Date of Filling : 05.08.2013
Date of Disposal: 13.10.2015
DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, THIRUVALLUR
PRESENT: THIRU. S.PANDIAN, B.Sc., L.L.M., … PRESIDENT
TMT. S.SUJATHA,B.Sc., … MEMBER-I
CC.43/2013
Tuesday, the 13th day of October 2015
Tmt.S. Gowri
w/o Late.R.N.Sivaiah
Alangadu Village,
Tharatchi Post,
Uthukottai Taluk,
Thiruvallur District. …Complainant
/Vs/
- The Manager,
LIC of India, Divisional Office -II,
C-47, IInd Avenue,
Nagar Plaza, Anna Nagar,
Chennai - 600 040.
- The Branch Manager,
LIC of India,
J.N.Road, Oil Mill, Thiruvallur - 602 001. …Opposite Parties
….
This Complaint is coming upon before us finally on 23.09.2015 in the Presence of Thiru.V.Gajapathy, Advocate on the side of the complainant and Thiru.V.Rajkumar Joshi, Advocate for the opposite party and upon hearing arguments on the side of the complainant and perused the documents and evidence, this Forum delivered the following,
ORDER
PRONOUNCED BY THIRU. S. PANDIAN, PRESIDENT
This Complaint is filed by the complainant U/S 12 of Consumer Protection Act, 1986, to direct the opposite party to settle the claim of 4,00,000/- LIC policy No.719213973 along with interest and cost.
The Brief averments of the complaint as follows:
- Complainant’s husband died on 25.06.2011. Subsequent to his death,
the complainant has submitted a claim form seeking benefits under the Life Insurance Policy stated supra. Original Policy, Original death Register extract of her husband and Original Legal Heirs certificate etc., were submitted along with the Claim Form to the 1st opposite party at the instance of the 2nd opposite party. That the opposite parties have dragged her from pillar to post under some pretext or the other and postponed the payment of insurance policy amount to the complainant indefinitely. When the complainant had approached the opposite parties several times and requested them to disperse the Insurance Policy Benefits to her. When the complainant mounted pressure, the 1st opposite party sent a letter dated 10.10.2011.
- The accident to her husband took place in 2004 i.e. six years prior to
the Insurance Policy was taken by him. Moreover, the time when the Insurance Policy was taken, complainant’s husband underwent a thorough medical checkup by the authorized doctor of the opposite parties and fitness of the Insurer was confirmed. It is only after due procedure, complainant’s husband late. R.N. Sivaiah was permitted to take L.I.C.’s new Bima Gold Policy for a sum of Rs.4,00,000/-under the policy No.719213973. The death of her husband on 25.06.2011 was a natural death. There is no dispute regarding his heath.
3. The opposite parties have deliberately failed and neglected to settle the Insurance Policy claim to the complainant. The conduct of the opposite parties amounts to deficiency in service. The indifferent attitude of the opposite parties caused anxiety, mental torture and agony to the complainant, besides financial loss. In such circumstance, a notice dated 11.05.2013 was sent to the opposite parties. It was acknowledged by both of them. Unfortunately, they have neither complied with the demand of the complainant nor responded for the notice. Hence this complaint.
The contention of the written version of the opposite parties has brief as follows:
4. The complaint is not maintainable in law and on facts. That it entered into insurance contract for RISK COVER OF 400000 on the basis of the proposal form dt.16.07.2010 and medical report dt. 18.07.2010 signed and submitted by the deceased policy holder R.N.Sivaiah. Since the date of death of R.N.Sivaiah (deceased policy holder) is within one year from the risk cover date 18.07.2010 the opposite party II forwarded the claim forms and other connected papers to the opposite party I for their perusal and decision. The letter dt.10.10.2010 sent to the complainant by the opposite party I calling for treatment details of surgery underwent by the deceased policy holder is on the basis of the enquiry made by the opposite party I as early claim (death within one year) made under the policy.
5. The deceased policy holder met with a major road accident and hospitalized for days and underwent major surgery in National Hospital Chennai before taking the above policy. These facts were not revealed by the deceased policy holder while taking insurance cover or the complaint making claim under the policy. The opposite parties LIC called for the details regarding the accident and consequent medical treatments of the life assured in their letter dt.10.10.2010. In reply to this letter the complainant accepted the fact that the deceased policy holder met with a road accident and treatment was taken in the Chennai hospital but stated that no details available regarding treatment with her now. And the complainant produced a letter from the National Hospitals, Chennai stating that no records available now due to change of management”. If it had been disclosed LIC would have called for some more reports including treatment details and underwriting decision would have taken according the reports received. This opportunity of taking fair decision had been denied by the proponent by not disclosing the fact of accident.
6. The opposite parties LIC submit that the deceased met with a major accident before the proposal for the insurance policy in question and despite having the knowledge of the fact, he intentionally did not disclose the same in the declaration made on 16.07.2010 in the proposal for insurance and with held the same to secure the policy of insurance from the opposite party. The DECEASED LIFE ASSURED for questions No.11(b). Have you ever been admitted to any hospitals or nursing home, for general check up, observation treatment or operation? and Qn No 11(g) did you ever have any accident or injury?, in the proposal form dt.16.07.2010, stated as No Considering the purpose of the query in the policy, it is clear the complainant and the deceased did not stick to the principle utmost good faith while giving the personal information which was only within their personal knowledge, which should be construed as material suppression, made to enrich themselves by the insurance amount. IT IS AGAINST THE TERMS OF THE POLICY CONTRACT AND AGAINST THE INSURANCE LAW. The opposite parties LIC rightly rejected the claim through their letter.
7. In order to get death benefit from policy the complainant has raised a bogey of deficiency of service. The opposite party did not commit any deficiency of service as alleged by the complainant. Hence the complainant is not entitled to receive policy amount compensation and cost as demanded in the complaint. The complaint has no cause of action and deserves to be dismissed.
8. On the side of the complainant, she has filed the proof affidavit as her evidence and marked Exhibit A1 to A7. Similarly, the opposite party also submitted the proof affidavit for their evidence and marked as Exhibits B1 to B5.
8. At this juncture, the point for the consideration before this Forum is:
- Whether there is any deficiency of service on the part of the opposite parties?
- To what other relief the complainant is entitled?
10.Written arguments filed on both sides and the copies of the same is furnished
to either side. In addition to that, Oral Arguments also adduced by both parties.
11. Point 1: Accordingly to the case of the complainant is that the opposite
parties have repudiated the Insurance claim demanded by the complainant in lieu of the death of her husband Tr.Sivaiah under the L.I.C. policy bearing the No.719213973 for the premium of Rs.4,00,000/- without any valid reason. On the other hand, the opposite party vehemently demanded the allegation made by the complaint that they have repudiated claim as per the Insurance Law on the ground of suppression of material facts by the deceased Sivaiah, the husband of the complainant herein at the time of taking policy and therefore there is no deficiency in service.
12. At this juncture, it goes without saying that the complainant has
Bounden duty to prove the above said allegation against the opposite party by means of relevant evidence. At the outset, on perusal of the evidence of the complainant, it is learnt that the deceased husband of the complainant by name Tr.R.N.Shivaiah has taken L.I.C., NEW BIMA GOLD policy No.719313973 from the 2nd opposite party for a value of Rs.4,00,000/- during his life time which is marked as Exhibit A1, while the said policy was in force, the husband of the complainant died in 25.06.2011 and subsequently to the death of the husband, the complainant being the Nominee had submitted the claim form and seeking befits under the L.I.C. Act. The death certificate of the deceased and Legal Heirship certificate are all marked as Exhibit A2 & A3 respectively, But the opposite parties have repudiated the above said claim. Then the complainant was requested through Exhibit A4, the copy of the certificate, regarding the treatment details with discharge summary for the accident met by the deceased Sivaiah, the husband of the complainant here in. In this connection, the National Hospital, Chennai has addressed the LIC of India, Chennai dated 26.04.2013 by stating that the National Hospital has been given on long lease to M/S Kamakshi Memorial Hospital, Pallikarunai, since 16.06.2011 and as such they are not in charge of the administration which is marked as Exhibit B4, on the side of the opposite parties. So, in spite of the complainant had taken necessary efforts to produce the treatment details of the deceased Sivaiah, it could not be obtained for the reason stated by the concerned National Hospital as in Exhibit B4. Further, it is seen from the cross examination of the complainant, they have not claimed any compensation from the Motor Accidents Claim Tribunal, regarding the injuries sustained in the said accident since it was very minor one. So it can be easily presumed that the alleged accident was a minor one and not a major accident as alleged by the opposite party and it is no way affected the health of the deceased Sivaiah.
13. More so, it is categorically admitted by the evidence adduced by the opposite party that before issue of the policy the deceased Sivaiah was examined for through Medical check up as per rules under Insurance Act by the Medical Officer, Thiru. K. Vijayakumar, who is attached with LIC of India and issued certificate for fitness to issue of policy and then only the competent authority of LIC of India had scrutinized the same and decided to issue policy to the deceased Sivaiah. Not only that, it is an admitted fact that the application form for taking policy shall be filled up by the Agent in all cases and similarly in this case also Thiru.G.Mani, LIC Agent has filled up the application form and so it is no doubt that only after due satisfaction of him and then only the materials have been filled up by him. In such circumstances, unless the above said medical officer and the agent examined the real fact, could not be come to light. But the opposite party has not chosen to examine the above said witness before this Forum. Not only that, the witness Thiru.A.Jayakumar who examined on the side of the opposite party has clearly stated during his cross examination that there is no specific condition under Insurance Act that if the policy holder was met with an accident is not a disqualification for taking policy. It reads as, 2004š ÁtŒahΡF V‰g£l rhiy ég¤J v¤jifahdJ v‹gJ vd¡F neuoahf¤ bjçahJ. Insurance Act-‹go, vªj xU egU« VjhtJ rhiy ég¤Âš mog£lhš, mt® ghèÁ vL¡f¤ jFÂa‰wt® vd¡ F¿¥Ã£L ãgªjid VJ« Ïšiy.
14. In light of the facts and circumstances of this case, it is crystal clear that the complainant is entitled for policy value. At the same time, the delay in producing the detailed treatment report with discharge summary of the deceased Sivaiah, who was met with an accident in the year 2004 is on the part of the complainant also and to that effect it took larger delay in settling the claim of LIC policy. Therefore, it can not be said that there is deficiency in service on the part of the opposite party fully. Thus the Point No-1 is answered accordingly.
13.Point 2: In view of the conclusion arrived in point no.1 and considering
all the circumstances this Forum concludes that the complainant is entitled for the policy value with reasonable interest and cost and not entitled for any compensation. Thus the point no.2 is answered accordingly.
In the result, this complaint is allowed in part. Accordingly, the opposite parties are jointly and severally directed to pay a sum of Rs.4,00,000/-(Rupees four lakhs only) being the policy value of the L.I.C. Policy No.719213979, NEW BIMA GOLD, with accrued Bonus if any as per Rules of the L.L.C with interest at a rate of 10% from 10.10.2011 to till the date of this order i.e.13.10.2015 within one month from the date of receipt of the copy of this order and with a cost of Rs.5,000/- (Rupees five thousand only)
The above amount shall be payable within one month from the date of receipt of the copy of the order, failing which the said amount shall carry interest at the rate of 9% P.A. till the date of payment.
Dictated by the president to the steno-typist, transcribed and computerized by her, correctly by the President and pronounced by us in the open Forum on this 13th October 2015.
Sd/-*** Sd/-***
MEMBER I PRESIDENT
List of Documents filed by the complainant
Ex.A1/Dt. : Xerox copy of the New Bima Gold Policy Bond of the
complainant husband.
Ex.A2/Dt.22.07.2011: Xerox copy of the Death Certificate of complainant’s husband
given by the Deputy Tashildar, Uthukkottai.
Ex.A3/Dt.12.09.2011: Xerox copy of the Legal Heirship Certificate of the complainant
given by the Tashildat, Uthukkottai.
Ex.A4/Dt.10.10.2012: Xerox copy of the letter sent by the 2nd opposite party to the
complainant.
Ex.A5/Dt.11.05.2013: Office copy of the legal notice sent by the complainant’s counsel
to the 2nd opposite party.
Ex.A6/Dt. : Postal acknowledgement card of the 2nd opposite party.
Ex.A7/Dt : Postal acknowledgement card of the 2nd opposite party.
List of Documents filed by the Opposite Party
Ex.B1/Dt. : Xerox copy of the New Bima Gold Policy Bond of the
complainant’s husband.
Ex.B2/Dt. : Xerox copy of the proposal form and medical certificate of the
complainant.
Ex.B3/Dt.10.10.2012: Xerox copy of the letter sent by the 2nd opposite party to the
complainant.
Ex.B4/Dt.26.04.2013: Xerox copy of the letter of the said National Hospital, Chennai.
Ex.B5/Dt.19.09.2013: Xerox copy of the letter sent by the 2nd opposite party to the
complainant.
Sd/-*** Sd/-***
MEMBER I PRESIDENT
