Karnataka

Gadag

CC/13/2015

Amargouda.G.Goudar - Complainant(s)

Versus

The Manager, LIC of India & Another - Opp.Party(s)

S.V.Grampurohith

23 Apr 2016

ORDER

JUDGEMENT DELIVERED BY

SMT.C.H.SAMIUNNISA ABRAR, PRESIDENT:

The complainant has filed this Complaint against the Opposite Parties (herein after referred in short as OPs) u/s 12 of Consumer Protection Act, 1986 alleging unfair trade practice against OPs. 

 

2.    The brief fact of the case is that the father of the  Complainant had purchased the policy from OP No.1 through OP No.2 name of the policy being Janaraksha bearing Policy No.638346024, the Sum assured is Rs.50,000/-, the policy commenced from 31.03.2011 and matures on 13.04.2020.

 

3.      At the time of purchasing the policy all the requirement including medical test have been taken and thereafter only the policy was issued by obtaining a premium of Rs.1,718/- as a half yearly premium from the father of the Complainant. The Complainant had been nominated as a nominee by his father. Further, Complainant stated that his father fell ill and he was unable to pay the premium on 16.08.2013 his father paid all the dues outstanding along with the fine and the policy was revived and the Status was active, the father of the Complainant passes away on 28.08.2013 after the demise of the insured (father) the Complainant moved a claim Application to the OP, the OP rejected the claim quoting the false reason that the father of the Complainant was suffering from H.I.V. Positive since three years eight months seven day, at the same time of issuing the policy the father of the Complainant had been indemnified and for the first time and he was hail and healthy and was not suffering from any diseases. Hence, the Complainant alleged the reason for rejecting the policy is contrary.

 

4.      The Complainant had stated that his father was not suffering from the disease like Aids and had not infected by H.I.V. Positive, but the OP was aware that much before issuance of the policy, the father of the Complainant had suffered from HIV positive, the Complainant had urge the OP to prove the same. Hence, by quoting a false reason rejecting the claim is a unfair trade practice, the OP have committed gross negligency. The Complainant had issued a notice through his counsel on 02.09.2014. The OP had not replied for the same. Hence, the Complainant prayed to order the Ops to pay sum of Rs.50,000/- towards Sum Assured along with the interest and to award Rs.50,000/- towards mental agony and Rs.10,000/- towards litigation charges.   

 

5.      The predecessor on seat registered the Complaint and notices were ordered as such the OP No.1 has appeared before this Forum through his counsel and filed Written Version.

Brief facts of the Written Version are as under:

The OP had denied the contention made in the Complaint and admitted that father of the Complainant had purchased the policy, for assured sum of Rs.50,000/- and the nominee is the Complainant.

 

6.      The OP had stated that the date of commencement of the policy is 31.03.2011 which is not true, but the commencement date is 13.04.2011. Further, the OP had stated that the Complainant had suppressed the real and material facts, the policy was issued under non-medical general scheme, no medical test of the deceased were made on the date of the purchase of the policy. Only on the good faith of the said deceased the policy was accepted by the OP No.1.

 

7.      Further, the OP had stated that the said policy was lapsed for non-payment of premium due from April-2012 onwards. The same had revived on 16.08.2013 on receiving the payment of Rs.5,490/- the revival was affected by the deceased policy holder on the strength of his personal statement of health submitted. Hence, revival of lapsed policy is fresh contract and subject to providing insurability regarding health and habit of policy holder. The deceased had suppressed his status of health; the insured revived his policy on 16.08.2013 and died on 20.08.2013 i.e. within 04 days of effecting fresh revival. The father of the Complainant had furnished false information in this personal statement of health dated: 05.08.2013. The deceased suffering from AIDS tested H.I.V. Positive by District Hospital, Gadag and Certificate also issued by the Hospital Authorities with ART No.336 dated: 09.11.2009 and he had taken treatment from 09.11.2009 to 07.06.2013. The fact of the health is suppressed by the policyholder while obtaining the policy and at the time of revival of lapsed policy which is clearly breach or violation of insurance contract. Hence, repudiation of claim by the OP is legal and valid. There is no question of deficiency in service by OP.

 

8.      Further the OP stated that the repudiation of claim is conveyed to the Complainant on 24.06.2014 the Complainant, referred the matter to the Zonal Office, Hyderabad which also rejected the claim. Hence, OP had prayed to dismiss the Complaint with costs.

 

9.      In background of the above said pleading, the Complainant himself examined before this Forum as PW-1 and got marked the document as EX P1 to EX. P6 and some of the unmarked documents are also filed. Those are as follows:

EX-P1- Letter from Zonal Office,

EX-P2- Office copy of the legal notice  

EX-P3- Postal Acknowledgement

EX P3(A) – Registered Postal Receipt,

EX-P4 & EX P5- Postal Acknowledgement

EX P6 – Postal Receipt.

EX P6 (A) – Postal Receipt.

Unmarked documents are:

1. Copy of Insurance Policy,
2. Death Certificate of Insurer,
3. Revival L.I.C. premium paid receipt,
4. Letter from L.I.C.

On the other hand, AAO, Divisional Office, Dharwad was examined on behalf of OP No.1 and got marked as EX OP1 to EX OP13, the documents are as follows: 

1.   Policy Certificate,
2.   Proposal Form,
3.   Legal Notice,
4.   Reply to the Notice
5.   Letter (for repudiate of claim)
6.   Personal Statement about Health,
7.   Letter from Zonal Office, Hyderabad,
8.   Letter from L.I.C. Dharwad,
9.   Claim Statement,

10. ) Medical Attendance,
11. ) Certificate of Hospital Treatment,
12. ) Letter from ART Centre,
13. )  Letter from Art Centre.

On the basis of the above said pleadings, oral and documentary evidence, the following points arises for adjudication are as follows:   

 

1.   2.   3.	Whether the Complainant proves that OP had committed a unfair trade practice?   Whether the OP proves that deceased had suppressed the material fact?   Whether the Complainant is entitled for relief?
4.	What Order?

 

Our Answer to the above Points are:-

Point No.1 – Affirmative,

Point No.2 – Negative,

Point No.3 – Partly Affirmative,

Point No.4 – As per the final order.

 

10.    On consideration of pleading, objection, evidence, documents and arguments of the parties, we answer the above points as under:

                        R E A S O N S

 11.  POINT NO.1 & 2:  Since Point No. 1 & 2 are identical we proceed both the points together to avoid the repetition of fact.

  12.       This is the case of the complainant that the OP (LIC of India) had repudiated the insurance claim. The father of the complainant (Ganganagouda Goudar) had purchased a policy by paying a premium of  Rs.1,718/- which is half yearly premium for sum assured Rs.50,000/-(Fifty thousand). Complainant is the nominee, the policy stand lapse due from April 2012. The complainant had said that due to the illness of insured the premium stands due, thereafter on 16-6-2013 the father of complainant paid the entire dues along with interest and other charges and the policy was revived by the OP No.1. This is the undisputed fact by the OP.

 

13.         Immediately after four days i.e. 20/08/2013 the father of complainant died, the complainant being the nominee submitted that the Claim Form to the OP No.1 Claiming for assured amount. The OP No.1 had repudiated the death claim of policy No.63846024. On the ground “Suppress of material fact” based on evidence of treatment certificate issued by Senior Medical Officer ART Center District Hospital, Gadag.

 

14.         The OP No.1 had stated that the death claim under the Policy No.638346024, vide letter No. DC/1831/DSB, dated 26/03/2014 stating that 03 years 08 months 07 days prior to the date of revival the assured was tested HIV Positive, for which he had taken medical treatment from a hospital and a document produced by the OP marked as EX OP 13, the slip issued by the ART Center, District Hospital discloses that the deceased Ganganagouda Goudar had registered on ART at Hirehal under Registration No.336 pre ART registration dated: 09.11.2009, Pre ART registration No.744 treatment taken from 09/11/2009 to 07/06/2013 which carries the seal of the Senior Medical Officer and signed for him by somebody which does not carries any date, the person who had signed for Senior Medical Officer is authorized to do so or not cannot be established here.

 

15.         The Medical Officer ART Center District Hospital, Gadag had also issued a Certificate addressed to the Manager, LIC Divisional Office, Dharwad vide letter dated: 06/08/2015 stating that Ganganagouda.V.Goudar at Hirehal Taluk, Ron register in ART Center, Gadag. HIV tested dated 28/03/2005 placed on a RON patient transfer in from KIMS, Hubli, R.G. No.554 Gadag ART No.744 on 09/08/2009. On ART No.336 on 20/08/2009 death date 18/02/2014, treatment taken from “TB, Spine from PHC, Hirehal, Ron Taluk from 28/05/2012 to 26/10/2012 default TB No.252/2012”. This documents produced by the OP will not discloses that the deceased Ganganagouda Goudar was infected with HIV Positive, the Certificate only speaks that he had been tested for HIV and the date of death of Late Ganganagouda.V.Goudar had been mentioned as 18/02/2014 when the insured had died on 20/08/2013, copy of the Death Certificate produced by the complainant discloses the fact the Certificate issued by Senior Medical Officer, ART Center, Gadag and Medical Officer, ART Center Gadag surprisingly issued a different medical report in which the registration of the deceased Ganganagouda.V Goudar is same on ART numbers, but the date of registration and the period of treatment taken totally differ which had been marked as EX. OP 12 & 13.

 

   16.       Moreover that the Claimant Statement of LIC of India and Medical Attendant’s Certificate marked as EX OP 9, 10 & 11 respectively does not carries any date. Meanwhile the documents EX OP10 Medical Attendant’s Certificate prepared by the LIC, in column No.6 (c), it is said that the history had been reported by the son of the late Ganganagouda (Complainant) which does not carries his signature. In the aforesaid view, we are supported by the judgment cited in I (2016) CPJ 516 (NC) National Consumer Disputes Redressal Commission, New Delhi, (Life Insurance Corporation of India V/s Motia Rani). The important point reads as under:

         “Consumer Protection Act, 1986 – Sections 2 (1) (g), 14 (1) (d), 21 (b) – Insurance (Life) – Death of life assured – Claim repudiated – Suppression of material facts alleged – Deficiency in service – District Forum dismissed Complaint – State Commission allowed appeal – Hence revision – Medical Certificate issued by Doctor mentioned name of patient as “Gulshan Kumar” – No evidence placed by “Gulshan Kumar” were one and same person – It cannot be presumed that deceased was suffering from any disease and was admitted in hospital for treatment of acute Miocardial infarction – Repudiation without appropriate evidence amounts to deficiency in service – No error in impugned order”.

 

        In I (2006) CPJ 81 (NC) National Consumer Disputes Redressal Commission, New Delhi (Pyari Devi V/s Life Insurance Corporation of India), the important point reads as under:

                    “(ii)  Consumer Protection Act, 1986 – Sections 2 (1) (g), 14 (1) (d), 21 (b) – Insurance (Life) – Death claim – Suppression of material facts alleged – Claim repudiated – Deficiency in service – District Forum allowed Complaint – State Commission allowed appeal – Hence revision – Hospital record did not spell a single line or history that deceased was suffering from cough and breathlessness for last two years – OP failed to prove its case that disability was a material non-disclosure – It is just a technical one – Hospital record makes it clear that patient suffered breathlessness after 10 months of taking policy – impugned order set aside – Order of District Forum restored.”

   

It is very strange that LIC being a reputed insurance company should look in different angle in such cases the policy sum assured as just meager amount of Rs.50,000/- It is very disgusting that the Life Insurance Company earned huge amount by the way of lapse, unclaimed, discontinued policies etc. But indulge in the litigation for a meager  amount we really feel sorry for the that inhuman attitude of insurance company, the documents marked as EX OP 9,10 & 11 if does not carry any date it cannot be taken into the consideration, in question of law it is not a material to prove that the complainant’s father Ganganagouda had suppressed the material fact therefore we are of consideration that the OP had failed to prove that Ganganagouda had suppressed the material fact, since the OP could not establish the breach of terms of policy by material suppression of facts regarding his state of health, the OP had blindly repudiated the claim of the complainant, hence we answer the Point No.1 in affirmative and Point No.2 in negative.

 

12.  POINT NO. 3:  We have considered disputed contention of the complaint and perused the records whether the insured late Ganganagouda Goudar obtain the insurance policy by concealing the material fact that he was already suffering from AIDS because of the said reason the claim had repudiated.

 

13.         In order to find answer to this question, it is necessary to look on certain documents produced before this Forum, on perusal of the documents marked as EX OP 12 &13 both the medical reports submitted by the ART Center, District Hospital, Gadag is totally different. It is very much difficult to believe that the two different Officers of the same Institution (ART Centers) issued a unmatched report even the date of death mention does not match with the Death Certificate.

 

14.         Further the documents marked as EX OP9 Claimant Statement, Medical Attendant’s Certificate EX OP10 and EX OP11 Certificate of hospital treatment, on careful scanning, the documents Claimant Statement does not carry the signature, Medical Attendant’s Certificate said to be detailed reported by the complainant prepared by LIC’s Medical Officer does not carry any date, Certificate of hospital treatment also does not carries any date on carefully going through these records, it cannot establishes that the insured Ganganagouda Goudar has suppressed the material facts regarding his health, in the view of above noted materials information, we are at the consideration that the complainant being the nominee of Ganganagouda Goudar is entitled to receive the claim and compensation. Hence, we answer the Point No.3 in partially affirmative.

 

    15.       POINT NO.4: For the reasons and discussion made above and finding on the above points, we proceed to pass following:  

 

//ORDER//

        1.   This Complaint is partly allowed with costs.

2.   The OP No.1 is directed to pay a sum of Rs.50,000/- (Rupees fifty thousand) towards the Sum Assured in the Policy along with interest @ 09% p.a. from the date of filing this Complaint.

3.      OP No.1 is directed to pay a compensation of Rs.5,000/- (Rupees five thousand) towards mental agony and harassment. Further, OP No.1 is directed to pay Rs.2,000/- (Rupees two thousand) towards litigation charges.

 

4.      OP No.1 is directed to comply this Order within a period of 30 days from the date of Order, failing which OP No.1 is directed to pay interest @ 12% p.a. to the assured amount, till realization.

5.      Complaint dismissed against OP No.2.

6.      Send a copy of this Order to both the parties free of cost.  

 (Dictated to the Stenographer, transcribed by him, corrected and then pronounced by me in the Open Court on 23^rd day of April, 2016)

 

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