Andhra Pradesh

East Godwari-II at Rajahmundry

CC/15/2014

Nunna Radhika - Complainant(s)

Versus

The Zonal Manager, LIC of India, South Central Zonal Office - Opp.Party(s)

E.M.Sridhar Babu

04 Jun 2015

ORDER

 

                                                                                        Date of filing:      12.03.2014

    Date of Disposal: 04.06.2015

 

BEFORE THE DISTRICT CONSUMER FORUM-II, EAST GODAVARI

DISTRICT AT RAJAHMUNDRY

 

                       PRESENT:  Sri B.Vinay Kumar, B.Sc.B.L.  PRESIDENT

              Smt H.V. Ramana, B.Com., L.L.M., MEMBER.

                                                         Sri A Madhusudana Rao, M.Com., B.L., MEMBER

 

                              CONSUMER COMPLAINT No.15 /2014

                          Thursday, the 4^th Day of June, 2015

Between:-

 

1)  Nunna Radhika, W/o.late Naga Pattabhi Ram,

     Aged 46 years, R/o.D.No.2-8, Vegiwada,

     Via Tadikalapudi, Pedavegi Mandal, W.G. Dist.

 

2)  Nunna Hema Satya Venkata Sivananda,

     S/o.late Naga Pattabhi, Aged 28 years, Student

     (I I T, Bombay), R/o.D.No.2-8, Vegiwada,

     Via Tadikalapudi, Pedavegi Mandal, W.G. Dist.

 

3)  Nunna Sudheer Kumar, S/o.late Naga Pattabhiram,

     Aged 23 years, Student (M.Sc) Geetam College,

     Visakhapatnam.                                                                             …  Complainant

 

 

                                    And

 

1)  The Zonal Manager, LIC of India, South Central Zonal

      Office, Saifabad, Hyderabad – 500463.

 

2)  Senior Divisional Manager, LIC of India, D.No.85-6-18/1,

     V.L. Puram, Morampudi Road, Rajahmundry.                             …  Opposite parties

 

 

This case is coming on 08.05.2015 for final hearing before this Forum and upon perusing the complaint, and other material papers on hand and upon hearing the arguments of Sri E.Murali Sreedhara Babu, Advocate for the complainants and Sri D.V.K. Ramesh, Advocate for the opposite parties and having stood over for consideration till this day, this Forum has pronounced the following.

O R D E R

 

(Per Sri B. Vinay Kumar, President)

 

This is a complaint filed by the complainants under section.12 of the Consumer Protection Act, 1986 to direct the opposite parties to pay the entire amount of Rs.6,36,333/- with subsequent interest at 24% p.a. from the date of the complaint till the date of payment and pass such other reliefs.

2.         The case of the complainants is as follows:-  It is submitted that the husband of the 1^st complainant and father of complainant Nos.2 & 3 by name Nunna Naga Pattabhiram was died on 13.6.2013 due to Celebral Hemorrhage at Suraksha Hospital, Rajahmundry at 12.20 AM.  The amount covered by the Policy No.805858284 of a sum of Rs.5,00,000/- was not paid by the 2^nd opposite party and the same was repudiated by the 2^nd opposite party vide its letter dt.25.11.2013 informing that the deceased with held vital information regarding his health condition at the time of effecting the policy. The agent by name M. Ramachandra Rao got the signatures of the policyholder on the application and he got performed the medical test of the policyholder through the LIC authorized Doctor. The deceased never withheld any information regarding his health. The 2^nd opposite party with a view to avoid payment falsely contending that the deceased withheld material information and as such repudiated the claim. The complainant got issued a notice on 3.1.2014 to the opposite parties. The said notice was acknowledged and the 2^nd opposite party did not give any reply and the 1^st opposite party addressed reply on 8.1.2014 informing that they are considering the claim. But, till today no reply was given by the opposite parties. Hence, the complaint.

3.         The 2^nd opposite party filed its written version and the same was adopted by the 1^st opposite party and denied the allegations made by the complainants. The opposite party submits that the policyholder died due to Intracerebral Haemmhorage on 13.6.2013. It is a fact that during his life time, he had taken seven policies from LIC of India.  Out of these, seven policies, six policies were settled as per rules. Following the same obligations and conditions, the death claim on policy No.805858284 was examined. It is submit that during the probe of the events prior to death of the policyholder, it was known that the deceased policyholder suppressed material fact of having suffered from Haemophilia at the time of proposal for the life assurance submitted on 15.6.2012.  It was known that the deceased life assured had been suffering from Haemophilia since June, 2008, but with a fraudulent intention suppressed that fact. The opposite parties did not reject the claim of the complainants either illegally or arbitrarily. It is submitted that as per the contractual provisions under policy clauses, the death claim is processed and decision is taken as per the policy conditions. It is submitted that at the time of submitting the proposal gave false information on state of health and neither mentioned about Haemophilia suffered nor about the consultancy of the doctor; the questions of which are present in the proposal submitted by the deceased life assured.

What has been your usual state of health	Good
Are you suffering from or have you ever suffered from paralysis insanity epilepsy, fits, of any kind of nervous breakdown or any either disease or brain or nervous system	No
Give name and address of your usual medical attendant	No

 

Since, the policyholder died within a short period of taking the policy, this opposite party has very reason to be suspicious and the same warranted to make investigation into the matter. After thorough investigation in the matter, the opposite party came to know that the deceased policyholder was suffering from Haemophilia at the time of submitting the proposal and thereby the contract of life assurance was vitiated due to suppression of material fact by the proposer. As such, the proposer is duty bound to make true correct and faithful disclosure of his state of health in the proposal form. The proposal forms part of contract of insurance. The deceased policyholder in this case had failed to make faithfully disclosure of his state of health and suppressed vital information concerning his health.  He had made deliberately false statement in the personal statement when answering the questions about his health; thus he is guilty of misstatement and deliberately withholding of material information as regard his health. The nominee under the policy is the 1^st complainant who is none other than the wife of the deceased life assured.  The opposite party repudiated the claim under the above referred policy and communicated to the 1^st complainant. The contract of insurance was vitiated as the contract was rendered void abinitio.  Hence, there is no deficiency of service on the part of the opposite parties and the complaint is liable to be dismissed. 

4.         Proof affidavits filed by the both sides.  Exs.A1 to A4 have been marked on behalf of the complainants and Exs.B1 to B6 have been marked on behalf of the opposite parties. 

5.         Heard the complainant and the opposite parties.  

6.         The points that arise for consideration are:

      1) Whether there is any deficiency in service on the part of the opposite

     parties?

             2) Whether the complainants are entitled for the reliefs asked for?

             3) To what relief?

 

7.         The admitted facts are that the complainant obtained seven policies from the opposite parties and the opposite parties paid the amount covered under first six policies. The complainant died on 13.6.2016 due to intra cerebral hemorrhage at Suraksha Hospital in Rajahmundry.  The copy of the repudiation letter is herewith filed vide    Ex.A1 = B2. The opposite parties sent a letter vide Ex.A2 by stating that they are repudiating the claim. The complainant got issued a legal notice to the opposite parties vide Ex.A3 and the same was served to them vide Ex.A4.

            The opposite parties also admitted about the policies taken by the                         1^st complainant’s husband and they also filed the status report of six policies which was duly paid by them vide Ex.B1. The 1^st complainant’s husband obtained the policy bearing No.805858284 on 29.6.2012 and the death occurred on 13.6.2013 just within one year from the date of commencement of risk. The opposite parties herewith filed the original proposal form duly signed by the deceased life assured vide Ex.B2. After thorough investigation, the opposite parties came to know that the deceased policyholder was suffering from hemophilia at the time of submitting the policy and the certificate of hospital treatment is herewith filed vide Ex.B3. They further submitted that they also made a correspondence with the Secretary of Hemophilia Society, represented by          Dr. M.V.S.V. Prasad, who informed that they referred the patient had been investigated at CMCH, Vellore.  The correspondence letter is herewith filed and marked as Ex.B4. It is the bounden duty of the policyholder to disclose his state of health in the proposal form. But, the life assured failed to disclose his health condition. The opposite parties made an enquiry and the report is herewith filed vide Ex.B5. The opinion of the divisional medical referee, who came to the conclusion that the claim is not admissible and the same is marked as Ex.B6. The opposite parties submitted that they repudiated the claim after making thorough investigation and enquiry and there is no deficiency of service on their part.      

8. POINT No.1 & 2:  After perusing the material on record, it is observed that the deceased policyholder has taken policies from 1989 till 2012. Out of these policies, the claims against six policies were paid to the complainants. But, the opposite parties repudiated the claim under the policy No.7 i.e. No.805858284 of sum of Rs.5 lakhs and they wrote a letter dt.25.11.2013 informing that the deceased withheld vital information regarding his health condition and time of taking the policy. The complainants contended that the opposite parties willfully disallowed the claim and repudiated intentionally. As seen from the record, the policyholder died on 13.6.2013 due to INTRA CEREBRAL HEMORRAHGE. The main contention of the opposite parties is that the policyholder was having hemophilia for the last one year. Because of concealment of the above said fact, they repudiated the claim of the complainant.

            Here, we have to see what is hemophilia under medical terminology?

           Hemophilia (heem-o-FILL-ee-ah) is a rare bleeding disorder in which the blood doesn't clot normally.

As per the above said information, it is only a disorder, but it is not a disease and the policyholder died due to cerebral hemorrhage, not because of hemophilia. As per Ex.B4, the doctors stated that he never had spontaneous bleeding due to hemophilia. In Ex.B6, it is mentioned that the deceased life assured went to Hemophilia Society, Vijayawada in June, 2008, 2009 & 2011 before taking the policy.

            As seen from the entire text of hemophilia, we come to a conclusion that it is only a disorder, but it is not a disease. As seen from the other material and reports filed by the opposite parties, in which their medical examiners confidential report is also there. The said medical examination was done by the opposite parties panel doctor before issuance of the policy to the life assured. It is also clearly mentioned that the life assured was died due to intra cerebral hemorrhage. They also mentioned that he had hemophilia past one year, but they never mentioned that the life assured was died due to hemophilia. Therefore, we opined that the complainants are entitled for the claim amount under the disputed policy. The opposite parties failed to pay the claim amount to the complainants, this amounts to deficiency in service on their part.  

 

9.  POINT No.3:  In the result, the complaint is allowed, directing the opposite parties to pay Rs.5,00,000/- with interest @ 9% from the date of repudiation i.e. 25.11.2013 till realization to the complainants. We further direct the opposite parties to pay Rs.5,000/- towards costs of this complaint to the complainants.  Time for compliance is two months from the date of this order. 

 

      Typed to my dictation, corrected and pronounced by us on this the 4^th Day of June, 2015.

 

                  Sd/-                                                          Sd/-                                                  Sd/-

           MEMBER                                            MEMBER                                      PRESIDENT

 

 

 

 

APPENDIX OF EVIDENCE

WITNESSES EXAMINED

FOR COMPLAINANTS: None                                                                      FOR OPPOSITE PARTIES: None

 

DOCUMENTS MARKED

FOR COMPLAINANTS:

 

Ex.A1    Xerox copy of the application of the deceased Nunna Naga Pattabhiram.

Ex.A2    Repudiation letter dt.25.11.2013.

Ex.A3    Notice dt.3.1.2014 by the complainants.

Ex.A4    Acknowledgements.

 

FOR  OPPOSITE PARTIES:

 

Ex.B1    Status Reports of Policies.

Ex.B2    Application and Medical Examiner’s Confidential Report of the deceased Nunna

             Naga Pattabhiram.

Ex.B3    Certificate of Hospital Treatment and Medical Attendant’s Certificate.

Ex.B4    Letter dt.10.10.2013 from LIC to Dr. M.B.S.V. Prasad and letter dt.23.10.2013

  from Dr. M.B.S.V. Prasad, Hemophilia Society, Vijayawada to LIC.

Ex.B5    Death Claims – Office Note and Claim Enquiry Report of LIC.

Ex.B6    Form for obtaining medical opinion from DMR/ZMR in respect of claim cases.

 

                 Sd/-                                           Sd/-                                             Sd/-

MEMBER                             MEMBER                                 PRESIDENT