DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, Civil Station, Palakkad – 678001, Kerala
Dated this the 29th day of January, 2010
Present: Smt.Seena.H, President Smt.Preetha.G.Nair, Member Smt.Bhanumathi.A.K, Member
C.C.No.60/2009
Viji Sajith, W/o.Late P.Sajith Chandran, Poorapotta House, Erimayur, Palakkad. - Complainant (By Adv.P.R.Hariharan)
Vs
The Manager, Life Insurance Corporation of India, Branch Office No.1, Shornur Road, Palakkad. - Opposite party (By Adv.A.Raji Vijaya Sankar)
O R D E R By Smt.H.Seena, President
Case of the complainant in brief is as follows.
The complainant is a widow of P.Sajith Chandran who died in a motor accident on 14.12.07. The complainant's husband has taken 3 life insurance policies from the respondent bearing Nos. 1)771360856, 2)771591600 and 3)774227041. Complainant's husband met with a road accident on 16.11.06 and was admitted at Palana Institute of Medical Sciences, Kannadi where he remained under going treatment till the date of his demise on 14.12.07. Complainant's husband sustained severe head injury in the accident on 16.11.06 and was comatose right from 16.11.06 upto date of his death. The complainant approached opposite party for settlement of the claims. Opposite party partially settled the claim in policy
No.771360856 to the tune of Rs.1,19,091/-. Opposite party has not given the complainant the benefit due and accrued under the accident benefit which was in force in the above policy in the case of death of the life insured. Opposite party has not given any reason for not paying the said benefit. Opposite party has also repudiated the claim of the complainant in policy No.774227041. The repudiation was made on the ground that the insured has made deliberate mis-statements and withheld material information regarding his health at the time of revival of the above policy on 20.11.06. According to the complainant the said repudiation is illegal and against natural justice. Complainant has submitted all the required documents for settling the claim. The said documents clearly show that the complainant's husband was critically ill and comatose when revival letter was given. Hence there was no suppression of any information regarding the health of the insured. According to the complainant the act of the opposite party amounts to clear deficiency in service. Complainant prays for an order directing the opposite party to pay the full amount covered under the accident benefit in policy No. 771360856 and the full amount covered in the policy No. 774227041.
Opposite party filed version contending the following. In policy No. 771360856 held by the life assured, as per condition 8 of the policy, accident benefit is payable only if death occurred is within 120 days of occurrence of accident. Subsequently it was amended as 180 days. Hence the death of the insured was after 180 days from the date of accident. As per the condition number 8 of the policy complainant is not entitled for the said benefit. Under the said policy a net amount of Rs.1,19,091/- was paid to the complainant and she has given full and final settlement receipt. Deficiency of service cannot be assumed in a case where benefit is denied on the basis of the terms and conditions contained in the policy. There was sufficient and genuine reason for not giving the accident benefit to the complainant as per the policy.
As regards policy No. 774227041, the policy lapsed on non-payment of premium due without acquiring any paid up value. Policy was revived on 20.11.06
on the strength of the personal statement regarding health dtd.20.11.06. Though the life assured met with an accident on 16.11.06 and suffered serious injuries and under took treatment from various hospitals, the fact was not disclosed in the personal statement of health at the time of revival of the policy on 20/11/06. The policy was in a lapsed condition as on the date of accident. Subsequently when the claim was lodged, the opposite party came to know from hospital records of the insured that he sustained severe head injuries and the policy was revived when the life assured was being treated for the same. The complainant herself has admitted that the life assured was critically ill on the date of revival of the policy. The personal statement regarding health carries a declaration as follows. “I do declare that the foregoing statements and answers are true and complete in every particular and agree and declare that these statements and this declaration along with my proposal for insurance under the lapsed policy shall be the basis of the contract of revival of lapsed policy between me and the LIC of India and that if any untrue averment be contained therein, the said contract shall forfeited to the Corporation”.
The policy holder has answered the following questions in the personal statement regarding health in negative. Since the date of your proposal for the above mentioned policy a) Have you ever suffered from any illness/disease requiring treatment for a week or more? Answer No. b) Did you ever have any operation, accident or injury? Answer No c) Did you ever undergo ECG, X-ray, screening, blood, urine or stool examination? Answer No. The complainant has also answered for question No.4. Are you at present in sound health? Answer is yes. Hence the repudiation made by the opposite party is proper. According to the opposite party the revival itself is null and void. If the assured was in a coma stage, such a declaration should not have been given by him and alternatively if the complainant contends that it is not signed by the life assured there is no revival at
all. Hence according to opposite party complaint is liable to be dismissed.
The evidence adduced by the complainant consists of the affidavit and Exts.A1 to A9 marked. Opposite party filed affidavit and Exts.B1 to B13 were marked.
Now the issues for consideration; Whether there is any deficiency in service on the part of the opposite party? If so, what is the relief and cost?
Issues 1 & 2: The specific case of the complainant is regarding two policies. One which was partially allowed and other which was repudiated.
As per policy No.771364856, complainant received a partial payment of Rs.1,19,091/-. But the opposite party has not disbursed the accident benefit as per clause 8 of the said policy. The reason stated is that the claimant has not died before 180 days from the date of accident. Opposite party has contended that as per clause 8, the said benefit cannot be disbursed in case the death occurs after 180 days of the date of accident and opposite party is completely justified in repudiating the said claim. It was vehemently argued on behalf of the complainant that even a lay man could see that the complainant was in a coma stage and could understand that the claimant was in a coma stage from the date of accident till the date of his death. In other words brain death has occurred from the date of accident itself and insured has never regain consciousness till his last breath.
On going through the evidence on record it can be seen that as per clause 8 of the said policy, the accident benefit is payable only if death is within 120 days on occurrence of accident. As per Ext.B1 it was amended as 180 days. As admitted by the complainant death was after 180 days from the date of accident. Argument of the complainant is that the insured is clinically dead after the accident itself. Brain
death and coma stage are two different concepts. Brain death means that the person can function without ventilation and other supportive mechanism. Withdrawal of support will means sudden death. A coma stage is were the individual is in a prolonged unconscious state and does not respond to stimulate and may have lowered brain activity. A person in a coma stage may some times regain consciousness. So the insured cannot be said to have clinically dead at the time of accident. So the stand of the complainant that the insured to be treated as clinically dead will not stand. Going through the entire records, we are of the view that opposite party is completely justified in repudiating the claim as per the terms and conditions of the policy.
The second policy was revived on 20.11.06 on a personal statement of insured given on 20.11.06. Admittedly the insured was in a coma stage at the time of issuance of this statement. Complainant has stated that nothing was suppressed by the insured. On going through Ext.A9 it can be seen that the personal statement was signed by the insured. Now the question arise whether the person in a coma stage is able to put signature and that too understanding its contents. It is settled law that, if the mind of the person signing cannot go with his signature, that documents itself is not a valid one. So the repudiation of the opposite party is justified. Another contention of the opposite party is that the insured suppressed material facts in the personal statement. On going through Ext.A9 the personal statement of the insured it can be seen that material facts are suppressed by the insured.
In view of the above stated facts and circumstances of the case the act of repudiation of the opposite party seems to be justified.
In the result we dismiss the complaint.
Pronounced in the open court on this the 29th day of January, 2010 Sd/- Seena.H, President Sd/- Preetha.G.Nair, Member Sd/- Bhanumathi.A.K, Member Appendix Witness examined on the side of complainant Nil Witness examined on the side of opposite party Nil Exhibits marked on the side of complainant Ext.A1 – Letter dtd.28/03/08 sent by opposite party to complainant Ext.A2 – Letter dtd.10/04/08 Ext.A3 – Photo copy of Certificate by employer Ext.A4 – Photo copy of Certificate of Hospital Treatment Ext.A5 – Photo copy of Medical Attendant's Certificate Ext.A6 – Photo copy of Certificate of Hospital Treatment Ext.A7 – Photo copy of certificate of identity and burial or cremation Ext.A8 – Letter dtd.28.08.08 sent by opposite party to complainant Ext.A9 – Photo copy of Form No.680 Exhibits marked on the side of opposite party Ext.B1 – Photo copy of Circular Ext.B2 – Original policy Ext.B3 – Full satisfaction note given by the complainant Ext.B4 – Original policy No.774227041 Ext.B5 – Personal statement regarding health of this policy dtd.20.11.06 Ext.B6 – Photocopy of certificate of employer Ext.B7 – Certificate of Hospital Treatment
Ext.B8 – Claimant's statement in policy 774227041 Ext.B9 - Claimant's statement in policy 771360856 Ext.B10 - Certificate of Hospital Treatment Ext.B11 – Discharge summary of Palana Hospital Ext.B12 – Letter of complainant Ext.B13 – Letter issued by opposite party to complainant | 
