The Manager, LIC of India, Madhira Branch, Khammam & Others The Divisional Manager, LIC of India, Hanumakonda The Zonal Manager, LIC of India, Hyderabad
...........Respondent(s)
BEFORE:
Complainant(s)/Appellant(s):
OppositeParty/Respondent(s):
OppositeParty/Respondent(s):
OppositeParty/Respondent(s):
ORDER
BEFORE THE DISTRICT CONSUMERS FORUM AT KHAMMAM Dated this, the 15th day of June, 2010 CORAM: 1. Sri Vijay Kumar, B.Com., L.L.B. - President, 2. Smt.V.Vijaya Rekha B.Sc. B.L. - Member 3. Sri R.Kiran Kumar, B.Sc. L.L.B - Member C.C.No.76/2009 Between: . Mandadapu Madhusudan Rao, s/o.Venkata Ramaiah, age: 58 years, occu: Agrl., r/o.Brahmanapalli village, Bonakal Mandal, Khammam District. Complainant And 1. The Manager, LIC of India, Madhira branch 2. The Divisional Manager, LIC of India, Balasamudram, Hanumakonda. 3. The Zonal Manager, LIC of India, Jeevan Bhagya, Saifabad, Hyderabad. Opposite parties This C.C. is coming on before us for hearing in the presence of Sri.M.Srinivasa Rao, Advocate for complainant; and of Sri.K.Jagan Mohan Rao, Advocate for opposite parties No.1 to 3; upon perusing the material papers on record; upon hearing arguments, and having stood over for consideration, this Forum passed the following:- O R D E R (Per Sri Vijay Kumar, President) This complaint is filed under section 12A of the Consumer Protection Act, 1986. 1. The averments made in the complaint are that the complainant has taken Jeevan Anand Policy bearing No.687027859 in the name of deceased, Mandadapu Thulasamma from the opposite party No.1. The sum assured is Rs.1,00,000/-. Subsequently, the wife of the complainant died on 24-1-2007 and the same was informed to the opposite party No.1 by furnishing of necessary documents for death claim. But the opposite parties did not come forward to pay the death claim to the complainant and the claim has been repudiated. On 26-1-2007 the opposite party No.2 had addressed a letter stating to approach opposite party No.3 for reconsideration of the claim. On 18-6-2008 the complainant addressed a letter to opposite party No.3 with a request to consider the claim. On 4-11-2008 the opposite party No.3 addressed a letter to the complainant to approach insurance ombudsmen. Inspite of approaching many a times to the opposite parties, the efforts made by the complainant went in vain. This act on the part of opposite parties amounts to deficiency in service. Hence, this complaint. 2. Apart from the complaint, the complainant filed affidavit reiterating the contents of the complainant. 3. On receipt of the notice, the opposite parties 1 to 3 appeared through their counsel and filed counter. In the counter the opposite parties have admitted that late Smt.Tulisamma had taken a policy for Rs.1,00,000/- as the death occurred within 3 years from the date of acceptance of risk treating the said claim as early, investigation was caused to the bonafides of the claim. During the said investigation, it came to light that the life assured was having pre-proposal illness of metastatic carcinoma of left breast i.e. cancer and was admitted into NIMS on 2-3-2004, operated on 8-3-2004 and discharged on 17-3-2004. It is further submitted that the life assured while submitting her proposals for insurance having complete knowledge of her illness and treatment for breast cancer, intentionally suppressed the material facts so as to fraudulently obtain the life insurance policy. The assured, late Tulisamma had answered to the questions in her proposal form, the answers given by her in the proposal form were false. Though she suffered with breast cancer and was operated for the same at NIMS, she has suppressed the real facts with a fraudulent intention had not disclosed health condition in the proposal form. The opposite party would not have issued the said policy had she disclosed the material fact of her pre-proposal illness related to Metastatic carcinoma of left breast. Therefore, the opposite party has rightly repudiate the claim and prayed to dismiss the complainant. 4. On behalf of the complainant, Exs.A.1 to A.4 are marked. Ex.A.1 - Photocopy of letter addressed to opposite party No.3, dt.18-11-2008 by the complainant Ex.A.2 - Letter addressed by the opposite party No.3 to the Complainant, dt.21-6-2008 Ex.A.3 - Letter addressed by opposite party No.2 dated 14-11-2008 Ex.A.4 -Letter addressed by opposite party No.2 to the complainant, dt.26-11-2007. 5. On behalf of the opposite parties 1 to 3, the following documents have been filed and marked. Ex.B.1 - Proposal form for insurance, dt.30-4-2004 signed by life assured. Ex.B.2 - Claim Form A Ex.B.3 - Certificate of Hospital Treatment Ex.B.4 - Discharge Record pertains to Tulasamma containing 21 pages. Heard both sides. Perused the oral and documentary evidence. Upon which the point that arose for consideration is, 1. Whether the repudiation of the claim by the opposite parties is just and proper? 2. To what relief? Point No.1: It is not in dispute that late Tulisamma had taken policy from opposite parties for Rs.1,00,000/- on 30-4-2004, she died on 24-1-2007. As the death of life assured is within three years, therefore, they made an investigation into bonafide of the claim. During the said investigation, it came to light that the life assured was having pre-proposal illness of Metastatic carcinoma of left breast, i.e. cancer, she was admitted into the NIMS, Hyderabad on 2-3-2004, operated on 8-3-2004 and discharged on 17-3-2004. On this aspect of the case, the opposite parties have referred Ex.B.4, discharge card, NIMS hospital, Hyderabad. On a careful perusal of Ex.B.4, discharge card, it clearly discloses that late Tulisamma was admitted into NIMS, Hyderabad with a complaint of left breast cancer. After undergoing all the tests, it was detected that she suffered with left breast cancer and she was operated on 8-3-2004 and discharged on 7-3-2004. A photocopy of discharge record is filed, wherein the entire record substantially established that late Tulisamma was a patient suffering with left breast cancer even prior to taking of policy. As against this, she has submitted a proposal form for taking insurance policy on 30-4-2004. In the proposal form in question No.11, she has clearly answered that she did not consult a medical practitioner for any ailment requiring treatment for more than a week; she also answered no to a question whether she was admitted in the hospital or nursing home for treatment or operation. She also replied no whether she was absent from place of work on grounds of health during the last five years; she also answered no whether she suffered with ailments, liver, stomach, hearth, lungs, kidney, brain or nervous system; she also replied no whether she had any Blood Pressure, Cancer, Epilepsy, Hernia, Hyderocele, Leprosy or any other disease. These answers given by late Tulisamma in question No.11 clearly go to establish that though she suffered with illness of left breast cancer and she was admitted into NIMS hospital, Hydeabad on 2-3-2004. Though she had complete knowledge of pre-proposal illness for breast cancer she intentionally suppressed the material facts so as to fraudulently obtain policy. On this aspect of the case, the opposite party refers to Ex.B.1 proposal form, which was signed by her on 30-4-2004. It is a clear case of suppression of material facts by the deceased, Tulisamma. She has given wrong answers in the proposal form and non-disclosure of material facts justified the repudiation of the policy. Though the basic fact of taking policy is not in dispute. The insured had undergone operation for left breast cancer. It was a major operation. Although the said operation was undergone by her even prior to the proposal made by her. She did not disclose the above fact prior to obtaining the insurance policy. As per section 45 of the Insurance Act, the power is given to the opposite party to investigate into the case whether the death occurs within a period of two years. On their investigation, this fact has come to the light that the insured was suffering from breast cancer. She has suppressed this fact fraudulently though it was material to disclose. Therefore, the opposite parties rightly repudiated the claim when the fraudulent fact is discovered. The intention of the proposal was not bonafide. This has been made clear by the medical record marked as Ex.B.4. The opposite parties have substantially established the suppression of material facts fraudulently made by the policy holder/deceased. A deliberate wrong answers were given in the proposal form. In lieu of the facts and circumstances of the case, we are of the opinion that the insured/deceased has suppressed the material facts and fraudulently obtained the policy by giving wrong answers in the proposal form. Therefore, the repudiation of the claim made by the opposite parties is justified and accordingly this issue is answered against the complainant and in favour of the opposite parties. In the result, the complaint is dismissed, holding that the deceased suppressed the material facts and made false and fraudulent statement and obtained the policy. Dictated to the steno, transcribed by her, corrected and pronounced by us in the open forum, on this 15th day of June, 2010. PRESIDENT MEMBER MEMBER DISTRICT CONSUMERS FORUM, KHAMMAM APPENDIX OF EVIDENCE Witnesses examined for complainant: -None- Witnesses examined for opposite parties: -None- Exhibits marked for complainant: Ex.A.1 - Photocopy of letter addressed to opposite party No.3, dt.18-11-2008 by the complainant Ex.A.2 - Letter addressed by the opposite party No.3 to the Complainant, dt.21-6-2008 Ex.A.3 - Letter addressed by opposite party No.2 dated 14-11-2008 Ex.A.4 - Letter addressed by opposite party No.2 to the complainant, dt.26-11-2007. Exhibits marked for opposite parties: Ex.B.1 - Proposal form for insurance, dt.30-4-2004 signed by life assured. Ex.B.2 - Claim Form A Ex.B.3 - Certificate of Hospital Treatment Ex.B.4 - Discharge Record pertains to Tulasamma containing 21 pages. PRESIDENT MEMBER MEMBER DISTRICT CONSUMERS FORUM, KHAMMAM
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