IN THE CONSUMER DISPUTES REDRESSAL FORUM, KANNUR Present: Sri.K.Gopalan: President Smt.K.P.Preethakumari: Member Smt.M.D.Jessy: Member Dated this, the 17th day of February 2010 CC.209/2006 1.Rohini.K. D/0.Kunhappa. 2. Sindhu, W/o.Sasidharan 3.Nithika(M) aged 11 years D/O.Sasidharan, Rep.by NF Mother Sindhu. Complainants Rajitha Bhavan, Kudukkimotta, P.O.Kanhirode 1.Senior Division Manger, Divisional Office, LIC of India, Calicut. 2. Senior Branch Manger, opposite parties LIC of India, Branch office II, Fort Road, Kannur. (Rep. by Adv.K.Vijayan) O R D E R Sri.K.Gopalan, President This is a complaint filed under section12 of Consumer Protection act for an order directing the opposite parties to settle the claim. The case of the complainants in brief are as follows: The deceased Sasidharan the son of the 1st complainant and husband of the second complainant and father of the 3rd complainant was the policy holder vide policy No.794267072 type ORD,DOC 15.10.2004 Maturity 10/2020. The sum assured is Rs.30, 000/-. The second complainant, wife is the nominee. Premium paid up to 2/06. On 25.2.2006 the policy holder admitted to Dhanalakshmi Hospital Kannur following vomiting blood and becoming unconscious. Thereafter he was referred to MIMS Hospital, Calicut. He was treated as inpatient till 30.3.06 and operation was conducted. Since there was no improvement in his ailment he was shifted to Pariyaram Medical college and he died on 18.5.2006. The cause of death shown as Cardiac arrest. Diagnosis shows his disease was CIRROSIS LIVER 9ALD0 PORTAL HYPER TENSION, HEPATIC ENCEPHLOPATHY. Complainant had spent about 10 lakh for the treatment. During his life time Sasidharan did not say anything about the policy to the complainants. The premium was due only after 4/06. Deceased was in coma since admission and not possible to pay the amount. Nonpayment of premium was due to above reasons. The claim form was repudiated on 23.8.06 on a sole reason of the non payment of the last premium 4/06. Hence this complaint for the settlement of the claim. Pursuant to the notice by the Forum opposite parties 1 and 2 entered appearance and filed version jointly. The brief facts of the case of opposite parties are as follows: the opposite parties did not know whether the complainant Rohini and Nithika are mother and daughter of deceased. The deceased Sasidharan was life assured under Endowment policy bearing No.794267072 commenced on 15.10.04. His wife, the 2nd complainant herein was the nominee. The sum assured is Rs.3, 00,000/-. Mr.Sasidharan did not remit him premium payable on 15th April 2006 and the contract provides a grace period of one month from the due date. The premium was not paid even during the grace period and therefore the policy got nullified on 15th May 2006. The deceased was an alcoholic and was having liver disease. The allegation that the complainant spent more than 10 lakh for his treatment is unbelievable and not correct. The cause of death is not cardiac arrest as alleged but it was due to pulmonary aspiration and respiratory arrest due to his liver disease. The claim rejected on valid ground. Complainant did not make any efforts to settle the matter apart from filing claim. The allegation that all efforts to settle the matter failed due to the hostile attitude of the opposite party are false. The deceased was having four other policies also and this opposite party had settled those claims. The premium of policy No.790488212 payable in March 2005 was not paid but that claim was settled as the policy ran more than three years and in such cases there is a claim concession as per terms of policy itself. The case in dispute ran only for 1 ½ years and therefore not entitled for claim concession. The complainant could have approach claim review committee if aggrieved. There is no deficiency of service on the part of these opposite parties. Hence to dismiss the complaint. On the above pleadings the following issues have been taken for consideration. 1. Whether there is any deficiency of service on the part of opposite parties? 2. Whether the complainant is entitled for the remedy as prayed in the complaint? 3. Relief and cost. The evidence consists of the oral testimony of PW1, DW1, and A1 to A4 and Exts.B1 to B3. Issue Nos. 1 to3 Admittedly the deceased Sasidharan’s life was assured under endowment policy bearing No.794267072 commenced on 15.10.04. Mr.Sashidharan breathed his last on18.5.06 from Pariyaram Medical College. He was shifted to Pariyaram since there was no improvement in his ailment by the treatment from MIMS, Calicut. The death certificate issued by Pariyaram Medical college Hospital, Ext.A1 shows that the cause of death is ‘Cardiac Arrest’. Ext.A1 also reveals that his disease was diagnosis as “CIRRHOSIS LIVER (ALDDD) PORTAL HYPERTENSION, HEPATIC ENCEPHALOPATHY’. The insurance claim repudiated by the opposite party on the reason that the premium payable on 15.4.06 was not paid. It is true that the premium due has not been paid. The main case of the opposite party is that the premium was not paid even during the grace period of one month and therefore the policy got nullified on 15th May 2006 and the complainant is not entitled for the claim. Ext.A3 repudiation letter reveals that the only reason for rejecting the claim is nothing but non payment of premium of 4/2005. Opposite party took the stand that the policy became lapsed since he did not make payment of premium payable on 15.4.06 on that date or during the grace period. It is pertinent to note that this is the only and last default committed by the policy holder. Ext.A4 proves that Mr.Sasidharan, the policy holder was admitted to MIMS Calicut on 27.2.06 and undergone treatment till his discharge on 30.3.06. Final diagnosis reads: “Cirrhosis of liver with PORTAL Hypertension (MELD SCORF-16) Hepatic encephalopathy, Left Lower lobe pneumonia, acute renal failure”. He was discharged from MIMS on 30.3.06. Ext.A1 reveals that on the very same day 8.50 P.M he was admitted in Pariyaram Medical College Hospital and undergone treatment till he breathed his last on 18.5.06. It is pertinent to note that Ext.A1 shows Diagnosis :HEPATIC ENCEPHALOPATHY-COMA’. Thus history of treatment reveals that the deceased was in coma during the period of treatment. Complainants pleaded this fact which had not been denied by the opposite party, though they have some other cases in connection with the disease. Whatever may be the contention it is a plain fact that the policy holder had been in death had capable of doing nothing. Under such circumstances it is inhuman to conclude that the deceased committed default of payment knowingly. In the usual course of common life one cannot expect from a person who had been laid up like that of deceased Sasidharan that there is chance for thinking of and paying of insurance premium from this most unfortunate death bed. It cannot also be ignored that he is a man of only 39 years. Opposite party should have been sympathetically considered the claim taking into account the peculiar state of affair under which the deceased had been laid up as totally invalid. Since the deceased was under coma which is evident in ext.A1 the death has to be considered taken place during the grace period. The impossibility on the part of the policy holder to do anything under the above explained condition cannot be straight away ignored, which definitely deserves for sympathetic consideration. There is no justifiable reason not to consider the claim sympathetically. We are of opinion that complainants are entitled to get the claim deducting the premium payable. Since the only ground to reject the claim was non payment of premium as per Ext.A3 there s no need to go in to deep in other points to decide this case. It is important to note that the deceased Sasidharan had four other policies in his name and opposite party had settled all other policies. That also confirms that opposite party is well aware of the position of the deceased. The case Pramila Vikram Khillare Vs. Life Insurance Corporation of India reported in IV (2205) CPJ 22 NC is a case, the facts of which are similar to the case in hand. In the above said case premium was not paid during the grace period. It was held that the Heirs are entitled to sum assured. It can be seen that the death took place therein during the grace period. In the light of the above discussion and the perusal of records we have no hesitation to hold that the complainants are entitled to get the sum assured deducting the premium payable. The issues 1 to 3 are found in favour of complainants. In the result, complaint allowed directing the opposite parties to settle the claim paying the sum assured deducting the premium together with a payment of Rs.1000/-(Rupees One thousand only) as cost of this proceedings, within one month from the date of receipt of this order, failing which the complainants are entitled to execute the order as per the provisions of Consumer Protection act. Sd/- Sd/- Sd/- President Member Member APPENDIX Exhibits for the complainant A1.copy of the death certificate of Sasidharan A2.Copy of the letter sent to OP A3.Letter dt.23.8.06 issued by OP A4.MIMS Dept. of Gastroenterology issued a report. Exhibits for the opposite party B1.Copyt of the policy No.794267072 B2.Copy of the status report regarding policy NO. 794267072 B3.Copy of the Medical attendant’s certificate dt.4.7.06 issued from Pariyaram Medical college. Witness examined for the complainant PW1.Rohini Witness examined for the opposite party DW1.Mohammed.A.P. /forwarded by order/ Senior Superintendent Consumer Disputes Redressal Forum, Kannur.
......................GOPALAN.K
......................JESSY.M.D
......................PREETHAKUMARI.K.P | | 
