ADV. RAVI SUSHA, MEMBER.

            This complaint filed by the complainant for getting the claim amount of Rs.62,156/- with 12% interest and compensation of Rs.10,000/-

          The averments in the complaint can be briefly summarized as follows:

          Complainant’s husband Sreerangan is a policy holder of the opp.parties. with policy number  is 781593790 and the assured maturity amount is Rs.50,000/-.  The proposal was submitted on 28^th March 2001 and the policy becomes effective from that date.   The complainant’s  husband died on 9.10.2003 at Lok Raksha Hospital, Thevalakkara, Karunagappally  following  kidney disease.   After the death of the policyholdler,  the complainant preferred death claim on the policy, which was repudiate by the opp.parties vide letter dt.31.3.2004alleging suppression of material facts regarding the health of the policy holder at the time of proposal    Thereafter as per the direction of the opp.parties the complainant preferred a representation to the Zonal Manager of the LIC of India at Chennai on  28.4.2004.    The decision of the opp.parties were upheld by the Zonal review committee and the 2^nd opp.party communicated the decision vide their letter dt. 22.3.3005.The opp.parties are estopped from repudiating the claim after the lapse of two years from the date of the policy.   The 1^st opp.party repudiated the claim of the complainant without any basic data as also based on surmises and conjectures.  There is clear deficiency of service on the part of the opp.parties.   Hence the complainant approached the Forum for relief.

          The opp.parties filed version contenting, interalia, that the complaint is not maintainable either in law or on facts.   The averments in para 1 and 2 of the complaint are admitted.   The Life Insurance Policy No.781593790 was issued by the LIC of India to Sree Rangam the date of proposal is 28.3.2001 and the date of commencement of the policy is 28.3.2001. The sum assured under the policy is Rs.50,000/- and the nominee is Smt Prasannakumar, the wife of the life assured.  The complainant’s husband died on 9.10.2003 at Lok Raksha Hospital, Thevalakkara and the cause of death was renal failure. The averments in para 5 and 6 of the complaint are false  and hence denied.    The deceased Sree Rangam died of Diabetic Nephropathy and as per the Certificate of hospital treatment From Dr. Vimala, Professor of Nephrology, Medical College Hospital, Thiruvananthapuram and was diagnosed to have type II diabetic mellitus twelve years back which was reported by the policy holder himself to the doctor on 27.2.2003.  The complainant’s husband has availed medical reimbursement for various ailments on different occasion from his employer M/s. Oriental Insurance Company from 1997-98 onwards.    Life Insurance is a contract between the holder of the policy and the Life Insurance Corporation of India, whereby the company agrees in return for premium, to pay a specified sum.  In this particular case at the time of submitting the proposal orm for the policy the life assured had fraudulently suppressed material facts regarding his illness.  Claim form B1 submitted by the complainant and the statement of leave availed by the life assured on medical grounds reveal  that the life assured was not in good health even prior to the submission of the proposal form.  The facts regarding his illness and the medical treatment he availed were not mentioned in the proposal form.    The fact that the Life assured had been undergoing medical treatment for Diabetics Mellitus for the last twelve years is evident from the certificate of hospital treatment and the certificate issued by the employer.  Since the death occurred within three years from the date of commencement of the policy the claim has to be examined for admission.  The investigation conducted by the LIC of India into the cause of death and his past medical records, it has come up in evidence that there is fraudulent suppression of material facts regarding his health and the LIC of India believed the answers given by the life assured in the proposal form which was subsequently proved false.  Under the above mentioned circumstances, LIC of India has no other alternative but to repudiate the claim of the complainant and letter dt. 31.3.2004 the opp.party intimated the decision.  There is no deficiency in service on the part of the  opp.party.  Hence the opp.parties prays to dismiss the complaint.

          The points that would arise for consideration are:

1.     Whether there is deficiency in service on the part of the opp.parties

2.     Reliefs and costs.

For the complainant PW.1 examined.  Ext. P1 is marked.

For the opp.parties DW.1 to 3 are examined.   Ext. D1 to D10 are marked.

POINTS:

          It is not disputed that the complainant’s husband has taken Ext. D2. policy and that the policy was subsisting when the complainant’s husband died.   Complainant submitted Ext. D1 claim which was repudiated by the opp.party as per Ext. P1 on the ground that the deceased having withheld material information regarding his heath at the time of effecting the assurance with the opp.party

          In column No. II [a] and [c] of the proposal form, for these two question the life assured had given negative answers.   Actually the life assured was not in good health even prior to the submission of the proposal form.  From Ext. D5 it is revealed that the life assured had been undergoing medical treatment for Diabatic Mellitus for the last twelve years and from column 7 [c]  in Ext. D5 shows that history of the disease was reported by none  other than the life assured himself. Since the death occurred within they had conducted 3years from the date of proposal.   According to the opp.party they had conducted investigation  into the past medical records of the Life assured, it has found that there is fraudulent suppression of material facts regarding his health in Ext. D1 proposal form.   The answers given in D1 proposal form regarding his health are false.   Ext. D6 and D8 are  the treatment of diabetic Nephrology and peritoneal haemodialysisduring the period from 28.3.198 to 28.3.2001.  This document also support the case of opp.party that there was suppression of material facts with respect to the health of the Life assured in Ext. D1proposal form.   As per clause 5 of the policy conditions in Ext. D2. Policy, any untrue or incorrect statement constrained in the proposal form, the policy shall be void and all claims to any benefit in virtue here of shall cease.   From the documents produced from the side of opp.party it is evident that the life assured had suppressed material facts.  In these circumstances we are of the view that the repudiation of the claim is proper.   There is no deficiency in service on the part of the opp.party.   Point found accordingly.

          In the result, the complaint fails and the same is hereby dismissed  without costs.

          Dated this the     31^ST        day of March, 2010.

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I N D E X

List of witnesses for the complainant

PW.1. – Prasannakumari

List of documents for the complainant

P1. – Repudiation letter

List of witnesses for the opp.parties

DW.1. – Chandrasekharan

DW.2. – Dr.l A. Vimala

DW.3. – Dr. A. Belicita

List of witnesses for the opp.parties

D1. – Proposal Form

D2. – Policy certificate

D3.- Death intimation  letter dt. 29.10.2003

D4. – Claim statement dt. 18.12.2—3

D5. – Hospital treatment certificate

D6. – Certificate of Employer [Oriental Insurance] dt. 15.12.2003.

D7. –Doctor’s certificate dt. 29.11.2003

D8. – Employer’s certificate dt. 12.4.2004

D8-b. – Medical certificate

D9. – Statement of medical reimbursement

D10. – Repudiation letter