Judgment On 29.12.2006
Present
Sri B.K. Samanta, President
Sri Kumar Mukhopadhyay, Member
Smt. Jyotsna Sarkar, member
This is a case for settlement of claim and compensation.
The Complainant’s case in short is that the Complainant’s son Dipak Kr. Giri obtained one insurance policy no. 433271866 for the sum assured Rs. 20,000.00 on 29.02.2000 with double accident benefit from the OP in which the Complainant is the nominee. The Complainant’s son was continuing the payment of half yearly premium for Sept. 2000. The said policy was renewed by payment of premium on 06.07.2001. The Complainant’s son Dipak Kr. Giri died on 23.10.2003. The Complainant, being nominee of his deceased son, submitted claim for having money of the policy in the month of February 2004. But the OP repudiated the claim for deliberate mis-statements regarding his health at the time of getting the policy renewed. Under the circumstances, the complainant prays for payment of sum assured amounting to Rs. 20.000.00/- together with interest at the rate off 20 persent p.a. and compensation Rs.20.000/- for mental agony etc.
The OP contested the case by filing a written statement wherein he denied the material allegation of the case and stated that the case is not maintainable. They further stated that one Dipak Kr. Giri(since deceased) made a policy being no. 433271866 on 28.03.2000 ( P&T .75.20 for Rs. 20.000/-). The policy was lapsed for non payment of premium. The said policy was revived on 06.07.2001 with two half yearly premiums for Sept. 2000 and Mar. 2001, on the basis of declaration of good health. The life assured died on 23.10.2003 due to Cardio Respiratory failure in a case of Multi drug resistance tuberculosis as per certificate of attending Medical Officer, Bhapwawanpur rural Hospital, Bhagawanpur I Purba Medinipur in Claim Form B. The doctor also stated that the life assured had been suffering from the disease for two years and the systems were cough, chest pain, hamoptysis and the said information were narrated by the life assured himself. The life assured was suffering from the disease and had suppressed the treatment for tuberculosis from April 2000 as it is evident from the prescription dt. 16.05.2001 of S.S. K.M. Hospital. He was also treated at Apex General Hospital from August 2000. The said policy was revived suppressing the material information regarding treatment and ill health. The claim was repudiated on 15.10.2004 on the ground of deliberate mis statement and withholding material information regarding his health at the time of getting the policy revived and such action of repudiation was intimated to the respective claimant by registered letter dt. 15.10.2004. Under the Circumstances, the OPs pray for acceptance of written objection.
Points for decision
On the basis of above pleadings of the parties, the following points are taken up for consideration
- Is the case maintainable?
- Is there any deficiency in service on the part of the OP?
- Is the Complainant entitled to any relief as prayed for?
Decisions
Points No.1. It is admitted by both the parties that the Complainant is the nominee of the deceased insured. So he is the consumer according to Consumer Protection Act, as such , the case is maintainable.
Point No.2- It is admitted by both the parties that Dipak Kr. Giri (since deceased) obtained a policy being no. 433271866 on 28.03.2000 ( P&T-75-20) for Rs. 20,000/- (Rupees twenty thousand only) and the said policy was lapsed due to non payment of premium due for Sept. 2000. The policy in question revived on 06.07.2001 by depositing premium up to March 2001 and making declaration of good health as per existing norms followed by LICI. The said Dipak Kr. Giri died on 23.10.2003. It is the cases of the OP that as per declaration made by the Complainant, he was in good health at the time of revival of the policy. It is a fact that he was suffering from tuberculosis which can be seen from the Medical Attendant’s Certificate (Ext. A) and subsequently cause of death was Cardio Respiratory failure in a case of multi drug resistance tuberculosis. The medical papers submitted by the OPs support this aspect. It is no doubt in the declaration form the Complainant did not mention this aspect. As per decision reported in 2006 (2) CPR-195, it has been clearly expressed in the judgment that chest disease is not a permanent disease but a recurring one. Chest disease can never be the cause of death itself. Moreover, the immediate cause of death of the deceased was Heart Attack and there is no nexus between the cause of death of the deceased and the chest disease. Considering this it can’t be said that there was suppression of material fact and therefore, liability of the insurance company arose under the policy. Thus, repudiation of claim is not justified. Further, in the said judgment it is also stated that even for the sake of argument that the deceased might have been suffering from disease TB. Now TB is 100 percent curable disease and pertinent of that disease can survive for a longer period. Besides this the immediate cause of death of the deceased in the instant case was heart attack and not TB and there is no nexus between the cause of the death of the deceased and TB. The death of the deceased having not been connected with TB, it can not be considered to be material so far death of the deceased is concerned. Thus, it can not be said that there was suppression of material fact by the deceased. The repudiation of insurance claim can not be made merely on ground of non mentioning of chest disease in declaration form, especially when death occurred due to heart attack. In the instant case, the OP filed documents (EXT.A) in order to show that Sri Dipak Kr. Giri died due to cardio respiratory failure in a case of multi drug resistance tuberculosis. However, as per decision cited above we can say that non mentioning of TB in the declaration form cant be considered as suppression of material fact. As such, non payment of insurance claim is no doubt deficiency of service on the part of the OP.
Point No.3. Based on the foregoing discussions and material on record we are of the opinion that the Complainant is entitled to have Insurance Claim of Rs.20.000/- along with compensation.
Hence,
Ordered
That the case be and the same is allowed on contest against the OP. The Complainant is entitled to have insured sum Rs. 20.000/- along with compensation Rs. 5.000/- from the OP. The OP is directed to pay the same by one month from this date failing which the complainant is at liberty to have the same by way of execution through this Forum after expiry of the period mentioned above along with interest at the rate of 8 percent p.a. from the date of filing this case till the date of payment.