness for a long period and took treatment from different local doctor including Dr.S.D.Mishra.  The LICI sent letter dated 5.7.2016, 26.8.2016 and 22.2.2017 to the complainant and requested her to submit previous treatment paper of the deceased life assured but she did not submit the said all papers including diagnostic report of the deceased life assured, prior to admission in Sun Hospital.  But till date these O.ps. have not received the said previous treatment papers including diagnostic report as required by these O.Ps.  Hence, these O.Ps. are not in a position to take a final decision for admissibility of the claim for non-submission of the requirement.   These O.P. also states life assured was suffering from Chronic Kidney Disease (Stage-V) with T2 Diabetes mellitus prior to take admission in the hospital and it is clear from the report of the Sun Hospital.  At the time of admission in the said hospital,  the history of previous treatment was stated by the Husband of the deceased life assured.  The claimant also stated in the Claim Form-A that duration of last illness of the life assured, Kakali Karfa was six months and as such all prescriptions and reports are available under the custody of the complainant.   These O.P. once again requested to the complainant to submit all previous treatment papers immediately for speedy settlement for the claim but the complainant did not submit those required documents till date and thus these O.Ps. are not in a position to take a final decision for admissibility of the claim for non-submission of the requirements till date and as such there was no fault and negligence on the part of these O.Ps. as alleged by the complainant.

These O.Ps. issued the policy in question, subject to the terms, conditions, exceptions and limitation thereof.  There was no negligence, deficiency in service and unfair trade practice on the part of these O.Ps. and as such the complainant is not entitled to get any relief/reliefs as prayed for in the instant case.  Hence, these O.Ps. prayed before your honour to dismiss the instant complaint with cost.

DECISION WITH REASON

            The complainant to prove her case has filed the affidavit of her examination in chief as PW-1, where she stated all the facts.  The O.Ps. prayed for adoption of their written version supported by affidavit, as the evidence of the O.Ps. and the written version was accepted as evidence of O.ps.  Thereafter both parties tabled an elaborate argument.  The complainant filed document like policy paper, premium receipt and treatment papers of Sun Hospital.   That during subsistence of the policy insured was admitted in the Sun Hospital but unfortunately the treatment sheet of the Sun Hospital also submitted.    She was admitted on 11.3.2016 and expired on 12.3.2016.  The medical attendance certificate as submitted with Claim Form-B is showing the particulars of the suffering of various disease and primary cause of death is stated for Cardio Respiratory Failure with Sepsis and Chronic Kidney Disease and Type-II Diabetic Mellitus.  That she was undergoing treatment from local doctor and all the history of illness was reported by the husband of the patient.  The life insured arrived in the hospital with cardiac problem along with all those diseases mentioned above and died on the next day of her admission.

            The treatment sheet of the Sun Hospital submitted by the parties also confirmed that it was a known case of Type-II Diabetic Mellitus and Chronic Kidney Disease of Stage-V on the date of her admission on 11.3.2016 and the physician suggested urgent Haemodialysis.  In the Form-3783 the husband of the deceased stated that his wife was suffering from those ailments for last six months.  Therefore, the Ld. Advocate of the O.Ps. rightly argued that since the insured was in a stage of critical Chronic Kidney Failure (Stage-V),   then how, the complainant can claim that her mother (insured) suffering from illness only for six months before her death.  Even inspite of repeated demand from the O.Ps. for sending the treatment sheet of last six months, but was never produced by the complainant.  So, it was very difficult for the O.P. Insurance Company to settle the matter without having the medical document including diagnostic report. O.Ps. rightly served notice upon the complainant repeatedly asking for those documents to take a final decision after going through the previous treatment papers of the deceased.  On the other hand, the complainant took plea that there is no question of previous treatment papers as her mother was not suffering from any disease. In contradiction, she again stated that her mother i.e. life insured was suffering from last six months and treated by local doctors.  Then why not she did produced all those documents of six months treatment papers?

            We have gone through the medical documents of the deceased submitted by the complainant along with claim form and medical documents also filed by the O.Ps. Reference from Wikipedia O.Ps. produced the explanation of Chronic Kidney Disease (Stage-V), CKD, is the end stage of Kidney Disease or Kidney failure.  Therefore, the argument of Ld. Lawyer of the complainant stated that deceased insured was not suffering from any serious illness and died due to Cardio Respiratory Failure simply, is not tenable.  There is misrepresentation of the fact regarding the disease of the insured and no documents was filed by the petitioner in support of her such claim.  Ld. Lawyer for the O.Ps. cited a decision as reported in CPJ II (2015) page-196 that ‘suppression of such material facts leads to repudiation of claim.  The contract is based on utmost good faith.  Therefore, any deliberate suppression of information leads to repudiation of contract.’

            After hearing argument both sides and on perusal of the medical documents the treatment sheet of Sun Hospital and the Claim Form filled up by the complainant, it is clear to this Forum that the life insured was suffering from Chronic Kidney Disease Stage-V with Type-II Diabetic Mellitus and her condition was so critical that she died next day of her admission in the hospital.  The complainant failed to produce treatment papers and deliberately withheld the medical documents of prior illness, even regarding treatment of six months prior to her death which she possessed.  Therefore, we do not find negligence or deficiency in service on the part of the O.P. Insurance Company as  they could not settle the claim awaited and  for medical documents of previous treatment papers from the complainant and even did not repudiated the claim. The O.P. Insurance Company is to settle the claim in terms and conditions with exception and limitation of the policy.    So, there is no negligence, deficiency in service and unfair trade practice on the part of these O.Ps.  Therefore, we find that the complainant failed to prove her case and she is not entitled to get any relief as prayed for.    C.F. paid is correct.  Hence, it is

Ordered

that the case be and the same is dismissed on contest without any cost.

Let the copies of this order be supplied to the parties free of cost.

         Jayanti Maitra (Ray)        

             Dictated and corrected by me.                                                         President      

                                                                                                                   D.C.D.R.F., Burdwan

                   Jayanti Maitra (Ray)

                           President,

                   D.C.D.R.F., Burdwan

(Nivedita Ghosh)

Member

D.C.D.R.F., Burdwan