Date of filing :-04/07/2011.
Date of Order:-25/08/2015.
DISTRICT CONSUMER DISPUTES REDRESSAL FOURM (COURT)
B A R G A R H.
Consumer Complaint No. 23 of 2011
Aruna Pradhan, W/o Late Asok @ Ashok Pradhan, aged about 42(forty two) years, R/o and Po. Kulunda, Ps. Attabira, Dist. Bargarh presently R/o Debahal, Po. Rengali camp, P.s. Attabira, Dist. Bargarh. ..... ..... ..... Complainant.
-V e r s u s -
Life Insurance Corporation of India represented through:
The Branch Manager, Life Insurance Corporation of India, Nuapada Branch Office, At/Po/Ps/Dist. Nuapada.
The Divisional Manager, Life Insurance Corporation of India, Sambalpur Division, At/Po/Ps/Dist. Sambalpur. ..... ..... ..... Opposite Parties.
Counsel for the Parties:-
For the Complainant:- Sri B.C Mahapatra, Advocate with other Advocates.
For the Opposite Parties :- Sri S.K. Dash, Advocate with other Advocates.
-: P R E S E N T :-
Mrs Anjali Behera ..... ..... ..... ..... ..... ..... ..... Member (w), I/C President.
Sri Pradeep Kumar Dash ..... ..... ..... ..... ..... ..... ..... M e m b e r.
Dt. 25/08/2015. -: J U D G E M E N T :-
Presented by Smt. A.Behera, Member(w), I/C President .
Facts of the Complaint in brief:-
The husband of the Complainant late Ashok Pradhan was a policy holder of LIC of India having two policies in his name bearing No.093478091 and 570524478 for sum assured Rs.2,00,000/-(Rupees two lakh)only and Rs. 50,000/-(Rupees fifty thousand)only respectively. This Ashok Pradhan dies on Dt.07/10/2008 for complicated malaria accordingly being the nominee of the said polices Complainant lodged her valid claim before the insurance authorities and later lodged grievance before the Insurance Ombudsmen. Subsequently Opposite Parties repudiated her claim but sent a cheque of Rs.38,124/-(Rupees thirty eight thousand one hundred twenty four)only in respect of policy No.570524478 for paid up value, bonus and refund f revival amount which the Complainant received under protest. So Complainant alleges deficiency of service against the Opposite Parties for repudiation of claim being illegal and harassment and mental agony hence this case Complainant claims Rs.2,00,000/-(Rupees two lakh)only and Rs.50,000/-(Rupees fifty thousand)only for the both the polices and another Rs.50,000/-(Rupees fifty thousand)only for the harassment and mental suffering.
Complainant relies as documents vide Insurance Policy, letter Dt.23/05/2011, Death certificate of the deceased.
Complainant filed
Letter No. SD/DC/SAP-II/Repaid Dt.30/05/2011.
Office copy of letter Dt.07/06/2011 of Complainant pursuant to letter No. SBO II/D CC AIMS Dt.28/05/2011.
Complaint allowed and admitted for judging passing all the initial scrutinization and preliminary admission hearing. Opposite Parties duly noticed, Opposite Party No.1(one) appeared on Dt.22/09/2011 through advocate S.K. Dash. Opposite Party No.2(two) appeared on Dt.12/08/2011 through advocate S.K. Dash.
Opposite Parties files their detailed written version, on Dt.08/04/2013 denying all the charges of deficiency of service levelled against them explaining reasons in the version and prays to dismiss this complaint against then with cost.
Opposite Parties files documents vide a list Dt.24/04/2013 and relies on them to establish their cause.
Notification and policy certificate along with policy proposal.
Leave application by insured along with request letter/ requisition to authority.
Rejoining letter by the insured.
Certificate issued by Nursing Home along with the request letter/ requisition by LIC.
Certificate issued by the Authority/ Treating Doctor by VSS Medical College Burla along with the request registration letter.
Letter issued to the petitioner.
Letter of repudiation.
Hearing was conducted on Dt.01/07/2015 in the presence of the parties through their respective counsels who submitted their causes in great details discussing and referring the documents relied by them.
After Hearing the matter, perusing the Complaint petition, written statement and the version documents filed with the case record the following points come out for consideration.
The two policies in the name of Late Asok Pradhan is admitted by both the parties and need no probe.
Opposite Parties paid a cheque of Rs.38,124/-(Rupees thirty eight thousand one hundred twenty four)only for policy No.570524478 where in the sum assured amount was Rs.50,000/-(Rupees fifty thousand)only which the Complainant received with protest.
Policy No.570524478 where in part payment has been done was issued on Dt.28/03/2001.
Policy No. 093478091 was issued on Dt.28/05/2008.
From documents filed by the Opposite Party it is found that a Midical Certificate one Ashok Pradhan was Treated since 31/07/2007 at Ashirwad Nursing Home for problems of Chronic Liver Disease and Chronic fever and advised long stay in the Nursing Home.
The document filed by the Opposite Party about application of CL for Treatment at Ashirwad Nursing Home is not dated though signed by Late Ashok Pradhan and it also indicates that the treatment was for Brain Malaria. Another leave extension petition also has been filed and it is undated also extends leave to another 5(five) days from 06/08/2007 to 10/08/2007.
Another application Dt.01/09/2007 signed by Late Ashok Pradhan applying for allowing the EL medical ground and rejoining to his duties, mentions dates as from 30/07/2007 to 31/08/2007.
Annexare-x though speaks about rejoining to duties by Ashok Pradhan on Dt.03/02/2006 after availing EL from 02/11/2006 to 02/12/2006 out does not speaks the reasons.
In response to provide some documents like copies of Bed head Tickets by LIC to Medical Superintendent, VSS Medical College Burla in reation to Late Ashok Pradhan regarding the policies 570524478 and 593478091 and further certificate of Treatment provided in a form of LIC at point No.6 it was pointed out that diagnosis was arrived at the hospital (VSS) to be Type of Diabetes Cirrhosis of Liver and Complicated Malaria. Further at point-7 on the same Medical Certificate it is reported that the deceased was aware about the Diabetic since 5 years.
Annexure -7 is the Medical Attendance Certificate where in at a point primary cause of Death is complicated Malaria and second cause is Cirrhosis of Liver and Type -II Diabetics. This report also speaks about his knowledge about being Diabetic since 5(five) year.
Annexure - 6 documents is about request letter to the Nominee in the policies in issue to provide last three years treatment details, total 4(four) letters same content.
Repudiation letter Dt.23/05/2011 speaks about reasons of repudiation.
On request of the Opposite Party to prove his contention further forum invited actions from the B.D.O., Maneswar and supply the originals of leave application and issuing letter of late Ashok Pradhan vide letter No.04 of 02/01/2015 and B.D.O., Maneswar supplied the documents vide originals of leave application and joining letters an 11/05/2015 vide letter No.978 Dt.06/05/2015.
Opposite Party argues that the insurer suppressed material fact about his well being and heaving Type-II Diabetic since 5(five) years and for other ailments he has been Treated at nursing homes for long period and to establish this contention refers to the Medical Certificates provided by the Treating Doctor at V.S.S. Medical College, Burla also the Death Certificate and correlating documents from B.D.O., Maneswar about the leaves taken by the deceased for same reasons and all these amounts to violation of Section 12,17 and 45(ii) of Insurance Act to the affect of that at the time of making the proposal form the declaration given were false ever if the insurer had prior knowledge of the health problems if amounts to fraud for which the repudiation is justified.
Opposite Party cites decision of Apex court.
(1) 2010 STPL (CL) 691 NC - Kokila Ben. Vrs LIC of India.
(2) 1962 STPL (LE) 2473 SC - Mithilal Malik Vrs LIC of India.
Wherein it was hold that repudiation for non disclosure of material facts relating to health at the time of taking policy is justified and proper.
Citation one is relevant and fits so also the second citation cited by the Opposite Parties and the citation(s) referred as a precedent being from superior forum and Apex Court.
Complainant in their written argument refer citation.
LIC Vrs Asha Goel and another case and refers to Section 45 of the Insurance Act and against that.
Section 45 Insurance Act 1988 says.
“No Policy of Life Insurance effected before the commencement of this Act shall
after the expiring of two years from the date of commencement of this act after the expiring of two years from the date on which it was effected be called on question by an insurance on the ground that a statement made in the proposal for insurance or on any report of a medical officer. On reference on friend of an insurance or in any other documents leading to issue of the policy was in allumate on false, unless the insurer shows that such statement was an material matter on suppressed facts which it was material to disclose and that it was fraudulently made by the policy holder and that policy holder knew at the time of making it that the statement was false on that if suppressed facts which are material to disclose.”
In the present case the correlated documents provided by the Opposite Parties in shape of the leave petition of the deceased policy holder prior to taking the policy, the Medical Certificate proving the knowledge of vital facts relating to health are within knowledge of the policy holder at the time of taking the policy which were not disclosed. So far the primary cause of death is concerned report says it to be complicated malaria and secondary causes as diabetes type II and cyrrohsis of lever and the medical report shows the deceased has knowledge about this. If the cause of death was only complicated malaria and in the medical report as well as death certificate info about type II diabetes and cyrrosis of liver then the leave application document's might not have got importance but the medical report and death certificate filed shows that the deceased was aware about the diseases while taking the policy No. 59347809 and hence suppressed material facts, when in absence of medical test policy have been issued on Truth with utmost faith to the declaration provided in the proposan.
Again- In Satwant Kaur Vrs New India Insurance Co. Ltd 2009 Section 316 Apex Court said
In para 17(seven teen), the term metarial fact is not defined in the Act and therefore it has been understood and explained by the court in general terms to mean as any, fact which would influence judgment of a prudent insurer in fixing premium on determining whether he would like to accept the risk. Any fact which goes to the root of its contract of insurance and has bearing on the risk involved would be material.
Under the circumstances the contention of the Opposite Party is accepted regarding violation of section 45 of insurance Act by the deceased policy holder.
In the written argument page 3(three) Complainant wrote that Opposite Parties accumulate documents about suppression of facts with the help of the Forum which is wild allegation against the Forum usual procedure is followed and on request of affected parties evidences in the shape of documents are called on from related public authorities if any and that is only to find out the truth and not to help any particular party either.
Further allegation of suppression of material facts are against a dead person and can not be concretely proved and as per complainant's referred citation 2006(3) CPR 79 NC, the insurance authorities had time to check the facts in declaration and if they have not dare they can not allege otherwise. Here as per laws when medical test was not mandatory in the present case and basing on the declaration policy was issued. So under the circumstances the declaration. Statement is vital for issuing of the policy so Forum feels that the decision relied is not applicable further the citation AIR 2007 Orissa page 19 C Divisional Bench too is unfit for the present case as situations are not same.
From the documents filed it is also evident that the case and facts for both the policies and different and not the same.
The allegation of suppression of material facts while taking policy does not sustains in the policy No.570524478 as it was before all the documents provided by the Opposite Parties. So by not giving the due assured sum in that policy Opposite Parties has committed gross negligence as in this case the nominee of the policy holder is entitled to get the full sum assured.
In the repudiation letter of the Opposite Parties . Opposite Parties have mentioned about revival amount being deducted but no further details were appraised before the Forum so the deductions made seem not justified and proper.
Under the said facts and circumstances. The Opposite Parties are not liable for deficiency caused for repudiation in case of policy No.593478091. But are liable of gross negligence and deficiency in case of policy 570524478.
Hence Forum Orders.
Opposite Parties are exonerated from any alleged deficiency related to repudiation of policy No.593478091.
Opposite Parties liable for deficiency of service by not paying the full sum assured as per the terms in policy No.570524478 and hence and directed to pay the balance of sum assured Rs.50,000/-(Rupees fifty thousand)only - Rs.38,124/-(Rupees thirty eight thousand one hundred twenty four)only = Rs.11,876/-(Rupees eleven thousand eight hundred seventy six)only with 9%(nine percent) interest per annum from the month of February-2009 as the death assured on Dt.07/10/2008 and the claim should have been taken care off within three month of the death till the date of this Order.
Further Opposite Parties are directed to pay a sum of Rs.20,000/-(Rupees twenty thousand)only for the harassment and mental agony including the litigation expenses to the Complainant within one month of the Order failing which the awarded amount(i.e. Rs.20,000/-(Rupees twenty thousand)only) carries an interest of 12%(twelve percent) till realization.
Disposed accordingly.
Typed to my dictation
and corrected by me.
I agree, (Smt.Anjali Behera)
M e m b e r(w),
( Sri Pradeep Kumar Dash ) I/C President.
M e m b e r
