This is a complaint filed U/s. 12 of Consumer Protection Act by the complainant Venkateshachari against the Respondent Divisional Manager LIC of India Divisional Office Raichur. The brief facts of the complaint are that:- The complainant is the natural father of minor boy-Prahalad aged about 15 years, student. The complainant has obtained a policy bearing No. 6638999436 on 28-07-06 under Table & Term 014-16 for assured sum of Rs. One Lakh and has paid premium amount regularly and that he is the nominee. The minor life assured-Prahalad died on 22-10-06 and after his death the complainant approached the Respondent Corporation for payment of policy amount & policy benefits if any, and then Respondent Corporation issued the claim form to the complainant who after duly filled-in submitted with required documents. But the Respondent has failed to settle his claim. So he got issued legal notice to the Respondent on 16-08-07 and the Respondent has replied to the said notice stating that Respondent Corporation is processing the claim. The complainant waited for (15) days and wrote another letter through his Advocate dt. 27-10-07 after that the complainant received a back dated reply letter dt. 05-10-07 repudiating the policy claim by stating that the life assured was suffering from Leukemia. The policy taken by the complainant in the name of his minor son Prahalad is a Medical Policy and the penal doctor has thoroughly examined the minor life assured Prahalad and filed the proposal form after thoroughly examining the life assured. Now the Respondent saying that life assured was suffering from serious disease Leukemia is false & baseless and it is done without applying their mind and have mechanically repudiated the policy claim in-order to escape from such liabilities. This itself clearly shows deficiency in service on the part of the Respondent Corporation in settling his claim. The life assured was hale and healthy before taking the policy. The life assured had suffered from Jaundice before one week of his death and was taken Ayurvedic Treatment. It is the bounden duty of the Respondent to pay death claim to the complainant as per the terms and conditions of the policy. So the repudiation of the policy amount by the Respondent is illegal. The complainant has lost his beloved son Kumar Prahalad at his early age of (15) years who is bright student and on account of his death the complainant is in great agony. Hence for all these reasons the complainant has sought for direction to the Respondent for payment of policy amount of Rs. One lakh together with accrued bonus and benefits and further direction for payment of Rs. 50,000/- towards compensation for wrongful denial of the claim and Rs. 50,000/- towards damages for causing untold hardship, in-convenience, loss, mental tension agony and Rs. 5,000/- towards cost of litigation expenses. 2. In-response to service of notice the Respondent Insurance Corporation appeared though counsel and filed written statement contending that: The complainant being the natural father of the minor life assured Prahalad has obtained policy in-question for assured sum of Rs. One lakh covering the risk from 28-07-06 by paying half yearly premium of Rs. 3,156/-. After receiving the claim form, the claim has been processed. As it was an early death claim this Respondent has caused Investigation and in the said investigation it came to know that minor life assured Prahalad has taken treatment at Rajiv Gandhi Super Specialty (Opec) Hospital Raichur and he was admitted as in-patient from 12-02-06 to 06-03-06. After the discharge again he was admitted in the Opec Hospital Raichur on 26-04-06 & discharged on 06-05-06 with a diagnosis that the said Prahalad was suffering from Acute Lymphoblastic Leukemia which is nothing but Cancer. The discharge summary and case sheet are filed. The complainant nominee and the deceased life assured have suppressed the material facts while taking the policy. The proposal form was filled on 25-08-06 and it was examined by doctor on 30-08-06. While filling the proposal form the deceased life assured and father of the complainant nominee have given wrong answers to the question No. 15(a) to 15(h) by stating as No and have suppressed the fact that late Prahalad has taken treatment as in-patient in Rajiv Gandhi Super Specialty Hospital, Raichur from 22-02-06 to 06-03-06 & from 26-04-06 to 06-05-06 and he was suffering from Leukemia. The complainant and the deceased have played a fraud by suppressing real facts in obtaining the policy. The basic principle of insurance contract is Utmost Good Faith which is violated abinitio. The Confidential Report of Medical Examiner shows that he had ascertained from life assured about his health as per column NO-5 of the report. This column states that if the answer to any of the questions in column NO-5 is stated as Yes then full details are to be given but the deceased Prahalad has given answers to the above questions as No. So it makes aboundantly clear that the doctor is recording what the insured i.e, deceased Prahalad tells him. It is not the result of any test/examination. If a person with holds any information the doctor would not know it, unless it is visible. The deceased Prahalad has with-held the correct information regarding suffering from Cancer. The medical examination by the Respondents authorized medical examiner relating to the proposal submitted by the deceased life assured for insurance cover outward medical examination is alone done basing on the answers given by the deceased life-assured & the proposer and no internal medical examination has taken place. The Respondent Corporation has collected all the case-sheet of deceased Prahalad and based the decision of repudiation of policy which is lawful. So there is no deficiency in service on the part of the Respondent in repudiating the policy and they have given reply to the legal notice. As the deceased life assured was suffering from Acute Lymphoblastic Leukemia Pericardial effusion with Tamponade, left pleural effusion and anterior mediastinal mass (lymph node) for which the deceased life assured was consulted medical men and taken treatment with them. However he did not disclose these facts while taking the policy and suppressed the material facts to make wrongful gain to the complainant. As such the Respondent has rightly repudiated the claim. Hence for all these reasons the Respondent Corporation has sought for dismissal of the complaint with cost. 3 During the course of enquiry the complainant has filed his sworn-affidavit by way of examination-in-chief as PW-1 and has cross-examined Dr. N.Shankar Pawar Medical Officer, Government Hospital Mudgal and Penal Medical Examiner of Respondent Corporation as PW-2. In rebuttal the Respondent Corporation has filed affidavit of its Administrative Officer by way of examination in chief as RW-1 and has got examined Dr. Suresh.V. Sagard Cardiologist OPEC Hospital Raichur as RW-2 through Forum Commissioner. On behalf of the complainant (8) documents have been got marked as Ex.P-1 to Ex.P-8. In rebuttal the (3) documents have been got marked as Ex.R-1 to Ex.R-3 for Respondent. 4. Heard the arguments of both sides and perused the records. The following points arise for our consideration and determination: 1.Whether the complainant proves deficiency in service by the Respondent corporation in not settling his claim under the policy, as alleged.? 2. Whether the complainant is entitled for the reliefs sought for? 5. Our finding on the above points are as under:- 1) In the Negative. 2) As per final order for the following REASONS POINT NO.1:- 6. It is the case of the complainant that his minor son Prahalad aged about 15 years, student was hale and healthy while taking policy bearing No. 6638999436 on 28-07-06 for assured sum of Rs. One Lakh and he has paid the premium amount regularly and he is the nominee of the above said policy. The minor life assured Prahalad died on 22-10-06. After the death of his son he filed claim form for payment of policy amount. But the Respondent has failed to settle his claim so he got issued legal notice to the Respondent on 16-08-07 for which the Respondent has replied that the Respondent Corporation is processing the claim. But in-spite of waiting (15) days time there was no response so he got issued another legal notice dt. 27-10-07 after that he received a back dated letter dt. 05-10-07 from the Respondent Corporation repudiating his claim on the ground that the life assured was suffering from Leukemia. It is also his case that while the policy was taken by the complainant the penal doctor of the Respondent Corporation has thoroughly examined the minor life assured Prahalad who was hale and healthy. Now the Respondent saying that life assured was suffering from serious disease like Leukemia is false and baseless. The life assured was suffering from Jaundice before one week of his death and has taken Ayurvedic Treatment. So the contention of the Respondent that life assured was suffering from Leukemia is false and baseless and in-order to escape from the liability of payment of assured sum. So there is deficiency in service on the part of the Insurance Corporation. 7. The Respondent Corporation has contended that since the death of the minor life assured was within three months from the date of the policy in-question so they investigated the cause of death which raveled that the life assured had taken treatment at Rajiv Gandhi Super Specialty (OPEC) Hospital Raichur and he was admitted as in-patient from 12-02-06 to 06-03-06 and after the discharge again he admitted in the OPEC Hospital Raichur on 26-04-06 and was discharged on 06-05-06 with a diagnosis that he was suffering from Acute Lymphoblastic Leukemia which is nothing but cancer. The complainant nominee and the life assured have suppressed the material facts while taking the policy. The proposal was filled on 25-08-06 and he was examined by the panel doctor on 30-08-06. While filling the proposal form the deceased life assured and father of the complainant nominee have given wrong answers to the question No. 15(a) to 15(h) by stating as No and thus they have suppressed the real facts about his having taken treatment as in-patient in Rajiv Gandhi Super Specialty Hospital, Raichur from 22-02-06 to 06-03-06 and from 26-04-06 to 06-05-06 and he was suffering from Leukemia. So they have played a fraud in obtaining the policy and they have mis-lead the Respondent Corporation by suppressing the material facts in obtaining the policy. The Confidential Report of Medical Examiner shows that he had ascertained from life assured about his health as per column NO-5 of the report. This column states that if the answer to any of the above questions in column NO-5 is stated as Yes then full details are to be given but the deceased Prahalad has given answers to the above questions as No. So it makes aboundantly clear that the doctor is recording what the insured i.e, deceased Prahalad tells him. It is not the result of any test/examination if a person with holds any information the doctor would not know it, unless it is visible. The life assured has with-held the correct information regarding suffering from cancer. So the medical examination report by the Respondents authorized medical examiner submitted by the proposal deceased life assured for insurance on the answers given by the deceased life assured then the proposer and no internal medical examination has taken place. The Respondent Corporation has collected medical case sheet of deceased Prahalad and based the decision regarding repudiation of policy has been taken so there is no deficiency in service on the part of the Respondent Corporation. 8. Both the parties have produced documentary evidence at Ex.P-1 to Ex.P-8 and Ex.R-1 to Ex.R-3 respectively. The complainant has examined the panel doctor-medical examiner of the Respondent Corporation as PW-2 whereas the Respondent Corporation has examined Dr Suresh.V.Sagard a cardiologist in Rajiv Gandhi Super Specialty Hospital, Raichur. This RW-2 Dr. Suresh.V.Sagrad who has been examined through Forum Commissioner states that the late life assured Prahalad was admitted on 22-02-06 in his hospital. He was suffering from Pericardial Effusion (Flued Collection around the heart). He was discharged on 06-03-06. He was again admitted on 20-03-06 and was under the treatment Dr. S.S.Reddy till 01-04-06 for left Pleural Effusion (Flued Collection in the lung). Patient was again admitted in the hospital on 26-04-06 till 06-05-06 and he has treated the patient for Pericardial Effusion left pleural & anterior mediastnal mass, (lymph mode). He under went investigation (FNAC of mediastnal mass and bone marrow aspiration) which revealed acute lymphoglastic leukemia (a type of blood cancer) hence he was discharged and referred to Kidwai Cancer at Bangalore. The discharge summaries dt. 06-03-06, 06-05-06 & 01-04-06 are marked at Ex.R-1 to Ex.R-3. In the cross-examination, of course, he has stated that he does not know what was the cause of death but has further stated that history of the disease is that the patient presented to the hospital with fever and breathlessness for one week duration prior to admission and that after verification (diagnosis), illness of the disease of the deceased can be cured is possible. He states that he is not a Specialist to treat the Cancer patient hence the patient was referred to Specialist Center. He cannot say what was the cause of death as he has not witnessed the death. Ex.R-1 is the Discharge Summary of Rajiv Gandhi Super Specialty (OPEC) Hospital. It shows the date of admission of the patient life assured Prahalad as on 22-02-06 and he was discharged on 06-03-06. Chief of complaint shows fever and breathlessness for few days and was admitted for evaluation. On diagnosis it was revealed: large Pericardial effusion with Tamponade. Pericardial Tapping. Ex.R-3 is the second Discharge Summary It shows the admission of the patient on 20-03-06 and discharged on 01-04-06 History of present illness shows: fever and breathing difficulty. Ex.R-2 is the third Discharge Summary. It shows that the life assured was admitted in the hospital on 26-04-06 and was discharged on 06-05-06 with same history of Pericardial effusion with Tamponade. On diagnosis it found: (1) Acute Lymphoblastic Leukemia, (2) Pericardial effusion with Tamponade, (3) left Pleural effusion. (4) Anterior Mediastinal Mass (Lymphonade); and it shows that he was advised to go to Kidwai cancer at Bangalore. The first discharge summary at Ex.R-1 and the third discharge summary at Ex.R-2 show that the patient life assured was under the medical treatment of Dr.Suresh.V.Sagrad (RW-2). The second discharge summary at Ex.R-3 shows that the patient was under the treatment of Dr. S.S.Reddy (in the OPEC Hospital, Raichur). The third discharge summary at Ex.R-2 shows that the patient was advised to go to Kidwai cancer at Bangalore. RW-2 Dr. Suresh.V.Sagrad in his evidence has stated about discharge summary at Ex.R-1 to Ex.R-3 and that the patient late life assured was suffering from Leukemia and he was treated for Pericardial effusion left pleural effusion & anterior. He underwent investigation which revealed acute lymphoglastic leukemia a type of blood cancer. He was advised to go to Kidwai cancer at Bangalore. 9. The complainant has examined Dr. N. Shanker Pawar, a Government Medical Officer and Penal Doctor of Respondent Corporation as PW-2. He states that he is the Penal Doctor of LIC of India Division Office Raichur since 2002, at Mudgal. On 30-08-06 late life assured Prahalad Achar was brought by LIC Agent Yenkavva for medical examination. He physically examined said Prahalad Achar with regard to height, weight, chest, BP & Pulse and noted down rates in the Medical Examiners Confidential Report which is a proforma supplied by the LIC Authorities. In the said proforma there are certain question as shown in Para-5 to 15. Accordingly he put each questions to the said Prahalad Achar who answered question NO-5 to 14 in the Negative and question NO. 15 in the Affirmative and he has accordingly written the answers as No to the question No. 5 to 14 and as Yes to the question No. 15. This Medical Report has been marked as Ex.P-1 with his signature at Ex.P-1(a). On the date of his examination vide Ex.P-1, the life assured Prahalad Achar was found healthy. After completion of Ex.P.1, he put further questions as stated in Para-14 to 31 in the Proposal Form for Insurance at Ex.P-2 produced by the agent. The life assured answered question No. 14(a) as Good and other questions upto question No-20 as No and he answered question NO-21 as Good. Accordingly he has written those answers to the respective questions in the proposal form and has put his signature at Ex.P-2(a). According to him the life assured Prahalad Achar and proposer (B.Venkatesh father of life assured) have made a declaration in-respect of the answers in the Proposal Form under headings/question No. 9 to 31 in the Proposal Forms and have put their signatures. In the cross-examination this PW-2 states that the life assured Prahalad Achar has not told before him that he was admitted in OPEC Hospital at Raichur and had taken treatment there. His medical examination was to the extent of physical examination of life assured as stated in Ex.P-1. So from the evidence of penal doctor PW-2 and the documents at Ex.P-1 & Ex.P-2 it clearly shows that the examination made by this doctor PW-2 to the life assured is physical test and not internal test and that the Life Assured did not tell before PW-2 about his earlier treatment before OPEC Hospital. Admittedly the life assured was examined by this doctor PW-2 on 30-08-06 but the discharge summary at Ex.R-1 to Ex.R-3 and evidence of Dr Suresh.V.Sagrad RW-2 go to show that much earlier, this life assured Prahalad was admitted in the OPEC Hospital for three times on 22-02-06 to 06-03-06 vide Ex.R-1, from 20-03-06 to 01-04-06 vide Ex.R-3 and from 26-04-06 to 06-05-06 vide Ex.R-2 and it was diagnosed that he was suffering from Pericardial Effusion (Flued Collection around the heart) and he was treated Pericardial effusion left pleural effusion Anterior Mediastinal Mass. (Lymph mode), and he was advised to go to Kidwai Cancer at Bangalore RW-2 Dr. Suresh.V.Sagrad in clear terms has stated that life assured Prahalad was suffering from Pericardial effusion and left pleural effusion and anterior Medistinal Mass (Lympho Mode), he underwent investigation which revealed acute lymphoglastic leukemia (a type of blood cancer) and hence he was discharged and referred to Kidwai Cancer at Bangalore. So from the evidence of PW-1 & PW-2 and the evidence of RW-2 Suresh.V.Sagrad of OPEC hospital, it goes to show that three months after the discharge of the life assured from OPEC Hospital on 06-05-06 vide Ex.R-2 with advise to go to Kidwai Hospital Bangalore the life assured was examined by the Penal Doctor PW-2 on 30-08-06 and his evidence clearly go to show that he has physically examined the life assured with regard to height, weight, chest, BP & Pulse etc., and has noted down the answers to the question No. 5 to 15 given by the life assured as Negative. Question No.5 in the Medical Examiners Confidential Report with regard to whether the life assured at any time in the past: (a) was hospitalized (b) was operated (c) met with accident (d) has undergone any bio-chemical, radiological, cardiological or other test (e) is currently under any treatment. The life assured has answered as No. Similarly to the question No. 15(a) to (g) in the proposal form regarding suffering from: (a)Persistent cough, asthma, bronchitis, Pneumonia, pleurisy, spitting of blood, tuberculosis or any disease of lungs. (b)High or low blood pressure, theumatic fever, pain in chest, breathlessness, palpitation, infraction or any disease of the heart or arteries (c)Peptic ulcer, colitis, jaundice, anaemia, piles dysentery or any disease of the stomach liver, spleen, gall bladder or pancreas. (d)Any disease of kidney, prostate or urinary system. (e)Paralysis etc., (f)Hernia etc., (g) Cancer etc., the life assured has given answer as No. Hence as rightly contended by the Respondent Corporation, the life assured and the proposer-complainant have suppressed the real facts of his medical treatment as in-patient in OPEC Hospital as per the discharge summary at Ex.R-1 to Ex.R-3 & the advised to go to Kidwai Hospital for blood Cancer. As per the death certificate at Ex.P-8 the life assured Prahalad died on 22-10-06 which is within the three months from the date of commencement of risk of policy dt. 28-07-06 vide Ex.P-3. If all these factors are taken into account, it is crystal clear that the late policyholder and his father the complainant, have suppressed material facts by giving false answers to the questions in the Medical Examiners Report at Ex.P-1 and Proposal Form at Ex.P-2 against medical treatment taken in OPEC Hospital for breathlessness and Leukemia and lastly he was advised to go to Kidwai hospital for blood cancer. Hence it shows suppression of existence of disease at the time of obtaining the policy. 10. In Para-7 of the complaint it is contended that the life assured was suffering from Janudice before one week of his death and he had taken Ayurvedic treatment. The complainant in his affidavit-evidence at Para-4 has stated the same thing. But except this bare statement the complainant has not substantiated by any material particulars. So the contention that the late life assured was suffering from Jaundice one week earlier to his death and had taken Ayurvedic treatment has remained without any substantial piece of evidence. Therefore we find justification in repudiation of the claim by the Insurance Company and thereby it cannot be said that there is deficiency in service by the Respondent Corporation. Hence we hold that the complainant has failed to prove deficiency in service by the Respondent in not settling his claim under the policy. Therefore the rulings relied upon by the L.C. for the complainant reported in: 1)II (2007) CPJ Page 242 (NC) 2)II (2007) CPJ Page 452 of Delhi State Commission, are of no avail to the complainant since they are on different footings. In the first ruling of our Honble National Commission, the policyholder in that case has died after one year two months from the date of obtaining of policy. Here in the case at hand the policyholder has died hardly within two months from the date of obtaining the policy. In the said ruling the Penal Doctor had taken X-ray of the policyholder and has certified that the policyholder was healthy. In the instant case the evidence of Penal Doctor as discussed above go to show that he has examined the life assured with regard to height, weight, chest, BP & Pulse and noted down the answers to question No-5 to 15 given by the life assured in the Negative in his report Ex.P-1. So the principles laid down in the said rulings are not applicable to the present case. Hence Point No-1 is answered in the negative. POINT NO:2- 11. In-view of our above discussion and finding on Point No-1, the complainant is not entitled for the reliefs sought for. In the result we pass the following order: ORDER The complaint of the complainant being devoid of merits is hereby dismissed. No order as to cost. Office to furnish certified copy of this order to both the parties forth with free of cost. (Dictated to the Stenographer, typed, corrected and then pronounced in the open Forum on 20-06-08) Sd/- Sri. N.H. Savalagi President Dist.Consumer Forum-Raichur. Sd/- Smt.Pratibha Rani Hiremath Member. Dist.Consumer Forum-Raichur. Sd/- Sri. Gururaj Member. Dist.Consumer Forum-Raichur.
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