Karnataka

Bidar

CC/42/2014

YASHODABAI W/O PRALHAD SUGANDHI - Complainant(s)

Versus

THE BRANCH MANAGER LIC OF INDIA B,KALYAN - Opp.Party(s)

P.M DESHPANDE

28 Feb 2017

ORDER

::BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AT BIDAR::

 

 

                                                                                                      C.C.No.  42/2014

 

                                                                                      Date of filing : 22/05/2014

 

                                                                                 Date of disposal : 28/02/2017

 

 

P R E S E N T:-              (1) Shri. Jagannath Prasad Udgata,

                                                                                         B.A., LL.B.,

                                                                                                    President.

    

                                      (2) Shri. Shankrappa,(Halilpurgi)

                                                                          B.A.LL.B.,

                                                                                     Member.

 

 

COMPLAINANT:          Yashodabai, w/o Pralhad Sugandhi,

                                      Age: major, Occ: house hold,,

                                         R/o Tq.Bhalki,Dist.Bidar.

                                        

 

 

                                     (By Shri. P.M.Deshpande, Advocate)

 

 

                                                      VERSUS

 

OPPONENT/S   :-             1     The Branch Manager, LIC of India,

                                                 Narayanpur road, Basavakalyan,

                                                Dist.Bidar-585327.

 

                                        2.      The Divisional Manager, LIC of India,

                                                Jeevan Beema Nagar, Court road,

                                                Raichur-584101.

 

 

                       

                                      (By Shri. Sanjay Kumar S.Patil, Advocate)

 

                                      

::   J UD G M E N T  : :

 

 

By Shri. Jagannath Prasad Udgata, President.

 

The complainant is before  us U/s. 12 of the C.P.Act., 1986, filed against the O.Ps alleging deficiency in service by the O.Ps.

 

2.           The gist of the case is as here under:

              The complainant is resident of Tq.Bhalki,Dist.Bidar.  The complainant’s deceased daughter by name Saroja D/o Pralhad Sugandhi in her life time had purchased  four LIC policies no. 665038821, 66255474, 66255482 and 66255477 with the O.Ps.  Thereafter, the  daughter of the complainant died on 22/08/2010 due to heart attack.  The complainant avers that after the death of her daughter the O.Ps  out of above said four policies, two policy(s) 665038821 & 66255474 were settled and the remaining two policies i.e. 66255482 and 66255477 not yet settled and O.Ps have repudiated the claim on the ground that the deceased policy holder had died due to sudden heart attack and there was pre-existing disease of heart.  As per complainant  Annexure 32 a certificate of Dr. Nirgude of Govt. Hospital, Bhalki  no  pre-existing disease was mentioned at the time of purchasing the policy.  The repudiation of the claim of the complainant has no  legal base and there is not suppression of material facts in the claimant’s statement, whereas the O.Ps are acting negatively by adopting unfair trade practice and  resorting to deficiency of service.  Hence, the complainant filed the complaint before this Forum.

3.              On receipt of the Court notice the O.P. no.1 and 2 have appeared before this Forum and filed their   written versions.  Therein  it is claimed the complaint filed by the complainant is misconceived both in law and facts and it is not maintainable.  The O.Ps did not dispute the content of para no.1 and 2 of the complaint regarding, the deceased obtaining claimed policies from the O.P.s  The averment made in para 3 to 7 are stated to be false and baseless without any proper records, hence the complainant be put to strict proof of the same.  The O.Ps. further avered  the complainant obtained four policy policy no.s 665038821, 66255474, 66255482 and 66255477 out of four polices the claim of policy no. 665038821, & 66255474  was paid to the nominee of the deceased.  The claim of the policy nos. 66255482 and 66255477 were repudiated by  O.Ps because before submitting proposal for the two policies the deceased Life Assured was a patient of Congenital Heart Disease and was treated by Dr. Vaijinath Dongappure, Bhalki which the policy holder had not mentioned in the Q.no.11 of the said proposal forms filed on 28/04/2010 for insurance.  Hence the policy holder had suppressed the material facts regarding her health and further the O.Ps have denied other contents of para no.2 specifically.  The  O.Ps claim to have repudiated the claims of two policies justifiably   and hence O.P. Corporation cannot be clamped with deficiency in service.  In replying para no.3 of the complaint, the O.Ps Corporation despite the contention of the complainant that at the time of issuing the policy the life assured had not given information regarding her health before the agent and further the O.Ps state  that the questions are mentioned bilingually i.e Hindi and English in the proposal form and the policy holder is expected to know and understand the question before answering them as it is a contract between LIC and the policy holder and she had to state the correct material facts in the interest of insurance policy.  Should the  proposer could not read the language mentioned on the proposal the agent is authorised to explain the question to the proposer to enable her to fill in the correct answers.  The deceased life assured as per the proposal form dated 28/04/2010 submitted under question no. 4(B) present occupation, the policy holder mentioned her occupation as Tutor and educational qualification as PUC.  The life assured has intentionally suppressed the material facts and answered wrong answers to Q.no.11.  The claims are also early claims.  Therefore there is procedure in insurance act in all early claim there must be inquiry done/ conducted, therefore during the claim enquiry it was revealed that the deceased life assured was patient of Congenital Heart Disease and was treated by Dr. Vaijinath Dongapure, Bhalki, in fact the policy(s) were issued on the basis of the proposal for insurance and bases on her declaration  hence the policy holder hadsuppressed the material fact regarding health.            

4.                  The contention of para no.5 of the complaint are not disputed to the extent of averments made regarding repudiation of policies on dated 30/03/2013 and further,  the complainant has appealed to the Zonal claims Review committee, which consist of a retired High Court Judge at Hyderabad.  The said committee upheld the repudiation decision taken by the Divisional Office Raichur.  In dissatisfaction the claimant was advised to approach the Ombudsman and complainant in fact had approached the Insurance Ombudsman at Hyderabad to get relief vide letter dated 23/11/2013.  Then the  Insurance Ombudsman sought the details of the matter from O.P’s office and the same was sent on 31/01/2014.  The insurance Ombudsman heard the case at Hyderabad on 04/02/2011 in presence of the complainant’s representative and Sri. Srinivasa Reddy Manager (Claims) who represented on behalf of LIC on India.  The insurance Ombudman dismissed the case and passed an order dated 20/02/2014 stating that the claim was rightly repudiated.  In reply to para no.7 and 8 of the complaint, the O.Ps Corporation does not admit the allegations made by the complainant.  The complainant has not disclosed the true facts about the illness of deceased.    This amounts to intentional suppression of material facts which attracts the provisions of section 45 of Insurance Act. 1938.  In case she had disclosed the material facts the polices would not have been issued by O.Ps.  Hence, there is no unfair trade practice and deficiency of service by the O.Ps.  So, it is claimed the complaint filed by the complaint may be dismissed with costs.

5.         Considering the rival contentions of the parties, the following points arise for our consideration:-

 

1. Does the complainant prove that, there has been a deficiency of service in the part of the Opponents?

 

2. What order ?

 

 

6.           Our answers to the points stated above are as follows:-

 

               1.  In the affirmative.

                4. As per final orders due to the following

 

 

                                                                    

 

 

 

 

 

:: REASONS ::

7.              It is apparent from the versions ofthe O.Ps ( para-2) that, three policies were obtained by the deceased life assured by name Saroja  i.e. no.665255474 for sum assured 20,000/-, no.665255482 for sum assured Rs.1,00,000/- and no.665255477 for sum assured 1,00,000/-, on a single day i.e. 28/04/2010.  Out of these three, the claim inrespect of first one has been settled by the O.Ps. while the later two were repudiated on the ground that, she was suffering from congenital Heart disease i.e. Atrial Subtal Defect and had suppressed her ailment while filling up col.no.11 of the proposal forms.  From the record, it is evident that, even the Insurance Ombudsman has rejected the claim affirming the repudiation.

 

8.           Primafacie, the O.Ps are relying on the medical certificate(s) issued by Dr. Vaijinath Dongarpure, dt. 26/12/2013 ( Ex.R.4) dt. 26/02/2013, in which he states not to have remembered the drugs prescribed to the patient Saroj.  Another copy of medical certificate, dt.17/07/2010 (Ex.R.5) followed by another two Ex.R6 dt. D15/07/ ( year abscured) Ex.R.7 dt. 16/07/2010 without proper etiology or diagnosis ever mentioned were produced.  We are intrigued as to how, a Doctor could at all arrive at a conclusion of cogential heart disease without resorting to E.C.G. angiogram, M.I.R., T.M.T. which are standard practice of the treating doctors.  One more amazing fact, the O.P. could not secure the presence of the doctor inspite of obtaining witness summons and thereafter had chosen to remain inert.  Hence, we have no hesitation to hold that, these medical certificates were made up by the O.Ps to escape the legal liability.

9.                Per contra, we fix our gaze at the medical certifidate submitted by the complainant at Ex.P.32, issued by Government Medical officer, from which it is revealed that, the deceased life assured got afflicted with jaundice which was diagnoised on 10/07/2010 and the affliction of hyper dyslipidimia was an offshoot ofthe primary cause.  The afflictions  afore stated were much after the filling up the proposal forms for which no concealment of facts can be attributed to the proposer.

10.              In view of the discussions supra, we hold that, the O.Ps have committed unethical trade practice coupled with deficiency of service and hence we proceed to pass the following

: :   ORDER : :

 

                  The complaint  is allowed in part.

1.         The O.Ps are hereby jointly and severally held liable to reimburse the claim of the complainant in respect of two repudiated policies i.e. no. 66255482 and 66255477 ( both dated 28/04/2010) together with all accrued benefits along with an interest @ 12 % p.a. to be calculated from the date of death of the policy holder i.e. 28/04/2010 till the date of realisation.
2. The O.Ps are further directed to pay compensation of Rs.20,000/- for the sufferings and mental agony undergone by the complainant, coupled with Rs.5,000/- towards litigation expenses.
3. Four weeks time granted to comply this order.

 

 

 

 

 

   ( Typed to our dictation then corrected, signed by us and then pronounced in the open Forum on this 28^th   day of February-2017 )

 

 

 

 

Sri. Shankrappa H.                                          Sri. Jagannath Prasad                 

        Member                                                                  President

 

Documents filed by the complainant.

 

1. Ex.P.1- Courier receipt.
2. Ex.P.2- Copy of legal notice, dt. 24/02/2014.
3. Ex.P.3-  Acknowledgement cards (2)
4. Ex.P.4-  Postal receipts
5. Ex.P.5- Copy of letter addressed to Chief Manager LIC dt.28/06/2012 by complainant
6. Ex.P.6- Copy of letter addressed to Asst.Br.Manager LIC dt.28/06/2012 by complainant
7. Ex.P.7-Copy of letter addressed to complainant by LIC.dt.03/07/2012
8. Ex.P.8-Copy of reminder letter addressed to LIC by complainant, dt.26/07/2012.
9. Ex.P.9- Copy of letter addressed to LIC by complainant, dt.17/09/2012.

 

10. Ex.P.10 Copy of letter addressed to complainant by LIC dt.22/09/2012.
11. Ex.P.11-  Copy of letter addressed to LIC by complainant, dt.16/10/2012.
12. Ex.P.12- Copy of  letter addressed to Insurance Ombudsman by the complainant dt.16/10/2012.
13. Ex.P.13- Replica letter of Ex.P.11
14. Ex.P.14-Copy of letter addressed to complainant by Office of Insurance Ombudsman,dt.18/10/2012.
15. Ex.P.15- Copy of letter addressed to Regional Manager, LIC by dt.31/10/2012.
16. Ex.P.16- Copy of letter addressed to complainant.
17. Ex.P.17-Copy of letter addressed to complainant dt.11/11/2012.
18. Ex.P.18- Copy of reminder letter addressed to LIC,dt.26/11/2012.
19. Ex.P.19-Letter addressed to complainant, dt.30/03/2013.
20. Ex.P.20-Copy of letter addressed to complainant,dt.01/07/2013.
21. Ex.P.21-Postal receipts (04)
22. Ex.P.22-Letter addressed to LIC, dt.30/08/2013.
23. Ex.P.23-Letter addressed to complainant,dt.15/10/2013.
24. Ex.P.24-Letter addressed to Insurance Ombudsman,dt.23/11/2013.
25. Ex.P.25- Letter addressed to complainiant,dt.29/11/2013.
26. Ex.P.26- Letter addressed to complainiant,dt.29/11/2013.
27. Ex.P.27- Copy of consent letter,dt.14/12/2013.
28. Ex.P.28- Copy of letter addressed to Insurance Ombudsman,dt.14/12/2013.
29. Ex.P.29- Copy of Insurance Policy.
30. Ex.P.30- Copy of Insurance Policy.
31. Ex.P.31- Copy of claimant’s statement.
32. Ex.P.32- Copy of Medical Attendants Certificate.
33. Ex.P.33- Copy of death certificate of Saroja.
34. Ex.P.34-Copy of confidential report by the agent.
35. Ex.P.35- Copy of Certificate of identity and burial or cremation/
36. Ex.P.36-Default notice and intimation of loan and interest.
37. Ex.P.37- Another Default notice and intimation of loan and interest.
38. Ex.P.38-Copy of Aadhar card of Yeshodhabai.

 

Documents filed by the Opponent.

1. Ex.R.1- Copy of proposal form, dt.28/04/2010.
2. Ex.R.2-Copy of proposal form, dt.28/04/2010.
3. Ex.R.3-Copy of award of the proceedings of the Insurance Ombudsman,dt.20/02/2014.
4. Ex.R.4- Certificate by Dr.Vaijinath Dongapure,dt.26/02/2013.
5. Ex.R.5-Copy of prescription by Dr.Vaijinath Dongapure,dt.19/07/2010.
6. Ex.R.R6- Copy of prescription by Dr.Vaijinath Dongapure.
7. Ex.R.R7- Copy of prescription by Dr.Vaijinath Dongapure,dt.15/07/2010.

 

 

 

 

Sri. Shankrappa H.,                                          Sri. Jagannath Prasad,                 

        Member                                                                     President.