Karnataka

Tumkur

CC/105/2016

K.S.Chandramouli - Complainant(s)

Versus

The Branch Manager,LIC of India - Opp.Party(s)

K.P.Manu Prakash

28 Apr 2017

ORDER

C.C. filed on:01.08.2016

C.C. Disposed on:28.04.2017

 

BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, TUMKUR

 

DATED THIS THE 28^th DAY OF APRIL –  2017

 

C.C. No. 105 OF 2016

 

:PRESENT:

SMT. PRATHIBHA. R.K. BAL LLM. PRESIDENT,

SMT. GIRIJA, B.A. LADY MEMBER

 

COMPLAINANT/S:

 

1.       K.S.Chandramouli

          S/o T.Shivananjaiah

Aged about 44 years

 

2.       Labhyath

          S/o K.S.Chandramouli

          Aged about 8 years,

          Since minor, Repted by his

          Natural Guardian & Father by

          1^st Petitioner K.S.Chandramouli.

 

          Both Petitioners are R/at

          Kodalagara, Dugadihalli Post,

          C.N.Halli Taluk,

          Tumakuru District.

 

 

( By Sri/Smt. K.P.Manju Prakash  –  Advocate)

 

-V/s-

OPPOSITE PARTY/IES

 

1.       The Branch Manager,

          LIC of India

          Gubbi Satellite Office

          TAPMCS Building

          N.H.206, Gubbi Town,

          Tumakuru District

 

2.       The Branch Manager

          Life Insurance Corporation of India,

          Railway Station Road,

          Gandhinagar, Tumakuru – 572 101

 

(OP No.1 – Ex-parte)

(OP-2 By Sri./Smt. Shams – Us Tabrez .A. Advocate)

 

 

 

 

: O R D E R :

 

 

BY SMT. PRATHIBHA R.K. – PRESIDENT

 

The complainants have filed this complaint under section 12 of the Consumer Protection Act 1986 against the OPs alleging deficiency in service on the part of OPs and prays to direct the OPs to pay a sum of Rs.3,00,000/- and other benefits with respect to life insurance police Jeevan Anand policy bearing No.613229979 in favour of 1^st complainant and to pay a sum of Rs.5,00,000/- and other benefits with respect to Jeevan Anukur policy bearing No.613229844 in favour of 2^nd complainant along with interest @ 18% PA  from the date of complaint till its realization and also prays to direct the Ops to pay damages, cost.

 

The brief facts of the complaint are as under:-

 

2.       The complainant Nos. 1 and 2 are the husband and son of deceased Smt.K.S.Pavanaganga respectively. Deceased Smt.K.S.Pavanaganga was working as Assistant Master at Government High School, Hulikere, Turuvekere Taluk, Tumkur District.  Smt.K.S.Pavanaganga during her life time had obtained two life insurance policies namely Jeevan Anand  policy bearing No.613229979 for sum assured of Rs.3,00,000/- dated:06.09.2012 and another policy i.e. Jeevan Ankur Policy bearing No.613229844 for sum assured of Rs.5,00,000/- dated:22.08.2012.  Deceased Smt.Pavanaganga had nominated her husband/1^st complainant as the nominee to the Jeevan Anand Policy and her son/2^nd complainant to Jeevan Anukur policy. 

          The complainants further submit that Smt.Pavanaganga demised on 30.11.2013 leaving behind the complainants as her legal heirs.   After the death of Smt.P.G.Pavanaganga, the complainants have claimed the above said two LIC policy amount with Ops, but the Ops have repudiated the said claims through their letter dated: 24.03.2015 by assigning false and various grounds.

          The complainants further submitted that the Ops have not settled the sum assured intentionally in favour of the complainants.  Hence, the complainants suffered mental torture and inconvenience and thereby the Ops have committed deficiency in service in not settling the sum assured under the policies.  Hence, the complainants filed this complaint.  

 

                             

3.       Upon service of notice, the OP No.1 has refused to take the notice issued by this forum and thereby he was placed Ex-parte.  The OP No.2 appeared through his counsel and filed the version contending that the allegations/averments made in the complaint are baseless, false and untenable and the same are hereby denied.

          The Ops submitted that there is no deficiency in service on the part of Ops as the Life Assured has obtained the policies by suppressing the material facts and thereby the OP has repudiated the claim.  The OP further submitted that the Life Assured Smt.K.S.Pavanaganga W/o 1^st complainant submitted a proposal for insurance on own life to the corporation on 22.08.2012 for sum assured of Rs.5,00,000/- and another proposal dated:22.08.2012 for Rs.3,00,000/-, both under Government’s salary recovery scheme.  The OP further submitted that at the time of submitting the proposal form, the Life Assured answered the questions has under:-

a)	During the last five years did you consult a medical practitioner for any ailment requiring treatment for more than a week?	No
b)	Have you ever been admitted to any hospital or nursing home for general check-up, observation, treatment or operation?	No
c)	Are you suffering from or have you ever suffered from ailments pertaining to Liver, Stomach, Heart, Lungs, Kidney, Brain or Nervous System?	No
d)	Are you suffering from or have you ever suffered from Diabetes, Tuberculosis, High Blood Pressure, Low Blood Pressure, Cancer, Epilepsy, Hernia, Hydrocele, Leprosy or any other disease?	No
e)	Do you use or have ever used alcoholic drinks, Narcotics or any other drugs or Tobacco in any form	No
f)	What has been your usual sate of health	Good

    

and Smt.K.S.Pavanaganga has given a declaration in the proposal forms that the statements and answers given by her are true and complete in every respect and that she has not withheld any information and also declared that if any untrue averments were contained in the proposal form the contract shall be absolutely null and void.  On the above based information furnished by Smt.K.S.Pavanaganga, the Ops have issued the policies.  

          The OP further submitted that the life assured Smt.K.S.Pavanaganga died on 30.11.2013 i.e. within a period of 14 months and 15 months from the date of commencement of policy Nos.613229844 & 613229979.  Hence, both claims were considered as early claims and the Ops have caused investigation into the bona-fides of the claim.  On investigation, the Ops noticed that she availed a pre proposal treatment at St.John’s Medical College Hospital, Bangalore for Type I Diabetes Mellitus and she was on insulin and it was explicitly recorded with Random Blood Sugar as 240 and was treated with ACTRAPIT (Short activated insulin) to have effective control.     

          The OP further submitted that on further investigation into the matter, it is revealed that the life assured was on treatment for her diabetes for quite some time and she had availed leave for her work from 08.09.2012 to 14.09.2012 (7 days) and from 21.09.2012 to 03.10.2012 (13 days) and around this period i.e. on 22.08.2012 and 06.09.2012 she had proposed for two policies for sum assured of Rs.8,00,000/-. 

          The OP further submitted that on 01.12.2013 the Father of deceased life assured stated before the police that the life assured Smt.K.S.Pavanaganga was suffering from Sugar, High Blood Sugar and many bodily ailments since a long time and that he had arranged for her treatment at St.John’s Hospital, Bangalore. 

          The OP further submitted that based on the principle of Utmost good faith i.e. Uberrima Fides and the information which are well within the knowledge of proponent have to be furnished by the proposer while proposing for insurance and all the questions asked in the proposal form, where relevant to the proposer or not are very much relevant to the insurer to assess the risk and hence the information should furnished correctly without suppressing the material facts.

          The Ops further submitted that it is obligatory for the insured to give correct answers at the time of obtaining the insurance policies as the life assured has suppressed the material facts regarding the disease and treatment taken by her.  Hence, the claims made by the complainants were rightly repudiated invoking Section.45 of the insurance Act 1938.  Hence, there is no deficiency in service or unfair trade practice or delay on the part of Ops.  The complainants have not come with clean hands and have concealed the true and materials facts.  The claim investigation conducted by the OP/Corporation has proved that the Life Assured was not having good health at the time of taking the policies in question.  Hence, the complaint is liable to be dismissed.

          The OP further submitted that if the claim is made within three years from the date of commencement of the policy and as per the rules, the matter will be investigated into the bona-fide of the claim and if it is found that the policy was obtained withholding material information relevant for acceptance of risk under the policy, then the OP will repudiate the claim by forfeiting the amount.          

          The OP further submitted that deceased Smt.K.S.Pavanaganga had obtained three more policies and the said policies were settled as they were prior to three years and hence without causing any investigation/enquiry, the death claim was settled in favour of 1^st complainant. 

          The OP further submitted that the death of Smt.K.S.Pavanaganga is not sudden but due to respiratory failure secondary lung disease which was secondary to high B.P., Sugar and other body ailments.  The claim of the complainant has been processed as per law and as per guidelines issued by IRDA and the claim has been repudiated after considering all the facts, records, evidence and details in the matter in accordance with and principles of natural justice.  Hence, in view of the suppressing of the information by the life assured, the claim made by the complainant was rightly repudiated by the Ops and the Ops/LIC of India is a trustee of the public money and therefore prays to dismiss the complaint with cost in the interest of justice.

 

         

4.  The complainant and OP No.2 filed affidavit evidence.  The complainant marked the documents as Ex.C1 to C4.  The OP produced the copies of documents, but not marked the exhibits.   We have heard the arguments on both sides and posted the case for order. 

 

5.       Based on the above materials the following issues will arise for our consideration.

1. Whether there was deficiency in service on the part of the OPs as alleged by the complainant?

 

2. What Order?

 

6.       Our answer to the above issues are as under:-

Issue No (1)          :         In the negative

Issue No (2)           :         As per final order below

 

: REASONS:

 

 

 

7.       On perusal of the pleadings, evidence and documents produced by both the parties, it is an admitted fact that the deceased life assured Smt. K.S.Pavanaganga during her life time had obtained two policies i.e., Jeevan Anand Policy bearing No.613229979 for sum assured of Rs.3,00,000/- dated:06.09.2012 and Jeevan Ankur policy bearing No.613229844 dated:22.08.2012.  It is also an admitted fact that deceased life assured Smt.K.S.Pavanaganga has nominated her husband the 1^st complainant to the Jeevan Anand policy bearing No.613229979 and her son the 2^nd complainant to Ankur policy bearing No.613229844.  It is also admitted fact that, Smt.K.S.Pavanaganga the life assured died on 30-11-2013.   

 

 

8.       The contention of the complainant is that after the death of life assured Smt.K.S.Pavanaganga, the complainants being the nominees under the policies, have claimed the sum assured with the Ops, but the Ops instead of settling the claims, have repudiated the claims by assigning false and frivolous grounds.  

 

 

9.       On the contrary, the Ops submitted that at the time of obtaining the policies deceased Smt. K.S.Pavanaganga was suffering from Type-I Diabetes Mellitus (DM) and she was taking treatment at St.Johns Medical Hospital, Bangalore and this fact was suppressed by the life assured stating to the answers to the questions asked by the Ops as under:-

a)	During the last five years did you consult a medical practitioner for any ailment requiring treatment for more than a week?	No
b)	Have you ever been admitted to any hospital or nursing home for general check-up, observation, treatment or operation?	No
c)	Are you suffering from or have you ever suffered from ailments pertaining to Liver, Stomach, Heart, Lungs, Kidney, Brain or Nervous System?	No
d)	Are you suffering from or have you ever suffered from Diabetes, Tuberculosis, High Blood Pressure, Low Blood Pressure, Cancer, Epilepsy, Hernia, Hydrocele, Leprosy or any other disease?	No
e)	Do you use or have ever used alcoholic drinks, Narcotics or any other drugs or Tobacco in any form	No
f)	What has been your usual sate of health	Good

   

Further Smt.K.S.Pavanaganga has given a declaration in the proposal forms that the statements and answers given by her are true and she has not withheld any information and also declared that if any untrue averments were contained in the proposal form, the contract shall be absolutely null and void.

 

10.     On perusal of the documents produced by the OPs, in the St.John’s Medical College Hospital discharge summary, the deceased Smt.Pavanaganga was admitted to the above said hospital for treatment on 18-10-2013 and discharged on 21-10-2013.  In the diagnosis column, it is mentioned as 1. Type I DM (Diabetes Mellitus) and 2. Acute gastroenteritis.  The history column mentioned as patient c/o pain abdomen and vomiting for 1 week. The presenting complaints column mentioned as Kl c/o DM1 ĉ last 1yr diabetic Neuropathy on Insulin, 14-0-18 and in the working diagnosis and issues column, it is mentioned as ? Diabetic Ketosis.

 

11.     Further, on perusal of the St.John’s Medical College Hospital Out-patient record: continuation and follow up OPD visiting record mentioned as is dated 12-10-2012, 31 years old, Type 1 DM x 1 ½ year.

 

12.     The medical report produced by the OP goes to show that, the deceased Smt.Pavanaganga was suffering from Type1 DM (Diabetes Mellitus). Hence, we come to conclusion that, the deceased Smt.Pavanaganga was suffering from type 1 DM (Diabetes Mellitus) from past 1 ½ years prior to 12-10-2012. The same was not disclosed by complainant at the time of taking policy and this amounts to suppression of material facts and it is violation of terms and condition of policy.

 

13.     In our view that, there is enough material on record to show that, the deceased Smt.Pavanaganga had type1 DM (Diabetes Mellitus) past 1 ½ years prior to 12-10-2012. Further the complainant counsel submitted that, the death of the life assured is not due to Type1 DN. As per the Postmortem report, the death of life assured is mentioned as “Death is due to respiratory failure as a result of disease of lung”

 

14.     In this regard, the learned counsel for the OP has relied on the following authority.

1.       Revision Petition No.1134/2016 rendered by Hon’ble National Consumers Disputes Redressal Commission, New Delhi, it is stated as under:

“Held:  As per discharge summary dated 15-7-2007 of the hospital, the deceased L.A. was admitted in the hospital on 13-7-2007 and was diagnosed as Hypertension, Diabetes Mellitus and Vertebrobasilar insufficiency. He had been suffering from D.M. for the last 10 years and Hypertension for the last 3 years and he was taking treatment for the said ailment. Thus, if the assured disclosed that, he was suffering from hypertension and Diabetes Mellitus, the corporation would have asked for special medical reports and a decision would have been taken whether to accept the proposal or not. Thus, the decision of repudiation of claim was justified and the complaint is consequently dismissed”.

2.       Revision Petition No.5554/2011 rendered by Hon’ble National Consumers Disputes Redressal Commission, New Delhi, it is stated as under:

“Held: In a contract of insurance, any fact which would influence the mind of a prudent insurer in deciding whether to accept nor not accept the risk is a “material fact”. If the proposer has knowledge of such fact, he is obliged to disclose it particularly while answering in the proposal form. Needless to emphasize that, any inaccurate answer will entitle the insurer to repudiate his liability because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering into a contract of insurance”.

 

 

          15.     A careful reading of the case on hand, on the back ground of yardstick of said decision of the Hon’ble National commission, it is crystal clear that, the guidelines of the said decision quoted by the learned counsel for the OP is aptly applicable to the present case on hands.

 

16.     On careful scrutiny of the case of the complainant in the background of policy condition, it is made crystal clear that, the OP has made scrutiny of the claim form of complainant and relevant documents with more than ordinary care and precision and came to conclusion that the claim of complainant falls under the policy terms and conditions. Accordingly the OP has rejected the claim of the complainant. The said repudiation of the claim of complainant by OP appears to be strictly in accordance with the terms and conditions of the policy, so it cannot be stated that the rejection of the claim of complainant by OP is illegal and against the terms and conditions of the policy. Since the repudiation of the claim of complainant by OP is in conformity with relevant documents and terms and conditions of the policy.  Hence, there is no negligence or deficiency in service can be attributed to the action of OP.  We are of the view that, the material evidence of OP placed before the forum are more believable trustworthy and acted upon than the oral and documentary evidence of complainant. So in view of the above discussion, we hold that, the complainant has failed to prove this point with convincing material evidence that, the OP is negligent and there is deficiency in service on the part of the OP in making rejection of his claim. Hence, we answer this point in a negative. In the result, for the foregoing reasons, we proceed to pass the following order:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ORDER

          The complaint of the complainant is hereby dismissed. No costs.

 

            Supply free copy of this order to both parties. 

 

(Dictated to the Stenographer, transcribed and typed by him, corrected and then pronounced by us in the Open Forum on this, the 28^th day of April 2017)

 

 

 

                                                         

LADY MEMBER                                                      PRESIDENT