Karnataka

Chitradurga

CC/26/2015

Mamatha W/o. Late K.B.Thippeswamy - Complainant(s)

Versus

The Branch Manager, L.I.C. of India - Opp.Party(s)

Shri.K.N.Viswanathaiah

15 Oct 2015

ORDER

COMPLAINT FILED ON : 20/02/2015

     DISPOSED ON: 15/10/2015

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHITRADURGA

 

CC. NO. 26/2015 DATED:  15th October 2015

 

PRESENT :-     SRI. T.N. SREENIVASAIAH      PRESIDENT                                      B.A., LL.B.,

                        SRI.H.RAMASWAMY,               MEMBER

                                         B.Com., LL.B.,(Spl.)

SMT.G.E.SOWBHAGYALAKSHMI,       

                                         B.A., LL.B.,                   MEMBER

 

COMPLAINANT	Smt. Mamatha, W/o Late K.B. Thippeswamy, R/at Dandinakurubarahatti, Chitradurga Taluk, C/o M. Jagadeesh, Amma Floor Mill, IUDP Layout, Chitradurga.   (Rep by Sri. K.N. Vishwanathaiah, Advocate)
OPPOSITE PARTY	The Branch Manager, LIC of India, B.D. Road, Chitradurga.   (Rep by Sri. L. Madhusudhana,  Advocate)

 

SRI. T.N. SREENIVASAIAH. PRESIDENT.

ORDER

The complainant has filed a complaint U/s 12 of C.P. Act 1986 against the OP for a direction to the OP to pay Rs.3,30,000/- towards the sum assured under the policies with bonus and other benefits with interest and cost etc.

2.     The brief facts of the case of the complainant are that, her husband K.B. Thippeswamy S/o Basanna @ Basappa died on 16.05.2014 while he was working as an Assistant Teacher at Higher Primary School at Pallavagere, Chitradurga Taluk.  Her husband during his life time, had taken two policies bearing No. 629932300 for a sum of Rs.3,00,000/- and another policy 668579094 for a sum of Rs.30,000/-.  He was regular in making monthly premiums up to date from the date of issue of said policies and they were in force.  The complainant is the nominee under the said policies.  After the death of life assured, complainant being a nominee under the said policies, submitted a claim form by enclosing original policies with death certificate and other necessary documents.  But the OP rejected the claim of the complainant by a letters dated 10.10.2014 without any legal and technical reasons and they are vague and imaginary.  The issuance of said policies are only after payment of the first installment premiums and the terms contained in the policies are one sided and not reciprocal one and they do not bind the life assured.  The deceased life assured had taken other six policies they were already settled by the OP to his daughter by name Jyothi, who is a nominee under the said policies.  The policies in question are issued by the OP only after confirming the medical fitness of the deceased and also on the basis of previous policies.  The deceased had no any alleged diseases or ill health at the time of taking the polices and had no such knowledge about his health and he was hale and healthy on the date of respective proposals.  OP has obtained false documents in its support in rejecting the claim.    Hence, there is a deficiency of service on the part of OP so, she sustained financial loss and mental agony and etc., and prayed for allow the complaint.

 

3. On service of notice, OP has appeared through Sri. L. Madhusudhana, Advocate and filed its version admitting about taking of the above said policies by the husband of complainant.  It is further stated that, OP has received all the early claim forms along with Hospital records issued by the Basaveshwara Medical College, Chitradurga, which shows the date of admission was on 29.04.2014 and the life assured was died on 16.05.2014.  The deceased life assured was suffering from diabetes mellitus since five years and he was consuming alcohol for last twenty years and the said informations were not disclosed in the proposal form submitted for both the policies.  Therefore, the claim made under the above said two policies was repudiated for suppression of material facts and an amount of Rs.19,767/- was allowed as exgratia basis under policy No.688579094 and the OP has repudiated the claim based on the answers given in the proposal form compared to Hospital records.  It is further submitted that, the proposal form submitted to the OP at Question No.11(a) to 11(j) were answered negatively without disclosing the previous ailments in both the insurance policies.  In the policy at Sl.No.5 it is mentioned that, any condition herein contained or endorsed hereon shall be controverted or in case it is found that any untrue or incorrect statement is contained in the proposal, personal statement, declaration and connected documents or any material information is withheld then and in every such case but subject to the provisions of Section 45 of the Insurance Act, 1938 wherever applicable, this policy shall be void and all claims to any benefit in virtue hereof shall cease and determine and all money's shall have been paid in consequence hereof shall belong to the Corporation excepting always in so far as relief as provided in terms of the privileges herein contained or may be lawfully granted by the Corporation.  It is an admitted fact that, OP received claim forms for the above said policies and after scrutiny rejected the claim of the complainant for the reason that, the deceased has suppressed the material facts that, he was suffering from diabetes mellitus for the last five years and was consuming alcohol for the last twenty years which was not disclosed in the proposal form.  Section 45 of the Insurance Act, 1938 stipulates that, No policy of the life insurance effected after the coming into force of this Act shall, after expiry of two years from the date on which it was effected, be called in question by an insurer on the ground that a statement made in the proposal for insurance or in any report of medical officer or a referee or a friend of the assured or in any other document leading to the issue of the policy, was inaccurate or false, unless the insurer shows that such statement was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the policy holder and that the policy holder knew at the time of making it that the statement was false or that it suppressed facts which it was material to disclose.  The phrase the date on which it was effected may be taken to mean the date of risk i.e., the date of payment of first payment of full or the date of acceptance letter whichever is later.  In case of revival, wherein claim is repudiated after two years from the date of effecting the policy, section 45 will be applicable and  the materiality and fraudulent intent is required to be proved by the Corporation.  Therefore, there is no deficiency of service on the part of OP.  Hence, prayed for dismissal of the complaint.     

        4. Complainant himself examined as PW-1 by filing affidavit evidence and documents are marked at Ex.A-1 and Ex.A-2. 

5.     On behalf of OP one Sri. K.R. Mohan, the Manager (Legal) & HPF Dept. of OP examined as DW-1 by filing affidavit evidence and the documents were got marked as Ex.B-1 to B-14.   

 

        6. Arguments heard.

 

7. Now the Points that arise for our consideration for the decision of the complaint are that:

 

Point No.1:- Whether the complaint proves that, she is entitled for compensation as stated in her complaint?

 

Point No.2:- What order?

 

        8. Our findings on the above points are as follows:

 

        Point No.1:- Affirmative.

        Point No.2:- As per the final order.

                                        ::REASONS::

 

9. Point No. 1:- It is not in dispute that, the husband of the complainant had taken two policies bearing No. 629932300 for a sum of Rs.3,00,000/- and another policy 668579094 for a sum of Rs.30,000/- and her husband made her as a nominee under the said policies.  He was regular in making monthly premiums and they were in force.  After the death of her husband, complainant submitted a claim form by enclosing all the necessary documents.  But the OP rejected the claim of the complainant without any legal and technical reasons.  The policies in question are issued by the OP only after confirming the medical fitness of the deceased and also on the basis of previous policies.  The deceased was hale and healthy on the date of respective proposals.  OP has obtained false documents in its support in rejecting the claim.    Hence, there is a deficiency of service on the part of OP and prayed for allow the complaint. 

 

10.  So, as on the date of death, insurance policy was in force.  It is the main contention of the complainant that he made a claim to the OP and in spite of policy was in force, OP has repudiated the claim on the ground that,  complainant was suffering from diabetes mellitus since five years and he was consuming alcohol for the last twenty years and husband of the complainant has taken the said two policies by suppressing the real facts and thereby she sustained financial loss and mental agony and OP has committed deficiency of service so, this complaint has been filed. 

 

       11.  In support of his contentions,  complainant has relied on her affidavit evidence in which she has reiterated the contents of complaint.  Complainant has also riled on documents like copies of repudiation letters dated 10.10.2014 issued by the OP which is marked as Ex.A-1 and 2. 

 

12.  On the other hand, it is admitted by the OP that, the husband of the complainant has taken above said two policies.  OP has received all the early claim forms along with Hospital records issued by the Basaveshwara Medical College, Chitradurga, which clearly shows that her husband was admitted to Hospital on 29.04.2014 and the life assured was died on 16.05.2014.  The deceased life assured was suffering from diabetes mellitus since five years and he was consuming alcohol for last twenty years and the said information were not disclosed in the proposal form submitted for both the policies.  Therefore, the claim made under the above said two policies was repudiated for suppression of material facts and an amount of Rs.19,767/- was allowed as exgratia basis under policy No.688579094 and the OP has repudiated the claim based on the answers given in the proposal form compared to Hospital records.  Therefore, there is no deficiency of service on the part of OP.  Hence, prayed for dismissal of the complaint.   

13.   In support of his contentions, OP has relied on  affidavit evidence in which it has reiterated the contents of version.  OP has also riled on documents like copies of repudiation letters dated 10.10.2014 with respect to the above said two policies which are marked as Ex.B-1 and B-2.  Copies of proposal forms which are marked as Ex.B-3 and   B-4.  Copies of Policy bonds which are marked as Ex.B-5 and B-6.  Copy of medical opinion dated 05.09.2014 which is marked as Ex. B-7.  Certified copy of clinical history issued by Basaveshwara Medical College which is marked as Ex.B-8.  Certified copy of OPD card dated 29.04.2014 issued by Basaveshwara Medical College which is marked as Ex.B-9.  Certified copy of Medical Certification of Death dated 16.05.2014 which is marked as Ex.B-10.  Certified copy of claimant's statement which is marked as Ex.B-11.  Certified copy of Employer by BEO marked as Ex.B-12.  Original copies of medical attendant's certificate and certificate of hospital treatment marked as Ex.B-13 and B-14.

14.   On going through the records submitted by both the parties it is seen that, the OP herein has accepted the policy bearing No.629932300 for a sum of Rs.3,00,000/- with monthly premium of Rs.2,085/- on 28.03.2013 and the said policy was a non-medical policy from the husband of the complainant.  Again on 14.06.2013 OP has accepted another policy bearing No.668579094 for a sum of Rs.30,000/- which was a medical policy.  OP has taken contention in its version that, the life assured has taken the policy by suppressing the real facts i.e., with regard to his health condition.  According to the OP, complainant obtained first policy, by that time, complainant was suffering from diabetic mellitus and he was consuming alcohol for the last twenty years.  But, OP made a second policy, never stated anywhere in the medical certificate that, the deceased life assured was suffering from diabetic mellitus and consuming alcohol.  Therefore, it is doubtful that, the life assured was suffering from disease as stated by the OP.  OP has produced medical certificates obtained from the Basaveshwara Medical College, Chitradurga.  In the certificate, with regard to past history, it is mentioned that, K/C/O DM, HTN since five years, A/o Alcohol consumption since twenty years.  But, OP obtained the second policy as a medical policy and never stated anywhere in the proposal form about the above said diseases.  The difference between issuance of non-medical policy and medical policy by the OP is only for three months.  The clinical history issued by the Basaveshwara Medical College, Chitradurga stating that the deceased life assured was suffering from diabetes mellitus since five years and he was consuming alcohol for the last twenty years is not justifiable because, the OP has not examined any Doctors to prove that, the deceased life assured was suffering from the diseases as stated by it.  It is very doubtful that, the certificate issued by the Basaveshwara Medical College is true or not.  Whenever the insurance company decided to accept the insurance policy from the life assured, its duty is to confirm the health condition of the life assured before issuing the policy by conducting medical tests from the doctors.  Herein, the OP failed to do so.  After issuing the insurance policy in the name of life assured and after his death, the repudiation of the claim made by the nominee i.e., the complainant herein cannot be reasonable and justifiable.   Therefore, we cannot accept the contention taken by the OP that the husband of the complainant has suppressed the real facts at the time of obtaining the insurance policy.  Hence, the complainant is entitled for compensation.  The decisions submitted by the OP are not applicable to the facts of the present case on hand.  No doubt the decisions given by the OP are clearly stated that, when there is a suppression of the real facts by that time only, the complainant was not entitled for any relief.  But, herein there is no suppression made by the husband of the complainant and the life assured was not suffering from any diseases.   Moreover, the OP has not examined any doctors to prove its contention.  Therefore, we cannot accept the contention taken by the OP that, the deceased was suffering from diabetes mellitus and he has taken insurance policies by suppressing the real facts.   Hence, the complainant is entitled to claim the sum assured amount under the above said two policies.  Accordingly, this Point No.1 is held as Affirmative to the complainant.

 

15.  Point No.2:- For the foregoing reasons, we pass the following.

ORDER

        It is ordered that the complaint filed by the complainant U/s 12 of CP Act 1986 is hereby allowed.

 

The OP is directed to pay the sum assured amount of Rs.3,30,000/- under the above said two policies to the complainant along with interest at the rate of 6% p.a from the date of complaint till realization. 

 

Further the OP is directed to pay a sum of  Rs.10,000/- towards mental agony and Rs.5,000/- towards costs of the proceedings. 

 

Further, the OP is directed to pay the above amount to the complainant within 60 days from the date of this order. 

 

 

        (This order is made with the consent of Members after the correction of the draft on 15/10/2015 and it is pronounced in the open Court after our signatures.)

 

 

 

MEMBER                   MEMBER                      PRESIDENT

 

 

-:ANNEXURES:-

Complainant by filing affidavit evidence taken as PW-1

Witness examined on behalf of Complainant:

                                                -Nil-

On behalf of OP one K.R. Mohan, Manager Legal & HPF Dept., by filing affidavit evidence taken as DW-1

 

Witnesses examined on behalf of OP:

 -Nil-

Documents marked on behalf of Complainant:

01

Ex-A-1& 2:-

Copies of repudiation letters dated 10.10.2014 issued by the OP which is marked as Ex.A-1 and 2

 

Documents marked on behalf of Opponent:

01	Ex-B-1 & 2:-	Copies of repudiation letters dated 10.10.2014 with respect to the above said two policies.
02	Ex-B-3 & 4:-	Copies of proposal forms
03	Ex-B-5 & 6:-	Copies of Policy bonds.
04	Ex-B-7:-	Copy of medical opinion dated 05.09.2014
05	Ex-B-8:-	Certified copy of clinical history issued by Basaveshwara Medical College.
06	Ex-B-9:-	Certified copy of OPD card dated 29.04.2014 issued by Basaveshwara Medical College.
07	Ex.B-10:-	Certified copy of Medical Certification of Death dated 16.05.2014
08	Ex.B-11:-	Certified copy of claimant's statement
09	Ex.B-12:-	Certified copy of Employer by BEO
10	Ex.B-13:-	Original copies of medical attendant's certificate
11	Ex.B-14:-	Certificate of Hospital treatment

 

 

 

MEMBER                   MEMBER                      PRESIDENT

Rhr.