COMPLAINT FILED ON: 26.11.2009
DISPOED ON: 31.01.2011
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)
DATED THIS THE 31ST JANUARY 2011
PRESENT:- SRI. B. S. REDDY PRESIDENT
SMT. M. YASHODHAMMA MEMBER
SRI. A. MUNIYAPPA MEMBER
COMPLAINT No.2784/2009
Complainant OPPOSITE PARTIES | Smt. Anusuya, W/o Late M.N. Rangaswamy, Aged about 30 years, R/at No.279, 6th Cross, Mantapa Road, Mallasandra Pipe Line, T. Dasarahalli, Bangalore – 560 063. Advocate: Sri. H.V. Bhanu Prakash V/s. 1. The Divisional Manager, L.I.C. of India, Peenya Branch, Tumkur Road, Yeshwanthpur, Bangalore. 2. The Zonal Office, L.I.C. of India, South Central Zone Office, “Jeevan Bhagya Saifabad, Hyderabad – 560 063. Advocate: Sri. G.N.Harish & Another |
O R D E R
SRI. B.S. REDDY, PRESIDENT
The complainant filed this complaint U/s. 12 of the Consumer Protection Act of 1986, seeking direction against the Opposite Parties (herein after called as O.Ps) to pay the policy amount of Rs.1,00,000/- along with interest at 18% p.a. from the date of death of deceased M.N. Rangaswamy and for damages of Rs.50,000/- on the allegations of deficiency in service on the part of the OPs.
2. The case of the complainant to be stated in brief is that:
The complainant is the legally wedded wife of deceased M.N.Rangaswamy who died on 19.04.2007 at Agadi Hospital, Bangalore. The deceased had obtained the two life insurance policies from OP-1 branch vide bearing No.614339676 and 615363513. OP-2 is the zonal office of OP-1. After the death of M.N. Rangaswamy, the complainant intimated death report along with original policy copies and death certificate before OP-1 by representation dated 22.09.2007. OP-1 after receiving the representation, issued letter dated 08.08.2009 intimating that the claim has been forwarded to the higher officer for consideration. OP-1 had settled one policy No.614339676 on 21.11.2008 for a sum of Rs.1,12,999/-. OP-1 had issued another notice dated 15.12.2008 to the complainant stating that the deceased M.N. Rangaswamy was suffering diabetes. After receiving the said letter, the complainant issued reply on 19.12.2008 stating that the deceased was not suffering from any diabetes and other disease. The deceased was hale and healthy and he has not taken any treatment from any other hospital. OP-1 informed the complainant through telephone during the first week of March – 2009 to produce any documents which reveals that the deceased has taken any treatment. The complainant wrote letter dated 18.03.2009 informed OP-1 that the deceased has not taken any treatment from any hospital during his life time. After receiving the said letter OP-1 repudiated the claim of the complainant of policy No.615363513 by its letter dated 24.03.2009. OP-1 sent cheque for Rs.6,949/- on 02.04.2009 along with covering letter, the amount refunded is the amount deposited by the deceased as a installment to policy during his life time. The deceased obtained two insurance policies each for Rs.1,00,000/-, OP-1 had settled one policy bearing No.614339676 for an amount of Rs.1,12,999/- and repudiated the another policy No.615363513 by its letter dated 02.04.2009. Legal notice was issued to OPs-1 and 2, OPs issued the reply to the notice on 14.10.2009. OP has not settled the policy amount. The act of OPs repudiation of the claim is malafide and illegal, there is deficiency of service. Hence the complaint.
3. On appearance, OPs-1 and 2 filed version admitting that the deceased M.N. Rangaswamy had obtained two life insurance policies bearing Nos.615363513 and 614339676 and after his death, the complainant preferred the death claim with OPs. The death claim under policy No.614339676 has been settled. It is stated that the life assured took policy No.615363513 vide its proposal dated 31.03.2007 on non-medical basis. Just after nineteen days from the date of commencement of the said policy, his death occurred. OPs have caused investigations and received the hospital reports and treatment particulars wherein it is shown that the life assured was suffering the uncontrolled diabetes since six months prior to the date of death. He had developed cellulites due to a wound on right lower limb. His uncontrolled diabetes prevented the healing and aggravated the cellulites. Thus the medical cause of death of life assured is centre septicemia shock, cellulites necrotising fascitis of right lower limb and uncontrolled diabetes. It is evident that death of life assured is due to uncontrolled diabetes and there is strong nexus between the cause of death and the disease suffered. Based on the hospital records and with due application of mind, the claim under the said policy has been repudiated on the grounds of suppression of material facts regarding his health by the life assured, at the time of taking the policy. OP-1 informed the complainant vide its letter dated 24.03.2009 reasons for repudiation of the claim and sent cheque for Rs.6,946/- being the bid value of the units held in the policy holder’s account under the above policy. OP-1 has also given complainant an opportunity to approach the OP-2 for reconsideration, if she disagreed with the decision of OP-1. The other policy which was taken by the deceased life assured during the year – 2004 has been settled. But the policy obtained by him on 31.03.2007 by suppressing material information regarding his health, it has been proved by the medical records. Hence her claim is rejected. The life assured, has violated the conditions of the contract in respect of the policy and so OPs repudiated the claim and complainant is not entitled for any reliefs. OPs have sent reply to the legal notice informing the complainant that her representation will be placed before the zonal claims review committee for its consideration. Hence it is prayed to dismiss the complaint with exemplary costs.
4. In order to substantiate the complaint averments, the complainant filed her affidavit evidence. The Divisional Manager, Legal & HPF Department, Divisional Office-1, of OPs filed affidavit evidence and got filed affidavit evidence of Dr. Ganesh Nayak and produced documents in support of the defence version.
5. The complainant filed interrogatories; Dr. Ganesh Nayak, replied the said interrogatories.
6. OPs filed written arguments, arguments heard on both sides. Points for consideration are:
Point No.1:- Whether the complainant has proved
the deficiency in service on the part of
the OPs?
Point No.2:- If so, whether the complainant is
entitled for the relief’s now claimed?
Point No.3:- To what Order?
7. We have gone through the pleadings, the affidavit and documentary evidence of both the parties. We record our findings on the above points:
Point No.1:- Affirmative.
Point No.2:- Affirmative in part.
Point No.3:- As per final Order.
R E A S O N S
8. The deceased M.N.Rangaswamy the husband of the complainant had obtained two life insurance policies from OP-1 branch vide bearing Nos.614339676 and 615363513. OP-2 is zonal office of OP-1. The deceased M.N. Rangaswamy died on 19.04.2007 at Agadi Hospital, Bangalore, the complainant being the wife of the deceased preferred the death claim with OPs. The death claim under policy No.614339676 has been settled. The claim under policy No.615363513 was repudiated by OPs on the ground that the life assured was suffering from uncontrolled diabetes since six months prior to the date of death. His proposal for the said policy dated 31.03.2007 suppressed the material facts regarding his health condition, as per the medical report of the hospital, the life assured was suffering from uncontrolled diabetes since six months prior to the date of death. He had developed Cellulites due to a wound on right lower limb. His uncontrolled Diabetes prevented the healing and aggravated the Cellulites. Thus the medical cause of death of the life assured is centre Septicemia shock, Cellulites necrotising, Fascitis of right lower limb and uncontrolled Diabetes. Based on the Hospital records and with due application of mind, the claim under the policy has been repudiated on the grounds of suppression of material facts regarding his health by the life assured at the time of taking the policy.
9. OP has produced documents at serial No.1 to 7 with memo dated 10.03.2010. The proposal for the policy reveals that while furnishing the personal history at column No.6, the life assured has answered in negative for question – (e) which reads:
“Are you suffering from or have you ever suffered from Diabetes, Tuberculosis, High Blood Pressure, Cancer, Epilepsy, Hernia, Leprosy or any other desease?” The life assured answered the same as “No”.
The copy of admission record reveals provisional diagnosis cause of death – Septicemia shock; history sheet copy of the Agadi Hospital reveals that the deceased M.N. Rangaswamy was admitted in Agadi Hospital on 19.04.2007. It is mentioned as patient a known Diabetic since six months, not on any medication (DHAs / insulin), noticed a small swelling over the medial surface of right lower limb about three days ago. He had been to the hospital near his house he has given injection swelling of the limb, but the patient did not find any relief. In the progress sheet of the hospital it is noted that Dr. Ganesh Nayak examined the patient and it is shown as uncontrolled Diabetes Mellitus, Cellulites and Chronic venous insufficiency. At 11.00 p.m. on the same day i.e., 19.04.2007 patient declared dead. The cause of death is shown as Septicemia shock secondary to Necrotising fascitis lower limb and uncontrolled Diabetes Mellitus.
10. As per repudiation letter dated 24.03.2009 it is stated that OPs have decided to repudiate all liability under the policy; the deceased having withheld material information regarding his health at the time of effecting the assurance with them. It is stated that the deceased answered the questions – 6. ‘a’ and ‘e’ of the proposal for assurance in negative and question – 6. ‘i’ as ‘good’. These answers were false as deceased was suffering from uncontrolled Diabetes prior to date of proposal. He did not however disclose these facts for his proposal. Instead he gave false answers therein as stated above.
11. It is well settled that suppression of material facts onus lies on LIC; it is for the OPs to prove that the complainant’s husband suppressed the material fact with regard to his health at the time of proposal. Except the Agadi Hospital history sheet wherein the deceased was admitted for medical treatment on 19.04.2007; there is no other records produced by OPs to prove the fact that the deceased had knowledge of Diabetes and he had taken any medical treatment earlier to his admission in Agadi Hospital on 19.04.2007. It is not clear as to who recorded in the Hospital sheet in the Hospital stating that patient known Diabetic since six months. Earlier to 19.04.2007 the deceased life assured had not taken any medical treatment for any of the diseases much less for Diabetic. Without there being any material on record there was no reason for recording in the history sheet of the hospital that patient a known Diabetic since six months. OP mainly relied on the note made in the history sheet of the hospital that patient a known diabetic since six months while repudiating the claim on the ground of suppression of material facts regarding the health of the assured. OPs failure to produce any medical certificate or records of any other hospital to show that the deceased has taken treatment for Diabetes before taking the policy. The affidavit evidence of RW-2 Dr. Ganesh Nayak of Agadi Hospital that patient was a known case of Diabetes since six months prior to admission in the hospital on 19.04.2007; without there being any supportive material with regard to earlier treatment taken in any hospital for Diabetes cannot be accepted. Under these circumstances we are of the view that OPs failed to prove that the deceased life assured had suppressed the material fact regarding his health while taking the policy. In view of the same OPs are not justified in repudiating the claim. The complainant being the widow of deceased and nominee under the policy is entitled for the claim amount. The act of OPs in repudiating the claim without due application of mind amounts to deficiency in service on the part of the OPs. Accordingly we proceed to pass the following:
O R D E R
The complaint filed by the complainant is allowed in part. OPs are directed to pay the policy amount of Rs.1,00,000/- along with litigation cost of Rs.2,000/- to the complainant within four weeks from the date of this order. Failing which the complainant is entitled for interest at 18/% p.a. on the said amount from the date of complaint till the date of payment / realization.
Send copy of this order to both the parties free of costs.
(Dictated to the Stenographer and typed in the computer and transcribed by him, verified and corrected, and then pronounced in the Open Court by us on this the 31st day of January – 2011.)
PRESIDENT
MEMBER MEMBER
Snm:
