By Smt. Saji Mathew, Member:

The gist of the case is as follows.

The diseased husband of the Complainant had taken a policy with the Opposite Party on 18.03.2006 vide policy No. 794379673. Before issuing the policy the policy holder was examined by the Opposite Part's Senior medical examiner, Dr. Subhash. E.C.G was taken and medical certificate was issued. The Opposite Party have refunded Rs.115/- to the policy holder being the refund of medical fee.

2. The policy holder died on 2.11.2006. As nominee of the policy, the Complainant forwarded claim for the policy amount of Rs.50,000/-. The Opposite Party refused the claim. Hence the Complainant prays for an order directing the Opposite Party to deliver the policy amount along with the bonus. The Complainant also requests for interest at the rate of 12%, on the policy amount for a period from 2.11.2006 and a compensation of Rs. 2,000/-.

3. The Opposite Party appeared and filed version. They admitted the issue of policy after a routine medical examination based upon the information given in the proposal form.

4. On 5.11.2006 intimation was received by the Opposite Party about the disease of the policy holder on 2.11.2006 with death certificate from the Complainant. The policy has completed 7 months and 4 days only as on the date of death of the assured. On investigation, it was revealed that the assured has been suffering from chromic obstructive Palmonary disease and was under continuous treatment since 28.04.2009. He was also a known case of Palmonary T.B and Diabetics meletus. Documentary evidence to prove these facts were received from the Doctor/ hospital were the assumed had been under treatment. The facts about the disease of the assumed were not disclosed in the proposal dated 18.03.2006. Pre-proposal illness and suppression of material facts were evident. So, the claim was repudiated on account of non- disclosure of material facts. The repudiation of claim was informed to the claimant vide letter dated 31.03.2007.

5. The diseased Gopalan Nair had other two policies and the Opposite Party had settled the death claim to the nominee. Policy No. 790061773 with date of commencement on 28.07.87 for Rs. 40,000/- and policy No.790246005 with date of commencement on 28.03.88 for Rs. 35,000/- have completed more than 2 years and were settled without any further enquiry.

6. The decision of Opposite Party to repudiate the claim regarding policy No. 794379673 is taken as per rules and regulations pertaining to the policies. The Opposite Party, LIC of India is expected to hold in trust the money collected as premium from the public and every claim should be evaluated so that only genuine claims are honored. Hence the Opposite Party prays for an order dismissing the complaint.

7. The Complainant was examined as PW1 and document was marked as Ext.A1. One witnesses Dr. Subhash was examined as PW1 on the side of the Complainant. The Opposite Party has filed proof affidavit and documents were marked as Ext.B1 to Ext.B5 on the side of the Opposite Party. One witnesses Dr. Vighneswar Bhatt also was examined as OPW1 for the Opposite Parties.

8. The matters to be decided are.

1. Whether there is any deficiency in service on the part of the Opposite Parties ?

2. Whether the Complainant is entitled for any relief ?

9. Point No.1. On the side of the Complainant Dr. Subhash, medical consultant of L.I.C has given evidence. He contented that he has issued certificate after detailed examination and the diseased was not having any health problem. E.C.G also was taken and report given to the L.I.C. This report is marked as Ext.B2. The Opposite Party consents that the policies are issued on good faith. But along with the declaration made by the proposer, medical certificate by the panel doctor of L.I.C and L.I.C agents confidential cum moral hazard certificate are necessary to be submitted before issuing a policy. Here the doctor who has issued Ext.B2 himself has adduced evidence and deposed that he had made all check up as per the requirement of L.I.C and reported on the perform given by the L.I.C.

10. On the other hand Opposite Party has produced a document Ext.B3 and witness OPW1 was examined to prove the document. OPW1 stated that he has treated the assured from 2004 to 2006. OPW1 was not cross-examined by the Complainant's counsel. Even then dates are seen corrected on 3 page of Ext.B3. There is no correction of dates on the case sheet regarding the year 2004. That also do is not show any admission. So Ext.B3 cannot be accepted as a clear evidence for pre-existing disease or continuous treatment suppressed in the proposal form by the assured. In this case, the assured has died 7 months after the issue of policy. If the ailment was prevailing chronically the L.I.C doctor should have dictated it. For the above said reasons, Point No.1 is found against the Opposite Party.

11. Point No. 2 As it is found that there is deficiency in service on the part of the Opposite Party in denying the insurance claim, the Complainant is entitled to get the sum assured.

Hence the Opposite Party is directed to pay the insurance amount of Rs.50,000/- (Rupees Fifty thousand only ) to the Complainant within 30 days of the receipt of this order.

The Opposite Party is also directed to pay interest on the amount at the rate of 10% per annum from the date of the complaint till payment. No order as to cost or compensation.

Pronounced in open forum on this the 31^st day of July 2009.

PRESIDENT : Sd/-

MEMBER I : Sd/-

MEMBER II : Sd/-

A P P E N D I X

Witnesses for the Complainant :

PW1. Jagadhamma Complainant

PW2. Dr. Subhash Doctor

Witnesses for the Opposite Party :

OPW1. Dr. Vighneswar Bhatt Medical Officer, Shrikrishna

Hospital, Pulpally.

Exhibits for the complainant :

A1. Photo copy of Proposal
 

Exhibits for the Opposite Party :

B1. Claimant's Statement

B2. Abstract of the Confidential Report.

B3. Case sheet

B4. Proposal form

B4(a) Declaration by the Proposer

B5. Insurance Policy