::BEFORE THE DISTRICT CONSUMER DISPUTES  REDRESSAL FORUM, AT BIDAR::

                                                               C.C. No.68/2017.

                                                            Date of filing: 07.10.2017.

                                                                   Date of disposal: 20.07.2018.

P R E S E N T:-    

                              (1) Shri. Jagannath Prasad Udgata,                                                                                                                                                                                          B.A., LL.B.,

                                                                           President

                             (2) Shri. Shankrappa (Halipurgi),

                                                                                 B.A.LL.B.,

                                                                                           Member.

COMPLAINANT/S:    1.   Smt.Kamala W/o Late Chandrakanth Natekar,

                                            Age:Major, Occ: House hold,

                                              R/o H.No.18-1-379 Janatha Colony

                                             Navadgeri, Bidar.                                     

                                       ( By Sri.Vilas Rao M.More., Adv.)                                        

                                                                 VERSUS

OPPONENT/S:        1)         The Sr.Divisional Manager, Life Insurance
                                             Corporation of India Divisional Office,

                                              P.B.No.43, Jeevan Prakash

                                              Station Road Raichur.

                                    2)        The Branch Manager,

                                             Life Insurance Corporation of India

                                             Branch Bidar Nandi Colony

                                             Station Road Bidar 585401.

                                         (By. Sri.Vijay Udgir., Adv.)

::   J UD G M E N T  ::

By Shri. Jagannath Prasad Udgata, President.

This is a complaint u/s 12 of the Consumer Protection Act, 1986 alleging deficiency of service against opponents.  The averments of the complaint is as follows:-

2.           That, the late husband Chandrakanth of the complainant had obtained L.I.C. policy bearing No.666300032 on 07.09.2015 for sum assured of Rs. 2,00,000/- by paying a premium of Rs.18577/-.  The policy was coupled with accident death benefit and the complainant was nominated for the benefits.  The complainant further avers in Para-4 and 5 of the complaint that the proposer was subjected to medical examination by the opponent corporation and the medical practitioner concerned had not indicated any sort of disease with the proposer.           

3.          It is further the case of the complainant that, her husband fell ill during the month of December 2015 for breathing problem, was admitted in Bidar Government Hospital on 13.12.2015 where from he was refered to another speciality hospital.  He was, on 13.12.2015 got admitted in Indo-US Multi speciality hospital, Hyderabad but died on 18.12.2015.

 4.        Consequent upon the death of the policy holder, the complainant lodged her claim with the O.P.s and had produced all relevant documents such as death certificate and others.  The opponents but repudiated the claim on 28.07.2016 on flimsy grounds that, while proposing the policy, the late life assured had given incorrect responses on his health condition so much so that, he was diabetic and had accelerated HTN with old pulmonary Koch and same was not disclosed in the proposal.  The complainant canvasses that, only because the late life assured died within three months of obtaining the policy cannot be a ground of repudiation as he was not suffering from any ailment while taking the policy concerned and the medical examiner of the opponents also had not found any such ailments.  Alleging therefore, the repudiation as deficiency of service, the complainant seeks redressals on different heads as below:-

5.         The complainant further avers that, through a legal notice calling up on the opponents to compensate her in the above manner and they have remained silent and therefore she is before this forum.

6.         Upon notice, the opponents have participated in the proceedings through counsel and have filed written versions.  In their canvassment the opponents have admitted the fact of issuance of policy by the corporation so also the nominee hood of the complainant.  They also admit about the hospitalization at Bidar and Hyderabad.  The O.P.s but deny that, the deceased proposer was not aware of his health problems, since from the admission card of Bidar hospital it is revealed that, he was suffering from H.T.N. and D.M. (Hypertension and Diabetes Mellitus) and had further undergone Orthopedic Surgery on his right hand.  On these grounds the opponents claim that, there were preexisting diseases mentioned above together with pulmonary Koch an hence they justify their repudiation, as the proposer had not disclosed the same in the proposal form is spite of being a Government employee and educated person.  The opponents further dispute the claim of Rs.7,50,000/-, as in their contract, the elements of reimbursements of medical, travelling and food expenses are not included.  As a whole the opponents raising a gigantic opposition pray dismissal of the case with costs.

7.         Both sides have submitted numerous documents as detailed at the end of this order, have filed evidence affidavits in efforts to justify their respective contentions.  Though parties were heard in tit bit manner in Course of proceedings, have failed to submit written arguments.

8.         Taking into consideration the rival Contentions of the parties the following points arise for our considerations.

1. Does the complainant prove deficiency of service in the part of the opponents?
2. Do the opponents prove that, their repudiation of Insurance Claim is justified?
3. What orders?

9.         Our answers to the points are as following:-

1. In the affirmative.
2. In the negative.
3. As per final orders owing to the following:-

:: REASONS ::

10.       The Points at No.1 and 2 being intimately inter webbed are being dealt simultaneously.  There is no dispute regarding the obtainment/issuance of policy, nomination or fact of hospitalisation and subsequent death of the proposer.  The dispute is but, while the complainant claims about the immaculate health condition of her husband, the opponents claim that, he was having a plethora of pre existing deseases and he had concealed those facts while putting up the proposal.  To drive in their point, the opponents have produced several documents out of which Annexure-R1 and Annexure –R7 are most important.  Annexure-R1 reveals that, the deceased proposer was admitted in Bidar Government hospital with complaints of breath less ness and loss of speech cough.  Then it mentions B.P. at 140/84 and know case of H.T.N. and D.M. on regular treatment finds mention.  Also recent orthopaedic surgery at (R) hand finds place but no specific date of such surgery is not there.  Diagnosis is acute respiratory distress syndrome which is partly corroborated inAnnexure-R3 of the referral hospital.  In this document provisional diagnosis is “Miliary pulmonary Koch/ARDS with other associated symptoms.

11.       The moot questions now proper up, were these ailments being undergone by the deceased proposer as on the date of the proposal? Was his sickness known to him and he had concealed the material facts?

12.       As is rightly claimed by the complainant, and is evident from Annexure-R7 (The copy of proposal form) submitted by the opponents, prior to acceptance of the proposal, the life Assured was subjected to medical examination by the corporation authorised medical examination.  Hypothetically, even if we infer that, the internal conditions of the party could not be observed by such doctor, how at all orthopaedic injury could not be seen by him?   Out of all the alleged illness/symptoms being
pre-existing claimed by the opponents, trace of them can be diagnosed by a qualified medical practitioner except Koch, which is an impression in the pleura due to healed up Tuber-Culosis or pleural lobular effusion.  At times the healing is spontaneous due to the impact of the auto immune system of body.  A layman cannot fathom it nor can feel it.  For other alleged pre-existing ailments, there is no evidence led by the opponents to the effect that, they were existing as on 07.09.2015 (the date of policy proposal).  After all two months time in a human life is quite sufficient to be afflicted by many unpredictable afflictions.  Hence the medical documents of December 2015 is not sufficient to arrieve at a conclusion that, the person was having such ailments during September 2015.  In the instant case, the opponents have resorted to imaginary circumstances and hence we hold that, the same is improper and answer point No.1 and accordingly.

13.       Attempting to compute the just reliefs of the complainant, we observe, her claim is highly unjustified, imaginary, exorbitant and speculative.  The policy was for life insurance simplicitor, in which in the event of death, subject to the policy in force the sum assured together with accrued bonus is payable by the Insurer.  Although the instant policy may be coupled with double accidental death coverage, the death being for physiological causes, accidental death coverage cannot be allowed, so also the cost of treatments etc.  Like in a Health Insurance policy.  The claimant would be eligible only for the sum assured and nothing more.  Hence we proceed to pass the following:-

                                                                                   ORDER.

1. The complaint is allowed in part.
2. The opponents are jointly and severally directed to pay a sum of Rs.2,00,000/- together with interest @ 12% p.a. calculated from the receipt of death intimation till realisation to the complainant;
3. Further sums of Rs.10,000/- towards mental agonies and sufferings undergone and Rs.5,000/- towards litigation expenses are payable by the opponents;
4. Four weeks time granted for compliance of the order.

 (Typed to our dictation then corrected, signed by us and then pronounced in the open Forum on this 20^th day of July 2018).

Sri. Shankrappa H.                                             Sri. Jagannath Prasad                                  

Member.                                                                President.                                                                                  

Documents produced by the complainant.

1. Annexure.A-Copy of death certificate of Late Chandrakant.
2. Annexure.B–Copy of family Ration Card of Late Chandrakant.
3. Annexure. C– Copy of Aadhar Card of the complainant.
4. Annexure.D—Copy of Voter ID Card of Late Chandrakant.
5. Annexure. E– Copy of Aadhar Card of Late Chandrakant.
6. Annexure.F-   Medical investigation reports (copy) of Indo-US Super

                         Speciality Hospital Hyderabad in respect of Late
                         Chandrakant.

7. Annexure.G- Copy of intimation of admissions of the about said
                           hospital together with death certificate.
8. Annexure.H- Office copy of legal notice date:10.10.2016 along with
                            copy of repudiation letter.
9. Annexure.J-Original of letter date: 27.10.2016 along with copy of
                         repudiation letter sent by the opponent to the Advocate
                         for the complainant.
10. Annexure.K and L- Postal receipts for Annexure-H.
11. Annexure.M and N- Original acknowledgement forms regarding
                                receipt of Annexure-H.

 Document produced by the Opponents.

1. Annexure.R.1- Copy of admission ticket of Late Chandrakant.
2. Annexure.R.2- Copy of Referral letter date 13.12.2015 of Bidar
                               Institute of Medical Sciences and Teaching Hospital.
3. Annexure.R.3- Copy of intimation of admission of Indo-US super
                              facility Hospital Hyderabad.
4. Annexure.R.4- Copy of intimation of admission of Indo-US super
                              facility Hospital Hyderabad.
5. Annexure.R.5- Copy of death summary together with course in the
                               Hospital.
6. Annexure.R.6- Copy of death certificate of Chandrakant.
7. Annexure.R.7-Copy of proposal forum of Chandrakant.
8. Annexure.R.8- Copy of repudiation letter date 28.07.2016.

Witness examined.

Complainant.

1. P.W.1- Smt. Kamala (Complainant).

Opponent No.1

1. R.W.1- Sri. C.K. Ravikumar S/o Late Krishana kumar Manager and
                authorised Signatory of LIC of India.

Sri. Shankrappa H.                                             Sri. Jagannath Prasad                                  

       Member.                                                                      President.