By. Smt. Bindu. R, President:

            This complaint is filed by Sunny. P. K, S/o. Kuriakose, Padinjarel House, Seethamount Post, Wayanad against  T. A. Jayan, Chief Life Insurance Advisor, Code No.M0025-79K, LIC of India, Sulthan Bathery Branch and others as Opposite Parties alleging deficiency of service and unfair trade practice from the side of the Opposite Parties.

            2.  The Complainant states that the Complainant is the husband of (Late) Shaini Varghese who died on 13.12.2021 at DM WIMS Hospital, Thazhe Arapatta, Meppadi Wayanad. Late Shaini Varghese had joined in a Life Insurance Policy for a total coverage of Rs.5,00,000/- plus Bonus and Interest vide Policy No.799305225 of Opposite Parties No.2 and 3 through Opposite Party No.1 LIC Insurance Advisor and had paid Rs.16,318/- towards the half year premium of the policy.  According to the Complainant the wife (late) of the Complainant joined the policy only because of the reason that the Opposite Party No.1 agent had approached the Complainant and his family several times and made them to believe that the said policy is the best among available and suitable for his wife (diseased) and the Complainant’s wife continued to renew the policy. The Opposite Party No.1 also assured that if any claim occurs, the same would be accepted then and there without delay and the claim will be refunded or reimbursed instantly.

            3.  The Complainant states that, the wife of the Complainant failed to pay for the half yearly premium during 7/2020 and revived the policy after receiving the intimation from the Opposite party No.2 by paying an amount of Rs.34,653/- on 12/02/2021.  At the time of revival, no health checkup was suggested by the Opposite Parties.  Later the Complainant’s wife was affected with Covid-19 in December 2021 and died due to covid on 13.12.2021.  The Complainant states that he had approached the Opposite Party No.2 for the sum assured in the policy and submitted the Death Certificate and Covid-19 Death declaration along with the claim form.  The Opposite Party No.2 forwarded the request to the Opposite Party No.3 and the Opposite Party No.3 paid only Rs.2,31,079/- as the remitted amount with interest and repudiated the claim stating that the deceased had Metastatic Breast Cancer.  According to the Complainant the wife of the Complainant died due to Covid-19 and the repudiation of the claim is by stating another reason.  The case of the Complainant is that the Opposite Parties had not conducted health check up at the time of revival of the policy.  Hence the Complainant states that he was cheated by the Opposite Parties which had resulted mental agony and the same amounts to deficiency of service on the part of the Opposite Parties.  The Opposite Parties are jointly and severally liable for the same and hence the Complaint praying for issuing a direction to the Opposite Parties to pay the balance of the total sum assured along with bonus after deducting the paid amount with interest and for other reliefs.

            4. Upon notice, Opposite Parties No.1 and 3 entered into appearance and filed their version.  Opposite Party No.2 is called absent and set ex-parte since not turned up. 

5.  Opposite Party No.1, in his version admitted that he is  the insurance advisor of Opposite Party No.2 and 3 and denied the statement of the Complainant that the deceased wife of the Complainant took the policy as per the advice of the Opposite Party No.1.  According to Opposite Party No.1 the Complainant and his wife came to the office of Opposite Party No.1 and enquired about the policy suitable for the wife of the Complainant.  Hence Opposite Party No.1 explained all the available policies of Opposite Party No.2 and 3 and it is the Complainant and his wife selected the policy.  Thus the wife of the Complainant signed the proposal form and submitted it to the LIC and LIC issued the policy to the wife of the Complainant.  Opposite Party No.1 states that after issuance of policy, the policy holder and the LIC are obliged to meet the conditions of the policy and Opposite Party No.1 has nothing to do with after issuing the policy by LIC.  According to Opposite Party No.1 when a premium is not paid, the policy will be renewed only after submitting a renewal form and a declaration which was done by the wife of the Complainant and thus the policy was renewed.   In connection with filling up of the declaration form the Complainant and his wife approached the Opposite Party No.1 and Opposite Party No.1 filled the form as per the instructions given by the Complainant and his wife and the same was signed after read and explained to the Complainant and his wife and the same was submitted in the LIC Office by the Complainant and his wife themselves and got the policy renewed.  According to Opposite Party No.1 there is no deficiency of service from the side of Opposite Party No.1 and he is not liable for any damage caused to the Complainant and hence prayed for dismissal of the complaint with costs.

            6. Opposite Party No.3 filed version stating that there is no merit in the petition and is to be dismissed inlimine as the same is vexatious, devoid of merits and not maintainable against Opposite Parties and there is no deficiency of service on the part of the Opposite Parties. According to them the policy bond in the instant case envisages and signifies specifically the details and conditions in the event of subsequent claims which is printed on the back of the policy documents and claim under the policy issued would be payable only on the basis of the terms and conditions given in the policy.  The breaking of the  payment of premium and the further renewal are admitted by Opposite Party No.2 and 3.  The statement of the Complainant that his wife, the life assured, died on 13.12.2021 due to Covid-19 is not true.  The statement that the Opposite Party paid only Rs.2,31,079/- along with interest and that the ground stated for repudiation of claim are correct.  But it is not for evading from the legal liability as stated in the complaint.  As far as the present claim is concerned, LIC investigated the claim as a usual practice and found that the life assured ie (late) Shaini Varghese was continuously treated at DM WIMS Meppadi.  As per the progress notes and doctor’s orders on 08.12.2021 it is a “known case of metastatic Carcinoma breast, stage four, S/P, left breast conservatory surgery axillary staging on 29/05/2017 and KRUKENBERY Tumor (metastatic disease of ovaries).  It is stated by the Opposite Party that as per the claim form B, the deceased life assured have previously consulted on 08.04.2017 in general surgery and on 28.10.2020 in OBG, all before the date of revival of the policy.  According to the Opposite Party the important facts relating to the health of the life assured were not revealed by the life assured at the time of revival of policy on 09/04/2021.  In the declaration form it is stated that she is of good and sound health and she had not undergone any surgery.  According to the Opposite Parties, the corporation would not have accepted the revival, if the insured had revealed the correct health ailments and treatment.  Hence there is suppression of material facts and the life assured acted with intention to mislead LIC and a fraudulent misrepresentation is made to misguide the LIC.  According to Opposite Party No.3 the repudiation of claim was strictly in accordance with the stipulation and hence Opposite Parties made payment of Rs.1,09,375/- along with Rs.72,750/- towards bonus and Rs.48,954/- as refund of premium collected on revival.  Thus an amount of Rs.2,31,079/- had been paid without any delay and there is no deficiency of service or unfair trade practice from the side of the Opposite Parties No.2 and 3.  According to the Opposite Parties the Complainant is not entitled or eligible to get any relief claimed and hence prayed for dismissal of the complaint with compensatory costs.

            7.  Evidence in this case consists of the oral evidence of PW1 and Ext.A1 to A6 are marked from the side of the Complainant.  The oral evidence of OPW1 and OPW2 and Ext.B1 to B4 and Ext.B6 and B7 were marked.  The marking of Ext.B5 objected and is marked as subject to proof.  The summoned documents are marked as Ext.X1 series. 

            8.  Heard both sides.

            9.  The following are the main points to be analyzed in this complaint to derive into an inference of the fact.

1. Whether the Complainant had sustained to any deficiency of service or unfair trade practice from the side of the Opposite Parties?
2. If so, the quantum of compensation and other reliefs for which the Complainant is eligible to get.

10.  Commission considered the matter in detail after verifying the oral evidences and the documents produced by both sides.

            11.   The case of the Complainant is that the Opposite Parties had repudiated the claim even though the policy is renewed by the wife of the Complainant (deceased) which amounts to deficiency of service and unfair trade practice from the side of the Opposite Parties.   The contention taken by the Opposite Party is that the Complainant’s wife had died due to ailments associated with cancer and not due to Covid 19.  They also contented that the repudiation of the claim is due to the reason that the life assured had suppressed the material facts regarding previous ailments and also disbursed the amounts for which they are eligible.

12. During cross-examination by Opposite Party No.1 the Complainant deposed that “ 1 mw FXrI£n insurance GPâmWv At±lw policy FSp¡m\mbn klmbn¨p.  Rm³ ]dª   details AbmÄ proposal form  fill  sNbvXp.  AXnsâ ASnØm\¯nemWv Opposite Party No.2 and 3 policy issue sNbvXXv”.  PW1 further deposed that “policy  XpI Xtc­Xv insurance company BWv.  H¶mw FXrI£nbpsS `mK¯v bmsXmcp tkh\hogv¨bpanà F¶p ]dªm icnbmWv.  C³jqd³kv I¼\nbmWv \jvS]cnlmcw Xtc­Xv”. 

13.  During cross-examination by Opposite Party No.2 and 3 the Complainant deposed that “F\n¡v  policy D­mbncp¶p.  AXv surrender sNbvXv ss]k hm§n.  Cu policy holder IqsSbmWv Rm³ policy FSp¯Xv.  AShv apS§nbt¸mÄ surrender  sNbvXp. Ext.A1 shown to witness CXv  policy proposal form BWv AXv policy BWv F¶v chief affidavit  ]dªncn¡p¶Xv sXämbn«mWv.  4þmw as¯ page  6-þmw column state of health “good” F¶mWv FgpXnbncn¡p¶Xv. Wife \v Hcp AkpJhpw D­mbncp¶nÃ. covid h¶mWv acWs¸«Xv. hb\mSv Wims Hospital  NnInÕbv¡p t]mbncp¶p. 2020 \v ap³]v I®nsâ NnInÕbv¡v t]mbncp¶p.  surgery \S¶Xmbn F\n¡v HmÀ½bnÃ. Local hospital  Nne kab§fn t]mIdp­v. Sreesha Hospital epw Padichira Govt Hospital  epw t]mImdp­v. Wims Hospital  left breast  cancer Bbn 29/05/2017  Shaini Varghese surgery ¡v hnt[bambncpt¶m F¶v F\n¡dnbnÃ.  2017 apX Iotam sXdm¸n¡v `mcy hnt[bambncpt¶m F¶dnbnÃ.  No^v A^nUhnänt\msSm¸w lmPcm¡n¡mWp¶ death summary (Ext.A3) patient  sâ t]cv Shiny Varghese BWv.  2þmw column 2^nd category FgpXnImWp¶Xv icnbmWv. Overy  cancer  I­p ]nSn¨Xmbn last line  ImWp¶p­v.  izmkw ap«embn«mWv wife s\ hospital  {]thin¸n¨Xv.  Cu document {]Imcw wife \v left breast cancer D­mbncp¶p F¶v ]dªm F\n¡dnbnÔ.  PW1 further deposed that “wife sâ t]cnepff policy ]WaSbv¡msX lapse Bbn t]mbncp¶p.   AXv revive sNbvX document BWv Ext.A2 (Shown to the witness) B revival sImSp¡p¶ kab¯pw bYmÀ° Heath Status sImSp¯n«nà F¶p ]dªm icnbÃ.  H¸nSm³ ]dª Øe¯v H¸n«p ss]k Rm³ AS¨p.  AhnsS health status good F¶mWv ]dªXv”.

            14.  OPW1 was examined on behalf of Opposite Party No.2 and 3 who deposed that “Ext.A3 bn first ImWp¶ cause of death  13.12.2021  ]dªncn¡p¶Xv severe covid 19 F¶mWv.  13.12.2021  cause of death \v \mev ImcW§Ä sIm­mWv.  Hospital records  cancer sIm­msW¶v ]dªn«p­v.  Suppression of material facts sIm­p am{XamWv claim repudiate sNbvXXv  Carsenoma Breast Cancer D­mbncps¶¦nepw acWImcWw covid 19 Bbncp¶p F¶p ]dªm icnbÃ. covid 19 severe Bbn izmkw FSp¡m³ IgnbmsXbmWv acWs¸«sX¶v ]dªm icnbÃ. Shiny Varghese sâ s]s«¶p­mb acWImcWw covid 19 \pw breathing se problem Dw BsW¶v ]dªm AXv Hcp ImcWw am{XamWv”.  In re-examination OPW1 deposed that “Shiny Varghese proposal form XpS§nb bmsXmcp tcJIfnepw declaration \pw tcmKapffXmbn tcJs¸Sp¯nbn«nà Proposal form  Cancer hnhcw declare sNbvXncp¶nsh¦n policy renew sNbvXv \ÂInÃmbncp¶p.  Insured  Xcp¶ declaration good faith  BWv FSp¡p¶Xv .  AXn Fs´¦nepw kqN\ X¶ncp¶psh¦n medical records Bhniys¸Spambncp¶p”. 

15.  OPW2 is a doctor working at WIMS Hospital who had produced treatment records and case sheets of Shiny Varghese and the medical records are marked as Ext.X1 series.  OPW2 deposed that “13.02.2017 se cytology report CXnep­v AXn tcmKnbpsS CSXp amdn \n¶pw Ip¯nsbSp¯Xn breast cancer BsW¶v t_m[ys¸«Xmbn tcJs¸Sp¯nbn«p­v (carcinoma breast) marked as Ext.X1(a) dated 13/02/2017”.  OPW2 further deposed that “08.04.2017 se OP record  Dr. Sarayu F¶ tUmIvSsd ImWn¨Xmbpw  patient ambn tcmKw kw_Ôn¨pw treatment kw_Ôn¨pw explain sNbvXXmbn ImWp¶p­v.  Marked as Ext.X1(b).  28.10.20   short case record  Breast cancer – underwent surgery three years back F¶v tcJs¸Sp¯nbn«p­v. Marked as Ext.X1(c) 28.10.2020  scar of breast conservation surgery F¶v tcJs¸Sp¯nb tcJbmWv Ct¸mÄ ImWn¨Xv    Marked as Ext.X1(d).  08.12.2021 \v Cu patient s\ ho­pw CtX hospital  {]thin¸n¨n«p­v. CXn³ {]Imcapff admission card  08.12.2021  {]thin¸n¨Xmbpw metastatic cancer – spreading of cancer stage -4 F¶pw tcJs¸Sp¯nbn«p­v”. OPW2 further deposed that “ 08.12.2021  high risk consent tcJs¸Sp¯nb Hcp record Dw CXnep­v. Marked as Ext.X1(e) AXv H¸n«Xv  Sunny. P. K, husband of patient BWv.  H¸oSn¨Xv Rm\mWv.  AXn Fsâ H¸pw D­v.   He further stated that “cancer IqSmsX severe covid 19 _m[n¨Xmbpw record sNbvXn«p­v.  Patient 2017 apX 22 hsc cancer patient Bbncp¶p.  FÃpIfntebv¡v cancer _m[n¨Xpw breast cancer spreading and covid BWv acWImcWw AXv tcJs¸Sp¯nbn«p­v”. 

16.  During cross by the Complainant OPW2 deposed that “WIMS  \n¶pw patient \v cancer kw_Ôn¨v treatment \ÂInbn«nÃ.  FNAC carcinoma Breast cancer BsW¶v ]dªXv tcmKnbpambn consult sNbvXpw pathologist sâ report {]ImchpamWv.  Patient ]dªXn \n¶mWv 3 hÀjw ap³t]  cancer D­mbncps¶¶v tcJs¸Sp¯nbXv.  Ext.X1(d)  Dr. Nimmy, breast examine  sNbvXv (physical examination)FgpXnbXmWv  tumor  FSp¯v scar D­v F¶v tcJs¸Sp¯nbn«p­v”.  He further deposed that “Breast cancer spreading covid 19 \v tcmKw accelerate sNbvXv acWImcWamImw.  AXpsIm­mWv Death Summary  first cause severe covid 19 infection category C F¶v tcJs¸Sp¯nbXv”.

            17.  In this case the argument of the Complainant is that the insured died due to covid 19 which is denied by Opposite Party No.3 on the basis of medical records stating that the insured was a cancer patient who had undergone surgery during 2017 and the same was not disclosed by the Complainant while reviving the policy on 12/02/2021.  The position being so, the crucial evidence in this case is the medical records produced as Ext.X1 series which supports the argument of the Opposite Party No.3.  From Ext.A1, it is evident that the insurance policy was taken on 02/01/2017 in which the state of health is mentioned as good.  It is the case of the Complainant that the policy was revived on the basis of Ext.A2 special revival campaign.  OPW1, in her chief affidavit it is stated that “ The wife of the Complainant Shaini Varghese obtained Policy No.799305225 commencing from 02./01/2017 with sum assured in the policy as Rs.5,00,000/-.  It was an endowment plan and as far as an insurance policy is concerned the underlying terms and conditions of that policy can very well be accessed through the policy bond issued at the time of purchasing the policy.  Hence the condition governing to the revival/claim too can be assessed likewise”.  According to Opposite Party No.3 since the insured had suppressed material facts at the time of revival of policy, the claim was repudiated and paid an amount of Rs.2,31,079/- which is the eligible amount according to the Opposite Parties.  Even though the Complainant argued that since the insured died due to void, the Complainant is entitled to the total insurance amount, he could not prove the same with cogent evidences. 

            18.  According to the Complainant, the marriage between the Complainant and deceased Shaini Varghese was in the year 2010.  But during cross examination he pleads ignorance about the disease of his wife and surgery made during 2016-17.

            19. In these circumstances, we have to give weight to the medical evidences produced from the side of the Opposite Parties which proves that the insured was affected with cancer from 2017 onwards.  During the revival of policy in 2021, the insured did not disclosed the disease. Even though an argument was taken by the Complainant that the proposal form and the details were filled up by Opposite Party No.1 who is the agent of Opposite Party No.2 and 3, PW1 in box he admitted that Opposite Party No.1 filled in accordance with the direction of the Complainant.

            20.  The overall consideration of the evidences on record reveals that the Complainant failed to prove his case on merit and the Commission found that there is no merit in the complaint.

            Hence Consumer Case dismissed without Costs.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 25^th day of June 2024.

Date of Filing:-18.10.2022.

PRESIDENT   : Sd/-

MEMBER       : Sd/

APPENDIX.

Witness for the Complainant:-

PW1.              Sunny. P. K.                                                 Teacher.

Witness for the Opposite Parties:-

OPW1.          Beena. K.                                                      LIC.

OPW2.          Dr. Anees. C. K.                                           Doctor.

Exhibits for the Complainant:-

A1.                  Copy of Proposal for insurance on own life.              Dt:29.12.2016.

A2.                  Copy of Policy Revival intimation.                                 Dt:12.02.2021.

A3.                  Copy of Death Summary.                                                           

A4.                  Copy of Death Certificate.                                               Dt:05.01.2022.

A5.                  Copy of details of deceased.                                           Dt:28.01.2022.

A6.                  Copy of Repudiation Letter.                                            Dt:01.07.2022.

X1(Series).    Documents produced from WIMS, Hospital, Wayanad.  (37 pages).

Exhibits for the Opposite Parties:-

B1.                  Copy of Office Order.                                                       Dt:27.06.2023.

B2.                  Copy of Policy Bond.

B3.                  Copy of Personal Statement Regarding Health.

B4.                  Copy of Intake Output Chart.

B5.                  Progress Note Draft Copy.

B6.                  Certificate of Hospital Treatment.                                 Dt:13.01.2022.

B7.                  Medial Attendants Certificate.                                       Dt:13.01.2022.

PRESIDENT   :Sd/-

MEMBER       :Sd/-

/True Copy/

Sd/-

                                                                                             ASSISTANT REGISTRAR

                                                                                                  CDRC, WAYANAD.

Kv/-