BEFORE THE DISTRICT CONSUMER

       DISPUTES REDRESSAL FORUM, BAGALKOT.

COMPLAINT NO.16/2017
Date of filing: 02/03/2017

Date: 30^th day of October, 2017

   P r e  s e n t: 

01) Smt.Sharada.K.                                                    President…

     B.A.LL.B. (Spl) 

02) Smt. Sumangala.C.Hadli.                         Lady   Member…

                            B.A (Music)

                V/s

JUDGEMENT DELIVERED BY SMT. SUMANGALA.C.HADLI, MEMBER

The Complainant filed this complaint u/sec. 12 of Consumer protection Act, 1986 seeking direction to Opposite Parties (herein after referred in short as Ops) to grant sum life insured amount of Rs.2,00,000/- with interest at 18% p.a. from the date of repudiation of complainant claim i.e. on 07.10.2016, till realization, Rs.80,000/- towards mental agony and harassment and Rs.25,000/- towards cost of this litigation and such other reliefs deems fit under the circumstances of the case.

2.   Brief facts of the case are as follows:

The complainant is a permanent resident of Muchakndi LT of Bagalkot taluk. The complainant’s husband by name Yashwant Rathod during his life time got insured his life insurance policy with OP No.1 under LIC’s New Endowment Plan with payment of Rs.10,021/- as a monthly premium amount for a sum assured of Rs.2,00,000/- which its policy bearing No.669548249 and said policy commence its risk from 07.06.2016 and the date of maturity is on 06.06.2015. Unfortunately, the complainant husband Yashwant succumbed to be died on 08.06.2016 due to Cardiac arrest in his home at Muchakandi while he was taking to hospital for treatment. The complainant who is wife of deceased Yashwant and also a nominee of said policy. The said policy is valid at the time of death of deceased Yashwant Rathod.

3.      Thereafter, as per the above said policy’s Terms and Conditions, the complainant filed the Application to OP-Office with praying to grant the Sum Assured of Rs.2,00,000/-. The complainant along with an Application submits the original policy bond, death certificate and other relevant documents for settlement of claim. But, unfortunate Ops have repudiated the complainant claim with intimation letter on dated: 07.10.2016 on grounds that deceased Yashwant Rathod had suppressed the material facts with regards to his health at the time of obtaining the policy. That prior to death of deceased Yashwant Rathod, he was hale and healthy person and not suffering any disease. Further, he was dead due to cardiac arrest which is not a disease and which is usually happens in suddenly depends upon the heavy working pressure conditions of persons, but now Ops have not fulfilling the main object of life insurance policy to this complainant. Hence, these Ops have causes deficiency in service by repudiating the claim of the complainant on un-reasonable grounds due to which complainant has sustained mental agony and financial loss. Therefore, complainant has filed the present Complaint seeking direction to grant sum life insured amount of Rs.2,00,000/- with interest at 18% p.a. from the date of repudiation of complainant claim i.e. on 07.10.2016, till realization, Rs.80,000/- towards mental agony and harassment and Rs.25,000/- towards cost of this litigation and such other reliefs deems fit under the circumstances of the case.

4.      After receipt of notice, the OPs-Counsel present before the Forum and filed Written Version.

          Written Version of OPs are as hereunder:

          The Complaint filed by the complainant against Ops is false and frivolous as such deserved to be dismissed. In the case, the policy is commenced on 07.06.2016 and on the very next day only that is on 08.06.2016 the policy holder Sri.Yashwant Rathod expired. As the death of life assured took place within 3 years from the date of commencement of the said policy the claim was categorized as EARLY-CLAIM and hence as per prevailing practice of the Corporation the investigation was necessary to ascertain about any suppression of material facts regarding his ill health of the deceased policy assured prior to taking the policy. In the said investigation, it is revealed that before he proposed for the above policy, the Deceased Life Assured had H/O Dysphora and Chest Pain since 6 months and taken the treatment for CHD PDA in a repudiated Hospital at KLE’s Hospital, Belagavi from 20.07.2011 to 28.07.2011, but whereas the policy was commenced on 07.06.2016. However, he did not disclose these material facts in his proposal form, instead of he gave false answers as Personal History prior to fill-up the proposal form at the time of issuing said policy. Hence, the repudiation of the claim by Ops-Corporation is in order and accordingly the Ops are not liable to pay any of the payment under this policy to the complainant. The complainant has filed this Complaint for wrongful gain from the Ops, knowing well that the decision of the Ops in rejecting fraudulent claim is genuine and lawful one. Hence, OPs prayed that the Hon’ble Forum may kindly dismiss the Complaint with cost in the interest of justice.     

5.     The complainant has produced documents. The said documents are as follows:

1. Xerox true copy of Insurance Policy,

2. Claim Repudiated letter dated: 07.10.2016,

3. Xerox true copy of Claimant Statement,

4. Xerox true copy of Certificate of Hospital,

5. Xerox true copy of medical attendants Certificate.

The Ops have produced documents. The said documents are as follows:

1. Copy of Summary Sheet of KLE Hospital, Belagavi,
2. Copy of the Proposal Form,
3. Copy of the Policy Bond,
4. Copy of the Status Report of the Policy.

6.      By way of evidence, complainant has filed affidavit and filed 05 documents in support of her case. On the other hand, OPs one Sri.Sunil S Deshpande, Manager, LIC of India, Divisional Office, Belagavi has filed affidavit. Heard the arguments and perused the documents.

7.      After considering the material placed on record, the following points that would arise for our consideration.

1. Whether the complainant has proved her claim as alleged by the complainant?
2. Whether the complainant is entitled to get compensation?
3. What order?

8.    After considering the evidence tendered by both sides and on careful consideration of the arguments advanced by both sides our findings for the above points are as follows.

1. Affirmative,
2. Partly in Affirmative,

2) As per final order.

R E A S O N S

9. POINT NO.1 and 2: As there two points are inter-connected with each. In the instant case, it is undisputed fact that the complainant’s husband by name Yashwant Rathod during his life time got insured his life insurance policy with OP No.1 under LIC’s New Endowment Plan with payment of Rs.10,021/- as a monthly premium amount for a sum assured of Rs.2,00,000/- which its policy bearing No.669548249 and said policy commence its risk from 07.06.2016 and the date of maturity is on 06.06.2015. Unfortunately, the complainant husband Yashwant succumbed to be died on 08.06.2016 due to Cardiac arrest in his home at Muchakandi while he was taking to hospital for treatment. The complainant who is wife of deceased Yashwant and also a nominee of said policy. The said policy is valid at the time of death of deceased Yashwant Rathod. It is also undisputed fact that as per the above said policy’s Terms and Conditions, the complainant filed the Application to OP-Office with praying to grant the Sum Assured of Rs.2,00,000/-. The complainant along with an Application submits the original policy bond, death certificate and other relevant documents for settlement of claim. But the Ops argued that the policy is commenced on 07.06.2016 and on the very next day only that is on 08.06.2016 the policy holder Sri.Yashwant Rathod expired. Ops also argued that as per prevailing practice of the Corporation the investigation was necessary to ascertain about any suppression of material facts regarding his ill health of the deceased policy assured prior to taking the policy. In the said investigation, it is revealed that before he proposed for the above policy, the Deceased Life Assured had H/O Dysphora and Chest Pain since 6 months and taken the treatment for CHD PDA in a repudiated Hospital at KLE’s Hospital, Belagavi from 20.07.2011 to 28.07.2011, but whereas the policy was commenced on 07.06.2016. However, he did not disclose these material facts in his proposal form, instead of he gave false answers as Personal History prior to fill-up the proposal form at the time of issuing said policy.

10.    On careful perusing the records, the husband of the complainant was admitted to the hospital from 27.07.2011 to 28.07.2011, the OPD Chit of the hospital is produced. In most of the recognized institutions, the patient will be observed very consciously and give treatment and when the patient is admitted with chest pain, usually they will be taken into ICU Care and immediate tested ECG & X-rays will be done when the patient is suffering from chest pain he will be checked by the Cardiologist compulsorily. But, in this case the Medical Officer In-charge has treated the patient and signed the report. If any operation is necessary, the doctors have written inoperable. If this point it shows that the chest must not have been acute. If so, they would have definitely been done ECG or Angiography would have done. Thus the question arises why did they write inoperable. Hence, in this case when a patient is admitted for chest pain, the treatment will be given by a Cardiologist and the report must be given. But, here it has not been done. When the OP has produced summary sheet of the patient, the incharge Medical Officer has done all the tests and signed the report. The report of the Cardiologist has not been produced. The OPD Slip has not shown the number of the patient.

11.    In KLE there are very known Cardiologists, they should have also given opinion or atleast the Medical Officer should have told the patient to consult a Cardiologist. Hence, the complainant has not suppressed any facts of his health. So for that reason he has filled the Proposal Form. In considering all the facts, we are of the opinion that it cannot be said that the Proposal forum filled by the patient does not hide the facts of any old treatment.    

12.    On careful perusing the records filed by the complainant, it is observed that as per EX C4 the Certificate of Hospital, the death of the husband of complainant is due to Cardiac Arrest and it is come to all peoples unfortunate. Though the husband of the complainant died immediately on the next day of the commencement of the policy as per the OP-Insurance Company, they had enquired at the K.L.E. Hospital, Belgaum, the deceased had undergone treatment in 2011, it is nearly 4 years after the commencement of issuing the policy.

13.    The husband of the complainant died due to Cardiac Arrest it is a fact that it may happen at any time anybody. Hence, we are of the opinion that complainant has made Hence, we are of the opinion that the OP is made deficiency in service in not settling the claim of the complainant.      

14.    In this case, the OP made deficiency in service, the next question arise how much complainant is entitled to get? In the light of our above observations, we are of the opinion that complainant is entitled to get a Sum Assured amount of Rs.2,00,000/-. Nodoubt, the complainant suffering from mental agony in OP is not settling the claim in-time. Hence, complainant is also entitled to get an amount of Rs.10,000/- towards mental agony and Rs.2,000/- towards the cost of this proceeding from the Ops. In the light of our findings and reasons, we answer Point No.1 in affirmative and Point No.2 in partly affirmative.

15. Point No:3 In the result, the complaint of the complainant is fit to be allowed in part. Hence, we proceed to pass the following:

O R D E R

     Complainant’s complaint is allowed in part as follows;

1. The OPs shall have to pay Rs.2,00,000/- (Rupees two lakh) towards Sum Assured to the complainant.
2.  The OPs shall have to pay an amount of Rs. Rs.10,000/- (Rupees ten thousand) for mental agony and Rs.2,000/- (Rupees two thousand) towards litigation expenses to the complainant.
3. The OPs are directed to comply this order within a period of 30 days from the date of receipt of this order, failing which the above said amount of Rs.2,00,000/- shall carry interest at the rate of 12% per annum from the date of order, to till realization.
4.  Free copy of this order shall be sent to the parties immediately.

        (Dictated to the Stenographer directly on computer corrected by me and then pronounced in the open Forum on this 30^th day of October, 2017).