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  1. #31
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    Order delivered by Sri. Nazeer Ahmed U. Shaikh, Member
    1)This is a complaint praying to direct the OPs to pay Rs.80,000-00 on each certificate with 18% interest, damages of Rs.10,000-00, compensation of Rs.25,000-00 towards mental torture and cost to the complainant.

    2)Brief facts of the complaint are that on an application No. T 1358310, the OP-2 issued certificate No.T 0132728 under Registered Folio No.T 03323333, worth Rs.5,000-00 of 500 number of units on 15-4-93. On another application also the complainant has received certificate worth Rs 5000-00 of 500 units both the certificates under the LIC Mutual Fund sponsored Dhan Vikas (I) scheme, which was to be terminated on 15-4-1998. After the termination of the scheme the complainant requested the OPs to return with formidable amount + interest with Bonus Units. On 29-9-93 he wrote a letter seeking payment of maturity amount. But the OPs till today have not repaid the amount. There is deficiency of service by the OPs and they are liable.

    3)The OPs filed WS admitting that the complainant applied for the Dhan Vikas Scheme by investing Rs.5,000-00 under Certificate No.01382728. The scheme was converted as an open ended scheme as LIC MF Equity Fund- Growth plan. A paper notification was issued in the daily newspaper. A letter to the applicants was also made to opt either the dividend or the growth option. The complainant has not replied the same. So his earlier scheme was converted into LIC MF Equity fund growth plan. He has not invested any amount of Rs.5,000-00 in another scheme. As on 24-2-2009 the unit value was increased to Rs.13.5296 as against the issue price of Rs.10-00. The NAV (Net Asset Value) of the fund is market related and changes daily. Therefore the complainant is entitled for the value of the unit on which the market value of the unit depends. There is no deficiency of service by OPs. The OPs pray to dismiss the complaint with costs.

    4)Both the parties have filed their affidavits. The complainant has got marked Ex.C-1 to C-10 and the OP Ex.R-1

    5)The point that arises for our consideration is: “Whether there is deficiency of service on the part of the OPs?

    6)It is the contention of the complainant that he invested Rs.5,000-00 + Rs.5,000-00 in the LIC Mutual Fund sponsored Dhana Vikas (I) scheme on 15-4-1993. The scheme is terminated on 15-4-1998. After the termination of the scheme the complainant demanded back the invested money with interest. But the OP till today has not paid the same. There is deficiency of service by the OPs and they are liable.

    7)On the other hand the counsel for the OP vehemently urged that the complainant has invested only Rs.5000-00 but not Rs.10,000-00 in the LIC Mutual Fund sponsored Dhana Vikas (I) scheme which was later converted into LIC MF Equity Fund Growth Plan after giving paper publication and issuing notice to the applicants. The fact is within the knowledge of the complainant. The market value of the units changes every day. So, the complainant is entitled for the value of the unit on which the market value of the units depends. The complainant is not entitled for the claim amount. There is no deficiency of service by the OPs and they are not liable.

    8)We have gone through the pleadings, affidavits and documents submitted by the parties. It is a fact that the complainant has invested Rs.5000-00 in LIC Mutual Fund sponsored Dhana Vikas (I) scheme in the year 1983. It is also a fact that the said scheme was converted into LIC MF Equity fund growth plan. The OPs contend that while converting this scheme it was published in the daily newspapers and intimation was sent to the applicants. But the records produced by the OPs are not sufficient to hold that any notice was issued to the complainant to show that the conversion of the scheme was intimated to the complainant. The complainant also has not taken any action since 1998. He has not denied the contention of the OP that the value of the unit depends upon the market value on every day. The (NAV) Net Asset Value of the fund is market related and changes daily. So, the complainant is entitled only for the value of the unit on the day he claims value of the Units under certificate No.T 0132728. Since the complainant has not substantiated the claim for another certificate it shall be rejected. So in our view if we allow the complaint directing the OPs to pay to the complainant the value of the units on the day the complainant seeks the refund. Since there is no record produced by the OPs that the scheme was converted into another scheme the OPs are liable to pay compensation of Rs.1,000-00 to the complainant with cost of Rs.500-00
    We pass the following order.
    ORDER
    The complaint is allowed. The OPs are directed to pay to the complainant the value of the units under certificate No.T 0132728 on the day the complainant seeks refund and pay compensation of Rs.1,000-00 (Rs.One thousand only) and cost of Rs.500-00 (Rs. Five Hundred only). The other claim of the complainant is rejected.

  2. #32
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    1. Nethrvathi Shedthi,
    aged about 53 years,
    W/o Manjayya Shetty

    2. Rajeeva Shetty
    aged about 47 years,

    3. Bhaskar Shetty
    aged about 44 years,

    4. Shivarama Shetty,
    aged about 41 years,

    5. Udaya Kumar Shetty,
    aged about 37 years,

    Nos.1 to 5 are the children of
    Late Subamma Shedthi and late
    Hiriyanna Shetty and residing
    in Kammarakodlu House,
    Hosadu Post, Kundapura Taluk,
    Udupi District.

    (Sri A.S.Hebbar, Advocate for the
    Complainants)
    ………… Complainants
    And

    Life Insurance Corporation of India,
    Divisional Office,
    ‘Jeevan Krishna’,
    Ajjarkad, Udupi – 576 101.
    Rep. by its Divisional Manager

    (Sri H.Jayaprakash Kedlaya, Advocate for the Opposite Party)
    …….. Opposite Party
    WRITTEN BY SRI P.C.GOPAL, PRESIDENT.

    1. The Complainants filed this complaint u/s 12 of CPA alleging deficiency in service in repudiating the claim of the Complainant against Opposite Party and prayed for a direction to pay to the Complainants, amount of death claim under
    Contd……..2
    Policy No.624200097 with interest at 12.5% per annum on the said sum from the date of death of H.Narasimha Shetty till payment plus Rs.25,000/- towards compensation for its deficiency in service and unfair trade practice and cost of the proceedings, etc.

    2. The case of the Complainants is that they are the sister and brothers of Sri H.Narasimha Shetty who was practicing as an Advocate at Udupi. H.Narasimha Shetty had insured his life with the Kundapura Branch of Opposite Party under Policy No.624200096 for Rs.55,000/-. He had named his mother Subbamma Shedthi as nominee under the said policy.

    3. H.Narasimha Shetty – insurer died on 26.07.2006. Thereafter the mother of the deceased viz. Smt.Subbamma Shedthi submitted her claim under the aforesaid policy. The Opposite Party vide its letter Ref. Claims/D/Rep. No.30/2006-07 dated 30.03.2007 repudiated the claim. Subbamma Shedthi died on 24.02.2007 leaving behind the Complainants as her legal heirs. The Complainant\s came to know about repudiation of the claim as above when 1st Complainant received copy of the said letter forwarded to her by the Kundapura Branch of Opposite Party Corporation vide its letter dated 12.10.2007.

    4. The Complainants submit that the reasons given by the Opposite Party Corporation for repudiation of the claim made by their mother Smt.Subbamma Shedthi under the aforesaid policy are factually and legally wrong and untenable. The Complainants do not admit the truth, genuineness, validity and binding nature of the evidence and reason on which the Opposite Party Corporation purports to rely on for its decision.

    5. The 1st Complainant was pursuing the matter with the Kundapura Branch Office of the Opposite Party Corporation. Since her efforts did not yield the desired result, when submitted a representation dated 15.12.2008 through her Advocate to the Hyderabad Zonal Office of the Opposite Party Corporation requesting for reconsideration of the decision of repudiation. The Opposite Party and the Hyderabad Zonal Office of the Opposite Party Corporation have replied that the representation would be placed before Zonal Claims Review Committee for consideration and decision. Though 3 months have elapsed since then nothing is heard from the Opposite Party Corporation.
    Contd…….3
    6. The Opposite Party Corporation has unjustly and illegally refused to settle the claim made by the deceased Subbamma Shedthi under the aforesaid policy of the deceased H.Narasimha Shetty. This is a case of deficiency in service on the part of the Opposite Party Corporation. In repudiating the claim the Opposite Party Corporation has practiced unfair trade practice and violated the conditions of the contract of the insurance entered into between it and the deceased. Hence this complaint.

    7. After service of notice of the complaint, Opposite Party appeared through their counsel and filed the version contending that the complaint is false, frivolous and vexatious and the same is not maintainable either in law or on merits. The Opposite Party Insurance Corporation submits that the Complainant has intentionally and deliberately suppressed certain relevant and material facts which are essential for the proper and adjudication of the matter in dispute so as to make unlawful gain at the cost of this Opposite Party. further submits that they stated that the Complainants are the sister and brother of the deceased H.Narasimha Shetty for that this Complainant has to produce the legal proof so as to ascertain that they are the legal heirs of the said deceased.

    8. This corporation submits that there is no dispute that the deceased H.Narasimha Shetty had insured his life with the Kundapura Branch of the Corporation under Policy No.624200097 for Rs.55,000/- and named his mother Smt.Subbamma Shedthi as nominee under the policy. The Opposite Party Corporation submits that there is no dispute regarding the date of death of the Life assured. As per the death certificate produced by the Complainant the life assured died on 26.07.2006.

    9. Opposite Party submits that on the basis of the documentary evidences obtained during the investigations, the Opposite Party has repudiated the claim under the policy and conveyed the decision to the claimant i.e. Smt.subbamma Shedthi the nominee under policy on 30.03.2007. Further this Corporation submits that it is not aware of the death of the nominee i.e. Smt.Subbamma Shedthi. The Complainants are put to strict legal proof thereof as the said Subbamma Shedthi had died.
    Contd……….4
    10. This Corporation submits that on the basis of the documentary evidences the Life Assured was suffering from “Iporiapis” for four years before he proposed for the above policy. The Life assured had consulted and taken treatment from a medical man in a hospital on various dates from 30.03.2001 to 16.08.2001. The Life Assured further consulted doctors in a hospital for Hypertension and had taken treatment from them on 19.9.2003, 25.9.2003, 13.12.2003 and on 17.12.2003. The Life Assured also complaints of both lower limbs. He was kept informed that the Hypertension from which he was suffering needed evaluation.

    11. The Life Assured did not however disclose all these facts in his proposal for the captioned policy despite having knowledge of above facts. Moreover. the cause of death of the Life assured has direct nexus to the illness he was suffering i.e. Hypertension. The contract of Insurance is of Ubberrima Fides (utmost good faith) wherein the proposer is required to disclose correct status of his/her health to enable the insurer to assess the risk. It is the proposer alone who is aware of the past and present history of the life to be assured and unless he answers all the questions in the proposal form correctly, to underwriter the risk. Hence, it is clearly mentioned in the declaration contained therein the proposal for assurance that if the proposer makes deliberate mis-statements and with holds any material information from the insurer regarding his/her health which is the basis of the Insurance Contract between proposer and insurer. Then the said insurance contract shall be absolutely null and avoid and all moneys which shall have been paid in respect thereof shall stand forfeited to the insurer. Therefore, the decision of repudiating the claim under the captioned policy is perfectly proper, genuine valid and legal as per terms conditions of the contract of assurance.

    12. Further it is submitted by the Opposite Party that as pe the reconsideration of the decision 0f repudiation on 15.9.2008 the Complainant has appealed to the Corporations, Zonal Claim Review committee which consists of a retired high court judge as one of the members. However, instantly the zonal CRC also upheld the Opposite Parties repudiation decision on 19.2.2009 and the same has been intimated to the Complainant’s advocate through Opposite Parties letter dated 2.3.2009, in the said letter it was informed to the advocate that they can send representation to the insurance ombudsman at Hyderabad.
    Contd……..5
    13. The Opposite Parties denies all the allegations made by the Complainant as they have rightly repudiated the claims in terms of the policy contract and declaration contained in the form of proposal for assurance for suppression of material facts leading to assess the risk the question of unfair trader practice and deficiency on the part of the Opposite Party does not arise and the repudiation of claim by the Opposite Party is justice and legal in all respect.

    14. The Opposite Parties is not responsible and liable for mental agony, hardship financial loss if any causes to the Complainant and the allegations are baseless. The Opposite Parties submit that this corporation is not concerned with the family matters the life assured hence it is out of purview of this Corporation. There is no cause of action for this complaint and the complaint is barred by law of limitation, there is no pecuniary jurisdiction to entertain the complaint. Hence, prayed to dismiss the complaint with cost.

    15. The Complainants have filed 4 documents marked as Ex.C-1 to Ex.C-4. Complainant filed affidavit. Opposite Party has produced 8 documents alongwith the version. We heard the Complainant. These are the materials placed before the Forum for deciding the complaint. The issues that arise out of the above are:
    1) Whether the Opposite Party is justified in repudiating the claim of the Complainant? If so.
    2) Whether the Opposite Party has committed deficiency in service? If so.
    3) Whether the complainant is entitled for reliefs? If so.
    4) What order?
    REASONS
    Point No.1

    16. There is no dispute that the deceased H.Narasimha Shetty had insured his life with the Kindpuara Branch of Opposite Party Corporation under policy No.624200097 for Rs.55,000/- and named his mother Smt.Subbamma Shedthi as nominee under the policy. There is also no dispute regarding the date of death of life assured(deceased) as per the death certificate produced by the Complainant the life assured died on 26.7.2006. The Complainants No.1 to 5 are the sister and brothers of deceased H.Narasimha Shetty.
    Contd……..6
    17. The Opposite Parties submitted that on the basis of documentary evidences that life assured was suffering from “Iporiapis” for four years before proposed for the above policy and the life assured had consulted and taken treatment from a medical man in a hospital on various dates from 30.03.2001 to 16.08.2001. Further it is submitted that the deceased consulted doctor in a hospital for hypertension and had taken treatment from them on 19.9.2003, 25.9.2003 13.12.2003 and 17.12.2003.

    18. The Complainant submits that the alleged disease ‘Iporiapis’ is a skin disease and it is of no grave nature so as to cause the death of the insured and there is no nexus between the cause of death of the insured and the alleged skin disease. There is no evidence to show that because of the skin disease, the death of the deceased was caused. Further it is submitted that the other allegation is that the insured had consulted the doctors in the hospital for hypertension.

    19. Complainant submitted that hypertension is a common to the people in the present society and the hospital records produced by the Opposite Party discloses that there was no chest pain and it shows the pulse rate = 80/mt, BP = 140/90 mmHg. and in the present society the BP of an aged person about 54 years is not an abnormal. The other reason the Opposite Party assigned is that he had undergone many pathological test in the hospital and he was suffering from the complaint of both lower limbs.

    20. The Opposite Party has not produced the death certificate of the insured. There was no post mortem. Opposite Party has not proved that there was nexus between the cause of death and the alleged ailment of “Iporiapis” which according to the Opposite Party the insured was suffering. In the absence of the same, we are unable to believe the version of the Opposite Party that the insured was sufferings from the disease which was not disclosed at the time of obtaining the policy.
    Contd……..7

    21. Inspite of the ample opportunities, the Opposite Party has not filed the interrogatories to the affidavit of the Complainant and Opposite Party has not filed affidavit in evidence and has failed to prove that there was nexus between the cause of death and the alleged ailment.

    22. In view of the above reasons, we are of the opinion that Opposite Party is not justified in repudiating the claim of the nominee/ Complainants. Hence, we answer the point No.1 in the Negative.

    Point No.2:
    23. In view of Negative answer to point No.1, we hold that the Opposite Party has committed deficiency in their service and hence the point No.2 answered in the Affirmative.

    Point No.3 & 4:
    24. In view of the Negative answer to point No.1 and Affirmative answer to point No.2, we are of the opinion that the Complainant is entitled for the reliefs claimed. Hence we answer the point No.3 in the Affirmative.

    25. In the result, we pass the following:
    ORDER
    The complaint is allowed. Opposite Party is directed to pay to the Complainants Rs.55,000/- alongwith interest @12% per annum from the date of claim, till realization. Opposite Party is further directed to pay to the Complainants Rs.2,000/- as cost of the proceedings. Opposite Party shall comply with the aforesaid order within one month from the date of receipt of this order.

  3. #33
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    ORDER


    COMPLAINT FILED: 28.01.2009 BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN) 08th APRIL 2009 PRESENT :- SRI. A.M. BENNUR PRESIDENT SMT. M. YASHODHAMMA MEMBER SRI. A. MUNIYAPPA MEMBER COMPLAINT NO. 235/2009


    COMPLAINANT Sri. H.C. Abhishek, S/o. Sri. Chandrashekar, Aged about 29 years, R/o. No. 80, “Sai Kuteer” 4th Cross, Manjunatha Layout, Kodichikkanahalli, Bannerghatta Road, Bangalore – 560 076. Advocate (S. Santhosh Shetty)

    V/s.

    OPPOSITE PARTIES

    1. The Senior Divisional Manager, Life Insurance Corporation of India, Divisional Office -1, J.C. Road, Bangalore – 560 002.

    2. The Branch Manager, Life Insurance Corporation of India, Sarakki Branch, Jeevana Soudha, 1st Floor, 1st Phase, J.P. Nagar, Bangalore – 560 078. Advocate (Saleela Bhat)


    O R D E R

    This is a complaint filed U/s. 12 of the Consumer Protection Act of 1986 by the complainant seeking direction to the Opposite Party (herein after called as O.P) to pay a sum of Rs.50,000/- towards the survival benefit and compensation along with litigation cost on an allegations of deficiency in service. The brief averments, as could be seen from the contents of the complaint, are as under: Complainant had taken two LIC policies bearing No. 720388424 dated 28.03.1994 for Rs.1,00,000/- maturity date being 28.03.2014 and another policy bearing No. 720388209 for a sum of Rs.50,000/- with a maturity date 28.03.2014. As per the terms and conditions of the said two policies OP’s are required to pay benefits of Rs.20,000/- and Rs.10,000/- with respect to the said two policies, but they failed to keep up their promise. Complainant made several correspondences intimating OP that he has not received the survival benefits as contemplated, but all his efforts went in vain. On repeated enquiry complainant was told that OP has already sent the said amount through cheques to his address, but those cheques are not received by him for the last 3 ½ years. The hostile attitude of the OP has caused him both mental agony and financial loss. Hence he felt the deficiency in service on the part of the OP. Under the circumstances he is advised to file this complaint and sought for the relief accordingly.


    2. On appearance, OP filed the version denying all the allegations made by the complainant in toto. According to OP the complainant is in a habit of changing his residential address every now and then, hence there is a communication gap between the complainant and the OP. When OP came to know of the benefits accrued in favour of the complainant they had sent the two cheques for Rs.20,000/- and Rs.10,000/- dated 18.03.2004 to the given admitted address of the complainant, neither those cheques are returned nor they were encashed. So no fault lies with the OP. It is the complainant who kept mum for more than 3 years and then made correspondence for the first time on 20.09.2007, sought for issuance of fresh cheque. Thereafter also OP obliged to issue fresh cheques as prayed, that would have been the end of the matter. But complainant has come up with this false and frivolous complaint alleging that OP retained the said survival benefit for more than 3 years. The complaint is devoid of merits. There is no deficiency in service on the part of the OP. Hence they are not liable to pay the said compensation. Among these grounds, OP prayed for the dismissal of the complaint.


    3. In order to substantiate the complaint averments, the complainant filed the affidavit evidence and produced the documents. OP has also filed the affidavit evidence. Then the arguments were heard.


    4. In view of the above said facts, the points now that arise for our consideration in this complaint are as under: Point No. 1 :- Whether the complainant has proved the deficiency in service on the part of the OP? Point No. 2 :- If so, whether the complainant is entitled for the reliefs now claimed? Point No. 3 :- To what Order?


    5. We have gone through the pleadings of the parties, both oral and documentary evidence and the arguments advanced. In view of the reasons given by us in the following paragraphs our findings on: Point No.1:- In Negative Point No.2:- Negative Point No.3:- As per final Order.


    R E A S O N S


    6. At the outset it is not at dispute that the complainant took two LIC policies the date of maturity being 28.03.2014. In the meantime he is entitled for the survival benefit as per the terms and conditions of the policy. The fact that complainant is entitled for the said benefit by 28.03.2004 to the tune of Rs.20,000/- plus Rs.10,000/- is also not at dispute. Now the grievance of the complainant is that though he is entitled for the said benefits by the end of 28.03.2004, OP failed to send the said cheques with respect to the said benefits right up to 20.09.2007 and retained the said huge amount for more than 3 ½ years without any substantial reason or cause. Hence he felt the deficiency in service.


    7. The fact that subsequent to 20.09.2007 OP paid the said amount to the tune of Rs.30,000/- to the complainant is not at dispute. The defence set out by the OP is that complainant used to change his residential address every now and then, hence there is some communication gap. After they came to know that complainant is entitled for the survival benefit by 28.03.2004, they did sent the two cheques to the given admitted address of the complainant. Neither those cheques were returned nor they are encashed. Hence no fault lies with the OP. We find substance in the defence set out by the OP. To corroborate their say OP has produced the copies of the letter addressed to the complainant, wherein there letter dated 27.02.2004 shows they have sent the post dated cheque on 28.03.2004 towards the survival benefit. The address mentioned in the said letters sent to the complainant is the admitted address.


    8. Complainant has not disputed the contents of the said letters including of address noted in the said letters. If complainant feels that those letters are concocted or forged he would have initiated the criminal action against the OP. But no such steps are taken. When the said letters written to the complainant with regard to sending of the cheques pertaining to survival benefit in the year 2004 itself, then we do not find any substance in the allegations of the complainant. It is purely a case of communication gap.


    9. OP’s have contended that complainant allowed his father to deal with the said LIC polices and receipt of survival benefits, etc. This fact is not disputed by the complainant. Complainant has not filed the affidavit of his father to rebut the said contention of the OP. The fact that the complainant has changed his residential address frequently is also not at dispute. So having taken note of all these facts and circumstances, we do not find there is any intentional delay committed by the OP and there is no malafide intention. If the complainant is prompt in claiming his survival benefits by the end of 28.03.2004, why he kept mum for more than 3 years without making correspondence with the OP is not known. After the expiry on 28.03.2004 for the first time he wrote letter to OP on 20.09.2007, OP considered the claim of the complainant and issued the cheque for Rs.30,000/-, that would have been the end of the matter. Under such circumstances we find the complaint appears to be devoid of merits. There is no proof of deficiency in service.

    The complainant is not entitled for the relief claimed. Accordingly we answer point nos.1 and 2 in negative and proceed to pass the following:


    O R D E R The complaint is dismissed. In view of the nature of dispute no order as to costs.

  4. #34
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    M.C. Bopanna,
    Residing at Everest Flat -7,
    Ujjodi, Kankanady Post,
    Mangalore. …….. COMPLAINANT

    (Advocate: Sri.S.P. Chengappa).

    VERSUS

    The Branch Manager,
    Life Insurance Coporation of India,
    Branch Unit –I, P.O. No.69,
    K.S.R. Road,
    Mangalore – 575 001. ……. OPPOSITE PARTY

    (Advocate: Sri.Ananthakrishna Udupa).


    ***************

    ORDER DELIVERED BY SMT. ASHA SHETTY, PRESIDENT;

    1. The facts of the complaint in brief are as follows:
    This complaint is filed under Section 12 of the Consumer Protection Act alleging deficiency in service against the Opposite Party claiming certain reliefs.
    That the Complainant obtained “ASHA DEEP POLICY” bearing No.611398354 along with accident benefit from the Opposite Party commencing from 25.11.1993 to be matured on 28.11.2008 and the sum assured is Rs.50,000/-. The Complainant states that on 5.3.2007 at 6.00 p.m. when the Complainant was looking after the farm activities at his estate at Kodagu District, he accidentally rolled down and fell from a considerable height of about more than 8 feets and sustained multiple fracture injuries on left knee. Thereafter he was shifted to OmegaHospital on 7.3.2007 where he underwent a major surgery and was discharged on 15.3.2007. On 3.8.2007 he filed his claim before the Opposite Party, on 12.6.2008 the claim of the Complainant was rejected by stating that Complainant did not come with the history of accident or fall from a height and that the cause for the Complainant‘s disability is Osteo Arthritis of the left knee and hence he is not entitled under clause 10(A) of the policy. Feeling aggrieved by the same the Complainant filed the above complaint before this Hon'ble Forum under Section 12 of the Consumer Protection Act 1986 (herein after referred to as ‘the Act’) seeking direction from this Hon'ble Forum to the Opposite Party to pay the claim amount and pay damages and cost of the proceeding of Rs.25,000/-.

    2. Version notice served to the Opposite Party by RPAD. Opposite Party appeared through their counsel filed version admitted the policy issued to the Complainant and submitted that the said policy was accepted with impairment extra Rs.1.50 per Rs.1,000/-, since at the time of taking the policy the Complainant was having deformity of the left knee. And it is denied that on 5.3.2007 the Complainant suffered injuries due to any accident or the incident was taken place on 5.3.2007. It is submitted that the Complainant was in Mangalore on 5.3.2007 and had consulted one Dr.Mahabala Rai and was admitted for open reduction and inter fixation of the left femur. The Complainant did not come with the history of accident or fall from a height and that the cause for Complainant‘s disability is Osteo Arthritis of the left knee and hence the claim of the Complainant does not qualify under clause 10(A) of the policy and contended that there is no deficiency and prayed for dismissal of the complaint.

    3. In view of the above said facts, the points now that arise for our consideration in this case are as under:
    (i)Whether the Complainant proves that the Opposite Party has committed deficiency in service?

    (ii)If so, whether the Complainant is entitled for the reliefs claimed?






    (iii)What order?

    4. In support of the complaint, Sri.M.C. Bopanna (CW1) filed affidavit reiterating what has been stated in the complaint and got marked Ex C1 to C7 as listed in the annexure. One Sri.S.Nagendra (RW1), Chief Manager of the Opposite Party filed counter affidavit and got marked Ex R1 to R13 as listed in the annexure. The Opposite Party has produced notes of arguments.
    We have considered the notes and oral arguments submitted by the learned counsels and we have also considered the materials that was placed before the Hon'ble Forum and answer the points are as follows: Point No.(i): Negative.
    Point No.(ii) & (iii): As per the final order.
    Reasons


    5. Point No. (i) to (iii):
    It is undisputed fact that the Complainant obtained Asha Deep Policy bearing No.611398354 with accident benefit from the Opposite Party commencing from 28.11.1993 for a period of 15 years. The sum assured was of Rs.50,000/- the date of maturity was on 28.11.2008.
    It is the case of the Complainant that, on 5.3.2007 at about 6.00 p.m. while he was looking after the farm activities in his estate at Koggoldu Village, Kodagu District he accidentally rolled down and fell from a considerable height of about more than 8 feet and sustained multiple fractural injuries on his left knee. After taking first aid treatment he was shifted to Omega hospital on 7.3.2007 and thereafter he underwent major surgery and discharged on 15.3.2007. After the discharge from the hospital, the claim application was submitted on 3.8.2007 but the Opposite Party repudiated the claim by stating that the claim is not qualify under 10 (A) of the Asha Deep Policy and rejected the claim on 12.5.2008.
    On the contrary, the Opposite Party denied that on 5.3.2007 at about 6 p.m. the Complainant accidentally rolled down and fell from a considerable height of about more than 5 feet and sustained multiple fracture injuries on his left knee. It is submitted that, the Complainant had consulted the doctor in Omega Hospital on 5.3.2007 recommending the Complainant’s admission for open reduction and inter-fixation of left femur and he was not in Kodagu on 5.3.2007 but was in Mangalore. And it is further stated that, the doctor had not mentioned about the accident or fall from the height, the cause of the Complainant’s disability is Osteo Arthritis of the left knee and the said ailment was not related to the alleged fall claimed by the Complainant and the case was fabricated as accidental fall, the claim did not qualify under clause 10 (A) of the policy. And further submitted that, the Complainant had been treated for aggravation of disability which existed at the time of the policy being obtained by the Complainant for which an extra premium of Rs.150/- per Rs.1,000/- was collected from the Complainant. As per the proposal, the Complainant had accidental fall in his younger age which resulted in deformity of left knee joint and the Complainant had again met with vehicular accident in 1982 and had fracture of left thigh bone. The Complainant had limited movement of left knee joint and was limb and the left leg was shorter by 1½ inch by the right leg. The disability of the Complainant is aggravation of the above existing deformity which was diagnosed as Osteo Arthritis of left knee and not accidental, alleged deformity did not qualify under Section 10(A) of Asha Deepa Policy conditions. There was no amputation of limb or feet on account of any accident as such the Opposite Party is rejected the claim.
    Now the point for consideration is that, in the present case, the entire burden lies upon the Opposite Party to show that the existing deformity was Osteo Arthritis of left knee and not accidental and the alleged deformity did not qualify under Section 10 (A) of Asha Deep Policy conditions and privileges for EPDB Claim.
    In order to prove the case of the Opposite Party, filed affidavit and also produced Ex R1 to R13. On careful scrutiny of the documents produced by the Opposite Party, wherein the Ex R2 is the prescription of Dr.Mahabala Rai dated 5.3.2007 reveals that on 5.3.2007 the Complainant was not in Kodagu Village of Madikeri Taluk but on the same day he was consulted Dr.P.Mahabala Rai, Consultant Orthopedic Surgeon. The above said document falsifies the contention taken by the Complainant that on 5.3.2007 at about 6.00 p.m. while doing farm activities in his estate at Kodagu Village of Medikeri Taluk he accidentally rolled down and fell from a considerable height and sustained multiple fractural injuries on his left knee. But on the other hand, that the Complainant was consulted for open reduction and inter-fixation of left femur on 5.3.2007 at Omega Hospital. And further the Ex R4 i.e., a certificate dated 30.8.2007 issued by the very same consultant doctor Mahabala Rai made us very clear that the Complainant underwent Osteo Arthritis of the left knee. In support of the above documents, the Opposite Party filed affidavit but the same has not been controverted by the Complainant. The entire evidence produced by the Opposite Party was not cross-examined by the Complainant. The entire evidence and the documents placed by the Opposite Party is unrebutted and it requires no further proof. It is proved that the Complainant obtained the policy bearing No.611398354 (i.e., Ex R1) for a sum of Rs.50,000/-. The said policy was accepted by the Opposite Party with impairment extra of Rs.150/- per Rs.1,000/-, since at the time of taking the policy itself the Complainant was having deformity of the left knee. Further the claim papers submitted by the Complainant also made us clear that there was no mentioning of the incident or alleged accident stated in the complaint. From the documents produced by the Opposite Party as well as the evidence of the Opposite Party proved beyond doubt that the Complainant has taken treatment at Omega Hospital for ORIF Osteo Arthritis of the left knee. It is very clear from the documents that the Complainant had been treated for aggravation of disability which existed at the time of taking up of the policy and not for accidental fall as stated by the Complainant.
    In view of the above discussion, we are of the considered opinion that the Complainant failed to establish that the injury sustained by him is due to the accidental fall. Hence the complaint has no merits deserves to be dismissed. No order as to costs.

    6. In the result, we pass the following:

    ORDER

    The complaint is dismissed.

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    The counsel for the J.Dr. filed memo enclosing a cheque for Rs.12,977/- drawn in favour of the D.Hr. and submitted that the D.Hr. has claimed only a sum of Rs.9,650/-, but she is entitled for Rs.12,977/-, as such cheque has been issued on that amount and submits that it satisfies the claim of the D.Hr. made in this execution petition. Sri Anandaprabhu received the cheque on behalf of HMM and conceeds that it satisfies the claim of the D.Hr. made in this execuiton petition. Hence, execution petition is closed as fully satisfied.

    The counsel for the J.Dr. filed memo enclosing a cheque for Rs.12,977/- drawn in favour of the D.Hr. and submitted that the D.Hr. has claimed only a sum of Rs.9,650/-, but she is entitled for Rs.12,977/-, as such cheque has been issued on that amount and submits that it satisfies the claim of the D.Hr. made in this execution petition. Sri Anandaprabhu received the cheque on behalf of HMM and conceeds that it satisfies the claim of the D.Hr. made in this execuiton petition. Hence, execution petition is closed as fully satisfied.



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    Cyprian Baxla s/o late Simon Baxla
    R/o Qr. No.-2-063, Sector-II/A,
    Bokaro Steel City. Dist.- Bokaro.
    Versus
    1.The Zonal Manager, Life Insurance Corporation of India, Eastern Zonal Office, Hindustan Building, 4 C.R. Avenue, Kolkata-700072.
    2.Branch Manager, L.I.C. of India Ltd. Branch No.II, Bokaro Office, Sector-IV, B.S. City, Dist.- Bokaro.
    Before-
    S.M.Alam, President
    Vijay Bahadur Singh, Member
    Shabnam Praveen, Member

    Date of Judgment-: 29 May, 2009
    Date of case filing-: 01 February, 2007.
    -: Judgment:-
    The complainant has filed this case against the
    opposite parties and sought direction of this Forum against them to pay death claim worth Rs. 50000/- with 18% interest since 17.03.2003 till payment, besides Rs. 50000/- as compensation and Rs. 10000/- as cost of litigation to the complainant.


    2 Brief facts of this case is that the wife of the complainant had taken a LIC Policy vide Policy No. 540123500 dated 15.01.2001 and sum insured was Rs. 50000/- on the basis of half yearly premium of Rs. 4580/- from the opposite party No.2 and the complainant was made nominee of the said policy. The date of maturity of the policy was 15.01.2007. Prior to taking policy wife of the complainant was physically and mentally fit and she was not suffering from any major disease or ailment. The premium was paid by her and receipts were granted in her name. But in the first week of June, 2002 she felt some health problem for which she was admitted in BGH on 18.06.202 and died on 04.07.2002. The complainant being nominee of the said policy of his wife filed death claim in the office of the opposite party No.2 with all relevant documents but the complainant was very much surprised to receive a letter dated 17.03.2003 by which Divisional Office of the opposite party repudiated her genuine claim, it was stated by the opposite party in his letter dated 17.03.2003 that at the time of taking policy she suppressed her ailment like diabetes mellitus tpy-2 and hypertension and on account of that the claim has been repudiated on account of that the claim has been repudiated. But as a matter of fact wife of the complainant was not suffering from such ailments prior to the said policy and the opposite party intentionally repudiated the valid death claim of the complainant. The complainant made several representation against the decision of the repudiation and ultimately he also sent a legal notice but the opposite party did not take any step against the said policy. Therefore, the above facts and circumstances it is clear that there is deficiency in service on the part of the opposite parties and on account of deficiency of the opposite parties the complainant is entitled to get claim and compensation from the opposite parties.


    3 Upon issuance of notices the opposite party/LIC appeared and filed their written statement disputing the claim of the complainant on various grounds that the complainant has not filed the complaint in proper manner and the cause of action is not valid etc. The opposite party further stated that the deceased concealed the material fact/information regarding her health in view to defraud the opposite party for wrongful gain. As a matter of fact the deceased was suffering from much chronic disease like diabetes, hypertension etc. before taking the policy and she intentionally concealed this fact before obtaining the insurance policy which was detected by the doctor of BGH and admitted by her husband. The life assured died on 04.07.2002 just after one year 5 months for taking such policy. The life assured deliberately suppressed the fact to take the advantage of insurance and she violated the basic condition of good faith of insurance contract. Therefore, after due enquiry and investigation the Divisional Office of the Corporation repudiated the claim of the complainant on 17.03.2003 as per the ground set forth above and the repudiation by the opposite parties is legal and not unlawful. There is no deficiency in service on the part of the opposite parties as alleged by the complainant and the complainant is not entitled to get compensation and damage for physical and mental agony as falsely claim by the complainant and in view of the above facts complaint case is fit to be dismissed.



    4 We have heard both the parties and have perused the entire case records and documents filed on behalf of the parties. While going through the medical attendant certificate issued by the concerned doctor and the certificate of hospital treatment also issued by the concerned doctor in respect of the insured deceased it is observed that patient was suffering from diabetes mellitus and hypertension. As per both the above certificates the deceased insured was in the knowledge of the above diseases since 7 years prior to the date of death in respect of D.M. and since 3 year prior to the date of in respect of hypertension. The LIC policy in question was obtained on 15.01.2001 and the date of death was 04.07.2002. In view of the above it is concluded that there has been suppression of facts regarding her dieses of D.M. and hypertension by the deceased insured at the time of taking of policy in question, since these facts were in the knowledge of the deceased insured at the time of taking her LIC Policy. As such there is no reason for our interference in the matter of repudiation of the complainant’s claim by the opposite parties LIC. We, therefore, do not hold the opposite parties negligent and deficient in service towards the complainant while repudiating the claim. The opposite parties are held not liable to pay any relief to the complainant.



    5 Under the facts and circumstances of the case, no merit is found in the complaint case; hence the same is dismissed hereby accordingly.

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    Shabareesh Rai,

    S/o. Shanthappa Rai,

    B-6, Postal Staff Quarters,

    Bolar, Mangalore – 575 001. …….. COMPLAINANT



    (Advocate: Sri. A.J. Holla).



    VERSUS



    The Branch Manager,

    LIC of India,

    Ganesh Building,

    Jodumarga – 574 218,

    Dakshina Kannada District. ……. OPPOSITE PARTY



    1. The facts of the complaint in brief are as follows:

    This complaint is filed under Section 12 of the Consumer Protection Act alleging deficiency in service against the Opposite Party claiming certain reliefs.

    The Complainant is a LIC policy holder bearing policy No.62114549 and 62145550. It is submitted that he had taken loan from the above polices of Rs.14,750/- each and the same has been repaid with interest on 9.11.2007 and issued receipts to that effect. It is alleged that the Opposite Parties have appropriated Rs.10,000/- each survival benefit in the said policies through their communication dated 22.01.2008 and have recovered interest Rs.664/- each from the said survival benefit treating him as a defaulter. And thereafter the Complainant wrote a letter to the Opposite Party to rectify the same within 7 days but they have not responded which amounts to deficiency in service and filed the above complaint before this Hon'ble Forum under Section 12 of the Consumer Protection Act 1986 (herein after referred to as ‘the Act’) seeking direction from this Hon'ble Forum to the Opposite Party to pay survival benefits on two policies at Rs.10,000/- each along with interest at 18% p.a. for two months and further claimed compensation for mental agony.



    2. Version notice served to the Opposite Party by RPAD. Opposite Party appeared through their counsel filed version admitted that the Complainant was the holder of the above two policies and the survival benefit under both the policies of Rs.10,000/- each was due in the month of January 2008. The intimation for payment of the same was generated two three months in advance prior to the repayment of the loan. It is submitted that, as per the records of the Opposite Party the loan was outstanding as on the date of the intimation. Opposite Party branch adjusted the amount of survival benefit towards outstanding loan and interest and the same was intimated to the Complainant vide letter dated 22.1.2008. While doing reconciliation Opposite Party come to know about the excess recovery of loan and loan interest under the above polices and the Opposite Party rectified the same.

    On 14.2.2008 Opposite Party received letter from the Complainant and Opposite Party set right the policy account by settling the survival benefit by paying the same under both the policies on 27.3.2008 for Rs.20,000/- which encashed by the Complainant on 9.4.2008. It is contended that Opposite Party has not committed any deficiency in service rather on coming to know about the repayment of the loan by the Complainant, the Opposite Party has set right the policy account of the Complainant and entire survival benefit paid without any delay and contended that there is no deficiency and prayed for dismissal of the complaint.



    3. In view of the above said facts, the points now that arise for our consideration in this case are as under:

    (i) Whether the Complainant proves that the Opposite Party has committed deficiency in service?



    (ii) If so, whether the Complainant is entitled for the reliefs claimed?


    (iii) What order?



    4. In support of the complaint, Sri.Shabareesha Rai (CW1) filed affidavit reiterating what has been stated in the complaint and answered the interrogatories served on him. Ex C1 to C10 were marked for the Complainant as listed in the annexure. One Sri.R.Sathish Shenoy (RW1), Manager (L&HPF) of the Opposite Party filed counter affidavit and answered the interrogatories served on him. Both the parties have filed written notes of arguments.

    We have considered the notes/oral arguments submitted by the learned counsels and we have also considered the materials that was placed before the Hon'ble Forum and answer the points are as follows: Point No.(i): Affirmative.

    Point No.(ii) & (iii): As per the final order.
    Reasons



    5. Point No. (i) to (iii):

    In the instant case, it is admitted that the Complainant was the holder of LIC policies bearing No.62114549 and 62145550 (as per Ex C1 and C2). Under both the polices survival benefit of Rs.10,000/- each was due on 15.1.2008. It is also admitted that the Complainant had taken loan from the above policies of Rs.14,750/- each. The same has been repaid with interest on 9.11.2007 and the Opposite Party issued loan clearance certificate as per Ex C3 and C4.

    The Ex C7 and C8 dated 22.1.2008 i.e., the communication sent by the Opposite Party reveals that they have appropriated Rs.10,000/- each survival benefits in the said policies to the above said loan account and they have recovered Rs.664/- each from the said survival benefit. The Complainant wrote a letter on 14.2.2008 requesting them to rectify within 7 days (as per Ex C9). The Opposite Party though admitted their mistake but stated that the survival benefit of Rs.10,000/- was due in the month of January 2008 the intimation for payment of the same was generated 2-3 months in advance prior to the repayment of loan. As per the Opposite Party records, the loan was outstanding as on the date of intimation the Opposite Party bank adjusted the amount of survival benefit towards the outstanding loan and interest.

    As could be seen from the foot note of the Ex C7 the Opposite Party had deducted interest from 15.7.2007 to 15.1.2008, the intimation is dated 22.1.2008 it is surprise to note that how can they obtain the print out of the same 3-4 months in advance. The date of intimation should have been 22.11.2007 to 22.12.2007 if their say is correct. There is no chance for putting the future date i.e., 22.1.2008. This aspect indicates that the same was generated only on 22.1.2008.

    And further the Opposite Party admittedly committed default but atleast after the receipt of the Ex C9 i.e., a letter dated 14.2.2008 issued by the Complainant, the Opposite Party ought to have settled the amount within 7 days from the receipt of the above letter. But in the instant case, the Opposite Party admitted in their version that they have settled the amount vide their cheque No.282125 dated 18.3.2008 for Rs.20,000/- which stands encashed by the Complainant on 9.4.2008 which shows there is a delay on the part of the Opposite Party and it shows their gross negligence, the service of the Opposite Party which amounts to deficiency in service. However, the Opposite Party at last rectified the mistake and paid the amount but not paid any amount for the inconvenience caused to the Complainant. By considering the facts and circumstances of the case, we hereby direct the Opposite Party to pay to the Complainant Rs.2,000/- as compensation towards the inconvenience and Rs.1,000/- towards the cost of the litigation expenses. Payment shall be made within 30 days from the date of this order.



    6. In the result, we pass the following:


    ORDER

    The complaint is allowed. Opposite Party is hereby directed to pay to the Complainant Rs.2,000/- (Rupees two thousand only) as compensation and Rs.1,000/- as cost of the litigation expenses. Payment shall be made within 30 days from the date of this order.

  8. #38
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    Default Life Insurance Corporation of India

    Smt. Sankari Karmakar

    Lt. Ranjit Karmakar

    Vill: Rahimpur, PO: Buniadpur, PS: Banshihari,

    Dist. Dakshin Dinajpur ………………………………Complainant(s)

    Present Add:

    Smt. Sankari Karmakar

    C/o Gantosh Karmakar

    Vill: Bajrapukur (Hatkhola), PO: Nayabazar,

    PS: Tapan, Dist. Dakshin Dinajpur



    V-E-R-S-U-S

    1. Divisional Manager,

    Life Insurance Corporation of India, Jalpaiguri,

    2. Branch Manager,

    Life Insurance Corporation of India, Balurghat Branch,

    PO.: Balurghat, Dist. Dakshin Dinajpur …………Opposite Party(s)

    Instant CC case bases upon a complaint u/s 12 C.P. Act, brought by the complainant Smt. Sankari Karmakar on 18.11.2008 against the OPs who are, in fact, two officials of the Life Insurance Corporation of India alleging deficiency in service.

    Complainant’s case as made out in the said complaint, in brief, is that her husband Ranjit Karmakar was the holder of the insurance policy bearing No.452016318 under L.I.C.I. on 6.5.2000 while the said insurance Policy remained effective the said Ranjit was murdered by some persons. The complainant thereafter laid before the insurance authority her claim in prescribed form for the accidental death of her husband enclosing necessary documents. The Branch Manager, L.I.C.I., Balurghat Branch–the OP 2 herein, made payment of an amount of Rs.30,000/- but did not pay the amount of benefit for accidental death and of bonus. Persuasion made to the Divisional Manager, LICI, Jalpaiguri Division – the OP 1 herein, also proved abortive. In the back drop of such circumstances, the complainant brought the complaint praying for obtaining the said accidental benefit and bonus.

    The OPs in their w.v. filed on 24.2.2009 have assailed the maintainability of the complaint and have denied the material allegation of such complaint. It has been their case that even though the death claim was “very early” in nature they settled the death claim and paid to the complainant the amount of sum assured Rs.30,000/- and the bonus of Rs.1,980/-. In the FIR lodged by the complainant over the incident it has been stated that the assured had illegal affairs with the wife of one Netai and that out of revenge the said Netai cut the throat of the assured by a knife and as a sequel thereto the assured suffered death. Here since dominant intention of the assailant was to kill, the killing was not accidental in nature. Therefore the complainant was not entitled to the accidental benefit. There was thus no deficiency in service on the part of OPs and so the complaint warrants dismissal.

    Upon the pleadings of the sides following points come up for determination :-
    Points

    1.

    Is the proceeding maintainable?
    2.

    Was there deficiency in service on the part of OPs?
    3.

    Is the complainant entitled to the reliefs sought for by her?

    Decision with reasons:

    The averments made in the complaint have been verified by the complainant herself. The complainant also in support of her complaint filed in this case a good number of documents some of which were annexed to the complaint while others were filed separately with notice to the OPs on 17.3.2009, 24.4.2009 and on 23.6.2009. Such documents include copy of FIR over the incident as a sequel to which alleged victim suffered death, Inquest Report, PM Report, Charge Sheet submitted by the police in the concerned PS Case, Judgement of the Criminal Court, copies of a number of letters issued to the complainant from the side of the OPs, copy of the complainant’s application made before Sub- Divisional Legal Services Authority in the year 2008.

    The averments made in the w.v. of the OPs have been authenticated by the Senior Branch Manager of the OP Insurance Company simply by putting his signature and official seal. No other evidence was adduced in this case from any of the sides.

    Let us now enter into the determination on the different points formulated above.


    Point No.1

    Copy of the OP 1’s letter dt. 28.12.2000 addressed to the complainant (filed by the complainant) purports that under such letter the OP 1 forwarded to the complainant a cheque for an amount of Rs.31,980/- being the basic sum assured and bonus towards the settlement of the complainant’s claim respecting the insurance policy. Drawing our attention to such letter dt. 28.12.2000 it was empathetically urged by the Ld. Counsel appearing for the OP insurer that since the settlement over the claim was made known to the complainant under such letter dt. 28.12.2000, it has to be regarded that the cause of action for this case actually arose on 28.12.2000 and so the present complaint having been brought on 18.11.2008 has to be regarded to have been barred by limitation under the provision of Sec.24A CP Act.

    Ld. Counsel appearing for the complainant, on the other hand, urged that though under the said letter dt. 28.12.2000 the OP insurer forwarded a cheque for the basic sum assured, the OP insurer in such letter did not state that the accidental benefit would not be given to the complainant. Rather, such OP insurer under their letter dt. 18.6.2001 informed the complainant that they would not be able to take any decision over the payment of accidental benefit till obtaining of the certified copy of the final judgment in the concerned Criminal Case. At no point of time subsequent to the issuance of the said letter 18.6.2001 the OP informed the complainant that the accidental benefit would not be paid and so the complaint cannot be said to have been barred by time.

    We have carefully gone through the materials on record and have taken into consideration the submissions advanced on behalf of the sides.

    Under the OP 1’s the said letter dt. 28.12.2000 OP insurer forwarded a cheque for the basic sum assured and bonus and stated that they were making the payment “towards the settlement of the claim on the Corporation” in respect of the policy. It does not appear to have been expressly purported in such letter that the payment was made in full settlement of the claim. It has not also been expressly purported therein that the payment was made in partial settlement of the claim.

    However, we find that the OP insurer under its letter dt. 12.2.2001 i.e. at a time subsequent to the OP insurer’s making payment of the basic sum assured the Jalpaiguri Divisional Office i.e. OP 2 asked the complainant to furnish certified copy of the judgment (in the concerned Criminal Case) for consideration of the complainant’s claim i.e. virtually for consideration of the complainant’s claim for the accidental benefit.

    The said Jalpaiguri Divisional Office of the OP insurer under its letter dt. 18.6.2001 addressed to the complainant (filed by the complainant) further appears to have stated as quoted below, besides others:-

    “*** As the charge sheet indicated some illicit relations between Late Ranjit Karmakar and Smt. Manju Mahanto, we will not be able to take any decision towards consideration of accidental benefit till we get the certified copy of the final judgment. Till then please bear with us ***”.

    Copy of the judgment passed in Session Case No.16/2005 / Session Trial No.11/2005- (filed by the complainant) purports that the concerned Criminal Case over the charge of committing murder ended in acquittal on 2.4.2005.


    Here it has not been claimed by the complainant and it is also not on record that the complainant furnished the certified copy of the judgment of the said Session Case to the OP insurer. The complainant might have figured as the defacto complainant in the said Criminal Case but it cannot readily be regarded that she came to be in possession of the certified copy of the final judgment of the Criminal Case or came to be aware about the passing of the said final judgment in the criminal case soon after the passing of such judgment.


    Here it has not been claimed from the side of the OP insurer and it is also not on record that the OP insurer at any point of time subsequent to their issuing the aforesaid letter dt. 18.6.2001 they informed the complainant that they turned down the complainant’s claim for the accidental benefit from a consideration of judgment of the criminal case or for failure on the part of complainant in furnishing the certified copy of the judgment of the criminal case in response to their letter dt.12.2.2001 mentioned hereinabove.


    Such being the position, we think that the complaint seeking virtually the accidental benefit for consideration of which the complainant was asked to wait under the OP’s letter dt. 18.6.2001, should be regarded to have been barred by time.

    No other point was urged assailing the maintainability of the proceeding. On the materials on record we do not find any thing else which may render the proceeding untenable. We thus answer the Point No.1 holding that the proceeding is maintainable.

    Point No.:2

    Here the complainant’s allegation is that despite the policyholder’s having been murdered by some persons, the OP insurer did not make payment of the accidental benefit in terms of the policy and this constitutes deficiency in service on the part of the OP insurer.


    Copy of the concerned certificate of insurance does not appear to have been brought on record from any of the sides in this case. However, that the accidental benefit was payable in the event of the assured’s accidental death, does not appear to have been disputed from the side of the OP insurer.

    It has also not been disputed in this case that the policyholder was murdered by other person or persons. What has been disputed by the OPs is that the murder of the policyholder in this case cannot be regarded to be an accidental death.


    In course of hearing it was contended by the Ld. Counsel appearing for the complainant that since the killing was by the 3rd party or parties it has to be regarded that the death was accidental. To strengthen his such submission Ld. Counsel made reference to a judgment to the Hon’ble Punjab State Commission report in 2009(1) CPR 292.


    Ld. Counsel appearing for the OP insurer, on the other hand, strongly urged that the narration of the incident in the concerned FIR indicates that the murder of the policyholder was an intentional murder effected out of revenge on the part of assailant and that too, in a repeated attempt and so such incident of murder was a murder simpliciter and could not be regarded to be an accidental one. In support of his such contention Ld. Counsel placed reliance upon an observation of the Hon’ble Apex Court made in the judgment reported in 2000 ACJ 801 wherein the Hon’ble Apex Court purports to have laid down that if the dominant intention of the act of felony is to kill any particular person then such killing is not an accidental murder but is a murder simpliciter Ld. Counsel placed reliance also upon a decision of the Hon’ble National Commission reported III(2006) CPJ 213 (NC) wherein Hon’ble National Commission upheld a decision of the Hon’ble State Commission refusing to allow “double accident benefit observing that the killing of the policyholder was an intentional killing.


    Here in the concerned PM report (filed by the complainant) it has been opined that the death was due to shock and haemorrhage resulting from a number of injuries which were ante-mortem and homicidal in nature.

    It has been the narration of the FIR lodged by the complainant that in a night at about 11:00 PM while the policyholder was asleep on bed in his room alongwith his wife – the complainant herein, one Netai and a number of other persons entered into such room having broken open the door and hit the policyholder by a ‘lathi’ and cut his throat by a knife resulting in his death. It has further been narrated that the policyholder prior to his marriage, had illicit relationship with the wife of the said Netai and that earlier there had been an occasion in which the said Netai had hit the said policyholder on his head by a ‘lathi’.

    Thus on the materials on record it can be regarded for our present purpose that the policyholder suffered death in an incident of murder which was effected with the object of causing death and also out of revenge and that attempt had been made on earlier occasion too on the life of the policyholder, as was contended by the Ld. Counsel appearing for the OP insurer.


    In the case reported in 2009(1) CPR 292 (Oriental Insurance Company Ltd. and Anr.–vs – Sukhdev Kaur and Ors.) to which reference was made by the Ld. Counsel for the complainant Hon’ble Punjab State Commission upheld District Forum’s order granting benefit basing upon the insurance policy term over the death by accident. In that case Hon’ble State Commission found that the death was caused by strangulation and that it was neither a natural death nor a case of suicide.


    The observation of the Hon’ble Apex Court to which reliance was sought to place by the Ld. Counsel for the OP insurer actually appears to have been recorded in Para-10 of the judgment made in the case of Rita Devi and Ors-vs- New India Assurance Co. Ltd. and Anr. reported in 2000 ACJ 801 and it goes to as under: -

    “*** The question, therefore, is: can a murder be an accident in any given case? There is no doubt that ‘murder’, as it is understood, in the common parlance is a felonious act where death is caused with intent and the perpetrators of that act normally have a motive against the victim for such killing. But, there are also instances where murder can be by accident on a given set of facts. The difference between a ‘murder’ which is not an accident and a ‘murder’ which is an accident depends on the proximity of the cause of such murder. In our opinion, if the dominant intention of the act of felony is to kill any particular person then such killing is not an accidental murder but is a murder simpliciter, while if the cause of murder or act of murder was originally not intended and the same was caused in furtherance of any other felonious act then such murder is an accidental murder***”.

    User of the expression “as it is understood, in the common parlance” goes to indicate that the said observation was made by the Hon’ble Apex Court to explain what the term “murder” ordinarily means as distinguished from the meaning of such term when used in some special field or subject. In the case that was dealt with in the reported judgment the driver of an autorickshaw had to suffer death while the passengers of such autorickshaw for the purpose of stealing away the autorickshaw eliminated the driver. In that case the question was whether the death of the driver could have been regarded to be “due to accident arising out of the use of the motor vehicle” so as to entitle the legal representative of the deceased to compensation under the MV Act.


    Having the applied the principles laid down in two decisions of the Court of Appeal namely “Challis–vs- London and South Western Railway Company, (1905) 2 KB 154 and Nisbet –vs- Rayne and Burn, (1910) 1 KB 689” Hon’ble Apex Court in that case held that the death caused to the driver of autorickshaw was an accidental murder and that it arose out of the use of the autorickshaw.


    From the said judgment of the Hon’ble Apex Court it is found that in the Nisbet’s case reasoning which was followed by the Hon’ble Apex Court in the said judgment, the Court of Appeal recorded an observation which runs as under:-

    “*** I think it was an accident from the point of view of Nisbet, and that it makes no difference whether the pistol shot was deliberately fired at Nisbet or whether it was intended for somebody else and not for Nisbet***”.

    The question as to whether the death caused due to murder of the insured, can be regarded to be “accidental death” came up for consideration before the Hon’ble National Commission in the case of ‘Maya Devi –vs- Life Insurance Corporation of India’ reported in III (2008) CPJ 120 (NC). In that case the Hon’ble National Commission having made advertence to the meaning of word “accident” appearing in Halsbury’s Laws of England and having found in that case dealt with therein that the insured had not been a party to the murder in the sense that there had not been provocation on the part of insured and that immediate cause of the bullet injury was not the result of any willful act of the insured, held that the death of the insured was accidental.

    In that judgment the Hon’ble National Commission took into consideration the observation of the Hon’ble Apex Court made in the case reported in 2008 ACJ 801 to which reliance was sought to be placed from the side of the OP insurer in this case. Reasoning given by the Hon’ble National Commission in the earlier case of ‘Prithvi Raj Bhandari –vs- LICI Ltd. and Ors. reported in III (2006) CPJ 213 (NC) to which also reliance was placed by the Ld. Counsel for the OP insurer in this case, was also disapproved by the Hon’ble National Commission.


    Here in the case in hand before us the incident of murder took place at about 11:00 PM at night while the policyholder was asleep on bed in his room. Even though it can be regarded that the said policyholder prior to his marriage, had an illegal relationship with the wife of Netai and that a quarrel had also taken place in between the policyholder and the said Netai prior to the policyholder’s marriage, as have been narrated in the FIR, an illicit relationship of the policyholder or his getting entangled in quarrel with the said Netai that took place prior to the policyholder’s marriage, cannot be regarded to have been the provocation for the incident of murder narrated in the FIR.

    Accepting that the said Netai since after the quarrel which took place prior to the policyholder’s marriage was threatening the policyholder to be murdered, as has been stated in the FIR lodged by the present complainant over the incident, it cannot readily be regarded that the incident of murder took place in the natural course of events or that a reasonable man would have the expectation of occurrence of such an incident.

    From a consideration of attendant circumstances and having kept in view of the said decision of the Hon’ble National Commission reported in III (2008) CPJ 120 (NC), and the decision of the Punjab State Commission reported in 2009 (1) CPR 292, we are of the view that the incident of murder of the policyholder in this case was an accidental murder.

    Failure on the part of the OP insurer in making payment of the accidental benefit and incidental bonus, if at all, is to be viewed to have been a deficiency in service on the part of OP insurer. Point No. 2 is thus answered.

    Point No.3:

    In view of our determination of Points No. 1 & 2 we hold that the complainant is entitled to accidental benefit. The complainant should also get from the OP insurer the bonus, if at all, incidental to the granting of the accidental benefit.

    In the circumstances, the complainant should also get interest over the sum of total of the accidental benefit and incidental bonus w.e.f.18.11.2008 - the date of institution of this consumer complaint case till actual payment.

    The complainant should also get from the OP insurer the costs of this proceeding which we assess at Rs.1,000/-.

    Point No.3 is decided accordingly.

    In the result, the complaint succeeds.


    It appears from the case record that in this case notices of the complaint meant for the OPs were issued fixing 29.12.2008 for appearance. The OPs appeared in the proceeding on that dt. 29.12.2008. Instant case took time for about six months since the appearance of the OPs in this case. This is, as it appears from the record, mainly in view of adjournments sought for from the side of the OP as well as from the side of the complainant.


    Under such circumstances, it is.

    O R D E R E D


    That the complaint u/s 12 of CP Act brought by the complainant Smt. Sankari Karmakar on 18.11.2008 is allowed on contest.


    The OPs shall pay to the complainant the accidental benefit respecting the Policy No.: 452016318 which stood in the name of Ranjit Karmakar since deceased and the amount of bonus if at all incidental to the granting of the accidental benefit, within 30 days from the service of copy of this order upon them. They shall further pay to the complainant by the aforesaid period interest over the sum total of the accidental benefit and incidental bonus @ 10% p.a. w.e.f. 18.11.2008 – the date of institution of this CC case till actual payment and a sum of Rs.1,000/- (Rs. One thousand) only as costs of this proceeding.

  9. #39
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    Default Life Insurance Corporation of India

    Sangde Radha, W/o.Late.Istari,

    Age:30 yrs, Occ:House wife,

    R/o.Venkulam, R/M.Rebbena,

    Dist.Adilabad. …Complainant.
    //AND//


    1. The Life Insurance Corporation of India,

    Rep.by its Branch Manager,

    Branch Office:Bellampally, Dist.Adilabad.



    2. The Life Insurance Corporation of India,

    Rep.by its Divisional Manager,

    Divisional Office:Karminagar. …Opp.Parties.


    1. The complainant’s husband Sangde Istari obtained a L.I.C. policy vide Policy No.683205029 dt:07.07.2001 during his life time, and paid premium regularly. After the death of policyholder, his wife/Complainant submitted a requisition letter to Opp.Party No.1 Office for settlement of claim, on that Opp.Party No.1 neither settled the claim nor gave any reply to the complainant. On 22.10.2008 the complainant issued a legal notice to both Opp.Parties. But the Opp.Parties failed to settle the claim within time, due to which the complainant suffered a lot physically and mentally, for that Opp.Parties are liable pay compensation of Rs.10,000/- to the complainant.

    Hence the Complainant prayed this Forum to allow this complaint and award policy claim amount of Rs.60,000/- to the complainant against the Opp.Parties and also award compensation of Rs.10,000/- for mental agony, and also award costs of this complaint to the complainant, in the interest of justice.



    2. The Opp.Parties No.1&2 filed counter. The contents of counter are as follows:

    It is admitted that the Opp.Party Corporation issued a 15 years Endowment Assurance policy with Profits (Plan & Term : 14-15) bearing Number 683205029 with date of commencement 07.07.2001 for a sum Assured of Rs.30,000/- on the life of Sri Sangde Istari, S/o.Arju Patel, Vill:Vankulam, Post:Navegoam, Mdl:Rebbena, Dist.Adilabad. The Opp.Party has not received any intimation from the complainant regarding the death of her husband Sri.Sangde Istari. The Opp.Party No.1 on receipt of the Legal Notice dt:22.10.2008 spoke to the Advocate over phone on 25.10.2008 and again on 05.12.2008 and informed about the requirements to be submitted by Smt.Sangde Radha (nominee) for processing the claim. The Opp.Party No.1 sent a letter on 16.12.2008 addressed to the claimant under intimation to Advocate Sri.T.Roshi Reddy, regarding the Claim Forms/Reports to be submitted by the complainant. The Opp.Parties No.1&2 prayed to dismiss the complaint.



    3. Both parties filed Proof Affidavits.

    4. On behalf of complainant Ex.A1 to A15 are marked. Ex.B1 to B4 are marked on behalf of Opp.Parties.

    5. Now the point for consideration is whether there are grounds to allow the petition?

    6. Heard both sides. Perused material papers on record. Ex.A15 copy of F.I.R. shows that the deceased sustained injuries in lorry accident (collusion between 2 lorries) and died subsequently. Ex.A9 is a document to show the deceased Istari died on 24.04.2008 at Asifabad. The fact that deceased Istari died in lorry accident cannot be disputed. The further fact that policy was in vogue. On the date of accident is also not disputed.



    7. The contention of the Ld. Advocate for the Opp.Parties is that before filing the case of this nature the complainant has to submit claim form and the Opp.Party will investigate the case and pass orders and that if the complainant is aggrieved she should work out her remedies. But required procedure is not followed in this case and the complainant directly came to this forum and filed this case. So deficiency of service cannot be attributed to the Opp.Parties.



    8. On the other hand Ld. Advocate for the complainant submitted that the Opp.Parties did not send the claim forms at all and the Opp.Parties took false endorsement under Ex.B2 from the complainant as if the claim forms were given to counsel for the complainant.



    9. As seen from record, there is no evidence (or proof) that Opp.Parties sent claim forms to complainant. For a moment it cannot be said that complainant received claim forms and he purposefully suppressed the same. Because it is the complainant who suffered a lot and not Opp.Parties. So what exactly happened was not before this Forum. But ultimately victim is the complainant, as she did not receive policy amount so far. Considering available material on record, as there is no letter of repudiation, we feel it is a fit case to direct the complainant to submit a copy of Inquest Report, a copy of P.M.E. Report, a copy of Charge Sheet to the Opp.Parties and Opp.Parties are directed to settle the claim preferably within 2 months from the date of receipt of the above documents.



    10. In the result complaint is allowed in part with suitable directions.

  10. #40
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    Default Life Insurance Corporation of India

    Pidugu Prameela @ Premala, W/o. Late Pidugu Pedda Rajaiah, Age 38 years, Occ: Housewife, R/o. Rompikunta village of Kamanpur mandal, Karimnagar district.

    …Complainant

    Life Insurance Corporation of India, Ramagundam Branch, NTPC X-Road, Jyothinagar Ramagundam proper and mandal Karimnagar district, R/by it’s Branch Manager.

    1. This complaint is filed under Section 12 of C.P. Act, 1986 seeking direction to the opposite party to pay an amount of Rs.50,000/- towards accidental benefit coverage with bonus, benefits, interest, damages and costs of the claim.



    2. The brief averments of the complaint are that the husband of the complainant by name Pidugu Pedda Rajaiah was an employee in S.C.C. limited. During his life time he obtained Insurance Policy for an assured sum of Rs.50,000/- with accidental benefit coverage from the opposite party bearing policy no.682589481 and he nominated the complainant as his nominee under the policy. It is submitted that as per the terms and conditions of the policy in case of death of the policy holder accidentally his nominee would be paid double the assured sum.

    The policy holder died accidentally on 14.6.2006 as he was murdered in Godavarikhani and a crime was registered by the Police, Godavarikhani II town under Sec 174 of Cr.P.C. and subsequently the section of law was altered to the offence under Sec 302 of I.P.C. It is submitted that the complainant being the nominee under the policy submitted claim forms along with required documents to the opposite party claiming paying of assured sum with accidental benefit coverage. But the opposite party paid the basic assured sum of Rs.50,000/- with bonus totaling Rs.68,300/- on 18.6.2008 treating the death of the policy holder as a natural death. It is further submitted by the complainant that the opposite party did not pay the amount of Rs.50,000/- covered under accident benefit coverage. Therefore, the complainant got issued Legal Notice on 11.1.2009 demanding opposite party to pay the same, but the opposite party failed to settle the claim which constitutes deficiency of service. Therefore, the complainant sought direction for payment of Rs.50,000/- with bonus, profits, compensation, interest and costs under accidental benefit coverage.



    3. The opposite party remained exparte and did not choose to file any counter.



    4. The complainant filed her Proof Affidavit reiterating the averments made in the complaint and filed documents which are marked as Ex.A1 to A10. Ex.A1 is the Status Report of policy No.682589481 issued by opposite party. Ex.A2 is the letter of opposite party pertaining to settlement of normal death claim Dt: 18.6.2008. Ex.A3 is the Xerox copy of F.I.R. Dt: 14.6.2006. Ex.A4 is the Xerox copy of P.M.E. Report Dt: 14.6.2006. Ex.A5 is the Xerox copy of Inquest Report Dt: 14.6.2006. Ex.A6 is the Xerox copy of Alteration of Section of Law petition Dt: 7.7.2006. Ex.A7 is the Office copy of Legal Notice got issued by complainant Dt: 11.1.2009. Ex.A8 is the receipt of professional courier. Ex.A9 is the Xerox copy of Death Certificate issued by Grampanchayat, Peddampet Dt: 10.7.2006. Ex.A10 is the copy of Final Report issued by Police, Godavarikhani II Town, submitted before JFCM, Mantheni.



    5. The point for consideration is whether there is any deficiency of service on the part of opposite party, if so, to what relief the complainant is entitled?



    6. It is contended by the complainant that the opposite party failed to pay the amount of Rs.50,000/- payable under accidental benefit coverage inspite of submission of all the documentary proof under Ex.A1 to A10. It is further contended that the opposite party paid the basic assured sum of Rs.50,000/- with bonus treating the death of the policy holder as a normal death. The criminal case records under Ex.A3, Ex.A4, Ex.A5 and Ex.A6 discloses that the deceased died due to injuries sustained by him. As per the terms of the policy the opposite party is liable to pay the amount payable under accident coverage and non-payment constitutes deficiency of service, therefore, claimed an order for payment.



    7. A perusal of the documentary evidence produced by the complainant discloses that the husband of the complainant obtained Insurance Policy on 28.7.1999 from the opposite party for a sum of Rs.50,000/-. The criminal case records under Ex.A3 to A6 and death certificate under Ex.A9 discloses that the policy holder died on 14.6.2006 due to head injury. After receipt of the claim from the complainant the opposite party settled the claim by paying an amount of Rs.68,300/- on 18.6.2008 along with letter under Ex.A2. The contents of Ex.A2 discloses that the opposite party paid basic assured sum of Rs.50,000/- with vested bonus of Rs.18,300/- totaling Rs.68,300/- and the payment of said amount is admitted by the complainant. The present complaint is filed by the complainant claiming the amount payable under accident benefit coverage.



    8. When the complainant accepted the payment of basic sum assured it is her duty to show that the opposite party agreed to pay the amount under accident benefit coverage. But the complainant failed to produce any copy of the policy Bond "or" any the document to show that the opposite party undertook to pay additional coverage amount of Rs.50,000/-. In the complaint "or" in the Proof Affidavit the complainant did not disclose the type of the policy obtained by her husband. There is no document placed before this FORUM to show that the opposite party issued the policy undertaking to pay double the sum assured in case of death of the policy holder accidentally. After registration of the crime regarding cause of death of the policy holder, the Police Godavarikhani II Town made investigation and filed Final Report under Ex.A10 before the Court of J.M.F.C. Mantheni reporting that the deceased was in the habit of committing theft of coal and on the date of incident he was in drunken condition and when the security persons chased him while running away fell down and sustained head injury resulting in his death. The Postmortem Report under Ex.A4 at "Col. D" it is reported that "Alcohol is found in the stomach of the deceased". Thus the evidence on record is clearly suggesting the death of insured is not accidental death and it is a suspicious death. Hence, it is the reason for the opposite party to settle the claim of complainant only to the extent of risk cover for normal death.



    9. Any how in the absence of placing any document of policy or relating record by the complainant that there is a contractual obligation on the part of opposite party to pay the amount as claimed by them for accidental benefits is not tenable and issuance of Legal Notice by the complainant under Ex.A7 will not caste any liability on the part of opposite party. It is much contended by the counsel for the complainant when the Forum sent the notice it was returned with an endorsement as refused, this it is sufficient to say that the opposite party is liable to pay the claim of the complainant. But the complainant herein is not examined the concern Postman that the notice was refused by the opposite party. Even otherwise since the burden lies on the complainant to prove his own case it cannot be depend on the weakness of the opposite parties. When the material is proving that opposite party settled the legally entitled claim of complainant it cannot be said that there is any deficiency of service. Since the complainant is not come to the Court with clean hands suppressing the facts about the nature of death of deceased, the complaint is liable to be dismissed and the opposite party rightly rejected the accidental benefits to the complainant.

  11. #41
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    Default Life Insurance Corporation of India

    Smt Rukkamma W/o Linga Reddy,

    Aged about 48 yrs, Occu: Household,

    R/o Chapta (K) Village, Narayankhed Mandal,

    Medak District.

    … Complainant

    1. The Life Insurance Corporation of India

    Rep.by its branch Manager, Branch Office

    At Zaheerabad, Medak District,

    H.No.3-4-6 Main Road, Zaheerabad, Medak district.



    2. The Senior Divisional Manager,

    Life Insurance Corporation of India,

    Divl.office at H.No.1-8-179, Lakpath Building,

    S.D.Road, Secunderabad – 500 003.

    ….Opposite parties

    2. The complainant is a resident of Chapta-K village of Narayankhed Mandal, Medak District. Her son Pogula Ashok reddy, while studying intermediate, had taken a policy of life Insurance vide policy No.601802683, dt.28.3.2005 for Rs.50,000/- for an yearly premium of Rs.3,263/- and the date of maturity of the policy is 28.3.2025 vide Table & Term 075 20.20. The policy was issued from Zaheerabad branch (60C) in which the complainant herein is shown as nominee.

    3. The policy holder Ashok Reddy paid premium amount of Rs.3,263/- on 10.4.2006 and next premium amount fell due on -3-2007. As the life assured Ashok Reddy was busy in preparation of intermediate examinations during the month of March, 2007 and due to busy schedule of work, he could not pay the premium amount during the month of March, 2007. Non payment of premium was not intentional or with any motive. Unfortunately on 08.05.2007 the life assured Ashok Reddy sustained grievous injuries due to burst of gas cylinder and while undergoing treatment succumbed to the injuries on 16.5.2007. After the death of her son the complainant approached opposite party No.1 and preferred a claim for payment of policy amount. On instructions of the concerned officers in the office of the opposite party No.1, the complainant obtained death certificate, LIC certificate and other necessary documents and submitted to opposite party No.1 for settlement of claim. The opposite party No.1 postponed settlement of the claim on one pretext or other, therefore the complainant got a legal notice issued to opposite party; No.1 on 10.11.2008, for which there is no reply which clearly shows deliberate negligence and breach of trust and it amounts to deficiency in service, hence the complaint.

    4. The claim is resisted by the opposite parties by filing a counter to the following effect:

    Taking of Life Insurance Policy by Mr.P.Ashok Reddy from the office of opposite party No.1 on 28.3.2005 for Rs.50,000/- is true. As on the date of death of the life assured, the policy was in lapsed condition due to non payment yearly premium on 28.3.2007. As per policy contract the corporation agrees to pay the sum assured subject to receipt of subsequent premiums as set out in the schedule to consider death claim. If the policy has acquired any paid up value as on the date of death, in terms of provisions under the Non Forfeiture Regulations-4 of conditions and privileges with in referred to in the policy document, in such case only paid up value is payable provided the claim is admitted. The opposite parties have not received any intimation in writing of the death of the assured and the claim forms as well. LIC’s usual procedure is that on receipt of intimation of death in writing and claim forms duly filled in by the claimant, the LIC would conduct enquiry into the bonafides of the claim in respect of early claim arising within 3 years of the commencement of policy and based on the enquiry report, information given by claimant in the claim forms and on the basis of proposal made for issuance of the policy, takes a decision with regard to payment of claim. In the instant case though nothing is payable under the policy as per the provisions of the terms of insurance contract, there is discretion of the competent authority to consider the claim on exgratia provided the claim enquiry report and duly filled in claim forms in relation to the material facts about the life assured’s health that were stated by the deceased life assured in the proposal form for insurance and the claim is admissible, as Life Insurance contracts are contracts of uberrimae fides. The allegations that the opposite parties are deliberately and intentionally avoiding to pay the policy amount is denied. Intimation of death of life assured was not at all received in writing from the climant with proof of death and claim forms. There is no negligence nor there is deficiency in service on the part of the opposite parties. The complaint may there fore be dismissed.

    5. Evidence affidavits of both parties filed to prove their respective contentions. Exs.A.1 to A.6 are marked on behalf of the complainant and Exs.B.1 to B.3 are marked on behalf of the opposite parties. No written arguments are reported for the complainant. Memo is filed by the counsel for the opposite parties to treat the evidence affidavit as written arguments. Oral arguments of both sides heard. Perused the record.

    6. The point for consideration is whether the complainant is entitled for the policy amount and compensation as prayed for ?

    Point:

    The case of the complainant is that her son Pogula Ashok Reddy had taken a life insurance policy from opposite party No. 1 for Rs.50,000/- vide policy No. 601802683, dt. 28.03.2005 and paid the first premium of Rs.3,263/- on 10.04.2006 and the next premium was payable on 28.03.2007. The complainant who is nominee under the policy. As the life assured was busy in preparing for intermediate examinations and due to busy schedule of work, he could not pay the premium amount which was due on 28.03.2007. But unfortunately on 08.05.2007 the life assured Pogula Ashok Reddy sustained grievous injuries due to burst of gas cylinder and while under going treatment he succumbed to the injuries on 16.05.2007. It is the further case of the complainant that non payment of the second premium before the due date i.e. on or before 28.03.2007 was not intentional nor with any motive, therefore she submitted a claim to the opposite parties for payment of the policy amount but the opposite parties refused to pay on the ground that there was no existing policy by the date of death of the life assured. There upon the complainant got Ex.A4 legal notice issued to opposite party No. 1 for which there is no reply and hence the complaint is filed.

    7. Reference to Ex.A1 is sufficient for disposal of this case, as facts are not in dispute to refer to the other documents.

    8. The opposite parties have not disputed the facts stated by the complainant . Their only contention is that the life assured Pogula Ashok Reddy did not pay the second premium which fell due on 28.03.2007 and died shortly there after on 16.05.2007, therefore in view of condition No. 4 of the “CONDITIONS AND PRIVILLAGES” printed on the back side of Ex. A1, the complainant is not entitled to any amount under the policy. Ex. A1 shows that it is subject to the conditions and privileges printed on the back of it. To better appreciate the same the said condition No. 4 is reproduced here under:

    9. “4. Non-Forfeiture Regulations: If, after at least three full years’ premium have been paid in respect of this Policy, any subsequent premium be not duly paid, this Policy shall not be wholly void, but shall subsist as a paid-up policy for a reduced sum payable on the Date of Maturity or at the Life Assured’s prior death provided the paid up sum assured is not less than Rs.250/- the amount of paid-up assurance per integral number of years premiums and will be calculated as per table given below, the policy so reduced shall thereafter be free from all liability for payment of within mentioned premium but shall not be entitled to participate in future profits, the existing bonus additions, if any, will remain attached to the reduced paid-up policy.

    Notwithstanding what is above stated, if after atleast three full year’s premiums have been paid in respect of this Policy, any subsequent premium be not duly paid, in the event of the death of the Life Assured within 6(six) months from the due date of the first unpaid premium the Policy moneys will be paid as if the Policy had remained in full force after deduction of (a) the premium or premiums unpaid with interest thereon to the date of death on the same terms as for revival of the policy during such period, and (b) the unpaid premium falling due before the next anniversary of the policy. Notwithstanding what is above stated, if after atleast five full year’s premiums have been paid in respect of this Policy, any subsequent premium be not duly paid, in the event of the death of the Life Assured within 12 months from the due date of the first unpaid premium the policy moneys will be paid as if the policy had remained in full force after deduction of (a) the premium or premiums unpaid with interest thereon to the date of death on the same terms as for revival of the policy during such period, and b) the unpaid premiums falling due before the next anniversary of the policy”.

    10. As admittedly second premium was not paid by the due date i.e. 28.03.2007 and as the life assured Pogula Ashok Reddy died on 16.05.2007, in view of condition No. 4 above, it is held that the complainant is not entitled either for the policy amount of Rs.50,000/- under Ex. A1 or for award of compensation of Rs.50,000/- as prayed for in the complainant. The point is answered against the complainant.

  12. #42
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    Default Life Insurance Corporation of India

    Lothugedda Rama Devi, W/o.late Lothugedda Nagaraju @ Nageswara Rao, aged 30 years, House hold duties, Katragada Village, Korama Post, Kotturu Via, Srikakulam District Andhra Pradesh. … Complainant.

    01) @@@@avarapu Bheemaraju, S/o.late Simhachalam,

    Aged 32 years, L.I.C.Agent, Kadumu Village,

    Kotturu Mandal, Srikakulam District. 02) Life Insurance Corporation of India, rep.by its Branch Manger,

    Gajapathi Marg, Parlakhemundi, Gajapathi District.

    Orissa State Pin – 761 200. 03) Life Insurance Corporation of India, rep,.by its Divisional Manager,

    Divisional Office, Jeevan Prakash, Khodasingi,

    Post Box No.18, Berhampur, Ganjam District,

    Orissa State. Pin-760010. … Opposite parties.


    O R D E R

    Husband of the complainant by name Nagaraju, Alias Nageswara Rao obtained LIC Policy and paid premiums to opposite party NO.1 who was LIC Agent residing at Kadumu Village in Srikakulam District. Husband of the complainant was involved in motor vehicle accident and died on 2-11-2006. Complainant is nominee under the policy. Complainant claimed policy amount from opposite party No.3 at Berhampur and opposite party NO.3 paid Rs.45,160/- through opposite party NO.2. Complainant received the same under protest. Complainant requested opposite party Nos.1 and 2 for payment of accident benefit of Rs.40,000/- and submitted required documents to opposite party NO.2. Complainant issued notice dated 14-7-2007 to opposite party Nos.2 and 3 for payment of accident benefit of Rs.40,000/- and compensation of Rs.25,000/-. Opposite party Nos.2 and 3 did not settle the claim. Hence complaint is filed for a direction to opposite party Nos.2 and 3 to pay accident benefit of Rs.40,000/- with interest at the rate of 24% per annum and compensation of Rs.25,000/- and costs.

    2) Opposite party No.3 filed counter stating that the deceased life assured by name Lothugedda Nagaraju alias Nageswara Rao, submitted his proposal dated 28-2-2004 to the Branch Office of Parlakhemundi and policy was issued in his favour. Complainant approached opposite party Nos.2 and 3 stating that her husband died on 2-11-2006 and she was nominee of the deceased Nagaraju. An amount of Rs.45,160/- was paid to the complainant on 27-3-2007 towards full and final satisfaction and discharge of all her claims under the policy. Complainant did not submit any document regarding occurrence of accident at the time of settlement of the claim under the policy. There is no deficiency in service on the part of the opposite parties.

    Opposite party Nos.1 and 2 remained absent.

    3) Complainant and opposite party No.3 filed affidavits. Exs.A1 to A6 are marked on behalf of the complainant. No documents are marked on behalf of opposite party No.3.

    Heard Advocate for the complainant Advocate for opposite party No.3 remained absent.

    Point for consideration is:

    Whether there is deficiency in service on the part of the opposite parties and this Forum has got jurisdiction.

    4) Point:

    Complainant filed affidavit with the same facts contained in the complaint. Opposite party NO.3 filed affidavit with the same facts contained in the counter. Ex.A1 is letter dated 19-4-2007 addressed by opposite party No.2 to the complainant stating that a cheque for Rs.45,160/- was issued to the complainant towards the claim under policy amount. Ex.A4 is office copy of notice dated 14-7-2007 issued by the complainant to opposite party Nos.2 and 3 claiming accident benefit of Rs.40,000/- and compensation of Rs.25,000/-. Ex.A5 is reply dated 18-7-2007 from opposite party No.2 to the complainant stating that for consideration of accident benefit Certified Copy of FIR, PIR, PFR or Charge Sheet and PMR are to be produced by the claimant, but till date she had not submitted the same.

    Hence no consideration was been made for admission of AB in absence of such requirements. Complainant was requested to submit the same to enable them to consider whether AB can be paid or not. Ex.A6 is letter dated 25-7-2007 from the Life Insurance Corporation of India stating that Parlakhemundi Branch Office addressed a letter dated 18-7-2007 requesting Certified Copy of FIR, PIR, PFR or Charge Sheet and PMR from the party for consideration of the accident benefit. Exs.A5 and A6 clearly show that the complainant had not submitted required documents for consideration of the claim of accident benefit. Still the complainant was requested to submit the same for consideration of the accident benefit, but the complainant had not done so. Complainant had preferred to file the present complaint on 26-10-2007 ignoring Ex.A5 letter dated 18-7-2007 and Ex.A6 letter dated 25-7-2007.

    5) Opposite party No.1 is agent of opposite party Nos.2 and 3. There is no evidence to show that the LIC premiums were paid to opposite party No.1. Complainant has not filed any document to show that LIC premiums were paid to opposite party No.1 who is residing within Srikakulam District. Complainant had received cheque for Rs.45,160/- towards policy amount along with letter dated 19-4-2007. It shows that the complainant had not claimed accident benefit for the death of her husband. Evenafter receiving Rs.45,160/-, complainant had not submitted required documents to opposite party Nos.2 and 3 for consideration of the claim under the accident benefit. Opposite party Nos.2 and 3 have not rejected the claim of the complainant. Opposite party Nos.2 and 3 requested the complainant by Exs.A5 and A6 letters to submit necessary documents for consideration of payment of accident benefit under policy.

    But the complainant did not like to approach opposite party Nos.2 and 3 with the required documents for consideration of payment of accident benefit under policy. We therefore hold that there is no deficiency in service on the part of opposite party Nos.2 and 3. Opposite party No.2 is situated in Parlakhemundi in Gajapathi District, Orissa State. Opposite party No.3 is situated at Berhampur, Ganjam District, Orissa State. Both are not situated within the District of Srikakulam. Complainant had obtained LIC Policy from opposite party No.2 situated at Parlakhemundi. Complainant had received Rs.45,160/- towards claim under the policy from opposite party No.2 which is situated at Parlakhemundi. Opposite party No.1 is not at all responsible for payment of the amounts under the policy. Opposite party No.1 is not authorized to receive LIC Premiums on behalf of opposite party Nos.2 and 3. Complainant has not filed any document to show that LIC premiums were paid to opposite party NO.1 who is agent of opposite party Nos.2 and 3. Opposite Party NO.3 filed counter stating that the complainant has not submitted the required documents for consideration of the accident benefit under the policy. Still opposite party Nos.2 and 3 are ready to consider the claim under accident benefit. Complainant has submitted to the jurisdiction of this Forum and opposite party Nos.2 and 3 have not rejected the claim of the complainant for accident benefit.

    This Forum can give direction to the complainant to approach opposite party Nos.2 and 3 with necessary documents and opposite party Nos.2 and 3 will consider the claim under accident benefit. Hence we answer the point accordingly. In the result, complaint is dismissed. No costs. Advocate’s fee is fixed at Rs.500/- (Rupees five hundred only). Complainant is directed to approach opposite party Nos.2 and 3 with necessary documents for consideration of the accident benefit. Opposite party Nos.2 and 3 are directed to consider the claim of the complainant for accident benefit after receiving the necessary documents.

  13. #43
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    Default Life Insurance Corporation

    This complaint is filed for directing the opp.parties to pay the policy amount of Rs.1,00,000/- with compensation and cost. It is stated in the complaint as follows:

    The complainant’s deceased husband Sri.A. Mohammed Mustafa availed a policy for Rs.1,00,000/- bearing policy No.781720600 from the 2nd opp.party in the year 1997. The mode of premium was once in three months. The policy was issued after due verification and enquiry from the side of the opp.parties and due medical examination by the approved doctor’s certificate of the opp.parties. The complainant’s husband fwas punctual in paying the premium from the very beginning and later he became a defaulter for four instalments. The entire premium amount till 24.6.99 was paid and the policy was renewed. After the renewal of the policy, the said A.Mohammed Mustafa the husband of the complainant effected premium till his demise date on 2.8.2000. The death of the complainant’s husband was a natural one.

    Since the complainant is the nominee cum legal heir of the policy amount of the deceased A Mohammed Mustafa the husband of the complainant, the complainant accordingly applied to the 1st and 2nd opp.parties for releasing the policy amount. But unfortunately the claim of the complainant was rejected by the opp.parties stating that the deceased was suffering from Tuberculosis and Diabetes since 11.4.1999, and he had suppressed these facts in the renewal statement dated 24.6.99. No such statement have been filled by the complainant’s husband. Only in certain documents filled by the 3rd opp.party in English alone were signed by the deceased husband without even knowing the contents therein as per the direction of the 2nd and 3rd opp.parties. The opp.parties have no right or power to reject the claim of the complainant after accepting all the relevant and original documents in connection with the policy from the complainant. There is deficiency in service on the part of the opp.parties. Hence prays for relief.

    The opp.parties have filed the version contending as follows: The complaint is not maintainable. The deceased Mohammed Mustafa had submitted a proposal for a money back Life Insurance Policy on 30.3.1997 and in consideration of the proposal a policy of insurance bearing No.781720600 for a sum assured of Rs.1,00,000/- with date of risk commencing from 28.3.97 and for a term of 15 years was issued on the life of Mohammed Mustafa. The premium was arrived at Rs.2411/- payable once in every quarter from 28.3.1997 till the date of maturity or till the earlier death of the life assured.

    The nominee under the policy is Rasiya Beevi the wife of the life assured. As per condition No.2 of the policy document if the said premium is not paid atleast within the grace period allowed after the due date, the policy will lapse. The life assured did not pay the consideration for the contract of insurance for its continuance viz, premium from 28.9.99 and did not care to pay further premium, thus causing the policy to lapse. The life assured opted for the revival of the policy. For that purpose he had submitted a personal statement regarding his health. His state of health as declared by him in the personal statement dated 24.6.99 is good. The 2nd opp.party received a letter dt. 23.8.2000 from Rasiya Beevi, the nominee that her husband who was the life assured under the policy died on 2.8.2000 and requested to settle the payment under the policy. She submitted the claim form and death certificate. Since the death of the life assured happened on 2.8.2000 ie, immediately after the revival of the policy an investigation was conducted in the matter of the claim.

    It was revealed in the investigation that the life assured Mohammed Mustafa was suffering from infection of lungs consolidation R midland lower zone and was also suffering from Recurrence of pulmonary Tuberculosis and diabetes mellitus since 1.4.99. He underwent treatment as an inpatient at Medical College Hospital, Thiruvananthapuram and inpatient number was 1908 as on 1.4.99. The life assured was a psychiatric patient and he also underwent treatment for the same at Medical College Hospital, Thiruvananthapuram before reviving the policy. He had not disclosed such ailments or such treatments while submitting the personal statement regarding for reviving the policy on 24.6.99. Since the death occurred within two years of the revival of the policy the matter of the claim preferred by the complainant was properly investigated and the decision to repudiate her claim had been arrived at after due application of mind in good faith in the larger interest of the insuring public. The reason for repudiation of the claim is made known to the complainant vide letter dt. 12.4.2001. There is no deficiency in service on the part of the opp.parties. Hence the opp.parties prays to dismiss the complaint.

    Points that would arise for consideration are:

    1. Whether there is deficiency in service on the part of opp.parties

    2. Reliefs and costs.

    For the complainant PW.1 is examined. Exts.P1 to P are marked.

    For the opp.parties DW.1 is examined. Ext. D1 to D5 are marked.

    Points 1 and 2:

    The Forum found that no positive evidence has been adduced by the opp.party to prove that the life assured was suffering from the diseases as alleged in the version. Forum allowed the complaint and directed the opp.parties to pay the complainant Rs.1,00,000/- with 9% interest from the date of filing of the complaint and also directed to pay Rs.1000/- as compensation and cost.

    Aggrieved by this order the opp.parties filed appeal before Kerala Stae Consumer Disputes Redressal Commission [Appeal No.215/2004]. After hearing the appeal, the State Commission remanded the matter to the Forum on the finding that the matter has not been adjudicated in the absence of objective evidence with respect to the contentions of the opp.party that the assured was suffering from the infection of lungs and recurrence of pulmonary Tuberculosis and diabetes since 1.4.99. The matter is remanded to the Forum by the State Commission with a direction to dispose the matter on merits within 3 months from the date of taking the matter into the file. Subsequent to that from the side of opp.parties DW.2 was examined and marked Ext.X1 case sheet of HDC sanatorium for chest diseases, Pulayanarkotta with regard to IP No.1008/99. During examination DW.2 deposed before the Forum that he has not treated the patient mentioned in Ext. X1 and further one of the treated Doctor. is now working in the hospital field.

    The specific contention of the opp.parties is that the Life assured having not disclosed of his suffering from pulmonary Tuberculosis and diabetic before revival of the policy. The only documentary evidence produced with regard to the said contention is Ext. X1 . There is nothing in Ext. X1 to show that prior to the revival of policy on 24.6.99, the Life assured was suffering and taking treatment for Tuberculosis and diabetic. The history recorded in Ext. X1 where the life assured was admitted in 1.4.99 cannot be treated as evidence, as the doctors, recording that history, were not examined as witnesses or their affidavit filed. So, it was not proved that the life assured was suffering and taking treatment for pulmonary Tuberculosis and diabetes even before the revival of the policy. Opp.parties failed to examined the concerned doctors. mentioned in Ext. X1. After marking Ext. X1 opp.parties submitted before the forum that they have no further evidence. From the available evidence we find that there is deficiency in service on the part of the opp.party who repudiated the claim of the complainant illegally. The complainant is entitled to get the policy amount.

    In the result the complaint is allowed directing the opp.parties to pay the complainant Rs.1,00,000/- with 9% interest from the date of filing of this complaint. The opp.parties are also directed to pay Rs.1000/- as compensation and cost.

  14. #44
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    Default Life Insurance Corporation of India

    P. Pandu S/o Late P. Jagannath

    U/g. of P. N. Narasappa S/o P. Marappa Potdar,

    Age: 48 yrs, Occ: Legal Profession,

    R/o H.No.2-907-76/47, Gubbi Colony,

    Gulbarga.

    // Versus //

    OPPONENT:- 1) Branch Manager,

    Life Insurance Corporation of India,

    IInd K.S.S.I.D.C., Building,

    Jewargi Road,

    Gulbarga.


    2) The Divisional Manager,

    Life Insurance Corporation of India,

    Divisional Office, Near Stadium,

    RAICHUR-584 101

    : : O R D E R : :

    1. This complaint is filed by one P. Pandu S/o Late P. Jagannath, U/g. of P. Narasappa S/o P. Marappa Potdar, R/o Gulbarga against O.Ps. u/s.12 of Consumer Protection Act 1986 praying that, direction may be given to O.Ps. to pay an amount of additional sum equal to sum assured towards death Rs.50,000/-, Bonus Rs.10,000/- loss of earning for wondering to the O.Ps. office for one year Rs.20,000/-, mental agony and torture Rs.15,000/- & Rs.5,000/- towards cost of proceedings and other expenses, total Rs.1,00,000/- in the interest of justice.

    2. The brief facts of the case of the complainant are as under;

    Complainant is the brother of deceased Jagannath S/o P. Marappa, the policy holder and guardian of minor complainant. The deceased was an employee as Pump Operator in Town Municipal Council, Deodurga of Raichur District. The deceased has taken an Endowment Assurance Policy with profits of accidental death benefits vide policy No.663371258 dated 24.3.2005 from O.P.No.1. The mode of payment of premium in the above policy is yearly installment of Rs.2,354/-. Accordingly complainant has regularly paid yearly installment from 24.3.2005 till 2007 for which O.P.No.1 has acknowledged for having received yearly premium installments. Unfortunately policy holder died in an accident of murder.

    Complainant feel if necessary to reproduce the wordings uttered in the above policy “if at any time when this policy is in force for the full sum assured the life assured, before the expiry of the period for which the premium is payable or before the policy anniversary on which the age nearer birthday of the life assured is 70 which ever is earlier is involved in an accident resulting in either permanent disablement/disability has hereinafter defined or death and the same is proved to the satisfaction of the corporation”. The Corporation is agrees in the case of (a) Disability of Life assured. (b) Death of Life assured. Under such circumstances, in the event of death of life assured, the O.Ps. as per their own commitment clause in the policy itself, have to pay the Additional Sum equal to the sum assured under the policy. Complainant has approached the O.Ps. and furnished all the requisite documents along with claim form. However, O.Ps. have sanctioned only Rs.57,350/- on 14.12.2007 in favour of complainant, out of the above amount, O.Ps. have deducted some amount and paid Rs.54,975/-. Hence O.Ps. have failed to pay an additional sum accident benefits equal to the sum assured in settlement of accidental Death Claims as per the terms of the policy.


    On and often complainant has approached the O.P. and requested to pay the benefits of accidental death as envisaged in the policy, however O.P. sent a letter dated 10.12.2007 asking to submit certain documents. As per the above letter, complainant has furnished documents such as copy of FIR, Death certificate, Post Martum Report, showing the cause of death to satisfy the O.P. to pay benefits of accidental death benefits as per the terms of the policy. Complainant has personally persuaded, insisted O.P. and placed representation, however O.Ps. have went on assuring that his claims will be settled early. Fed up with the attitude of O.Ps., complainant has issued legal notice. In spite of all these persuasion, O.Ps. have failed to settle the claim of complainant. Therefore, there is a deficiency of service on the part of O.Ps. Under these circumstances, it is submitted that complaint may be allowed and direction may be given to O.Ps. as prayed in the complaint.


    3. After registering the case, notices were issued to O.Ps After serving the notices, O.Ps. appeared through counsel and filed Written Statement contending that, it is true that, deceased life assured late Jagannath S/o P. Marappa was issued the policy brg. No.663371258 for sum assured for Rs.50,000/- with the mode of payment being yearly. The date of commencement of risk started from 24.3.2005 under the table and term 14-22. Master Pandu S/o Late Jagannath (Minor) was a nominee with P. Narasappa as appointee. The premium under the policy was paid regularly. It is true that, O.P. has received intimation of death of P. Jagannath, but it is false to say that, the deceased life assured died in an accident of murder.

    The reports of the police envisage that, life assured died of over consumption of alcohol. A police case under Crime No.52/2007 was registered in Netaji Nagar Police Station, Raichur. The policy condition No.10.2 is partly interpreted by the complainant, hence the other part of clause under 10.2(b) interprets to pay an additional sum equal to sum assured under the policy, if the life assured shall sustain any bodily injury resulting solely and directly from the accident cause by outward, violent and visible means. Thus, in this case, complainant claiming the accidental benefit is not applicable and thus is not entitled for the same. It is true that, complainant furnished all the details to the O.Ps. company, thus O.P. has already paid the basic sum assured amounting to Rs.54,975/- on 16.12.2007 along with bonus under the policy. The O.P. corporation shall not be liable to pay the additional sum assured, if the disability or the death of the life assured shall result from the life assured committing any breach of law as per the policy terms. It is absolutely false to say that, complainant visited the office of O.P. several times. There is absolutely no deficiency of service.

    The O.P. has already settled the claim and has made the payment of basic sum assured with bonus. It is submitted that, the life assured died due to over consumption of alcohol as is evidence from the police records but not due to any bodily injury as claimed by complainant. Thus complainant is not eligible to claim the accidental death benefits as the death does not due to accident as explained under clause 10.2(b)(i)(iv) of the terms and conditions of the policy. Hence, claim of complainant is false, vexatious and has filed the complaint with ill intention to obtain the policy amount fraudulently. The claim made by complainant seeking monitory benefits for mental agony, hardship and other benefits are all false and baseless. Under these circumstances, it is submitted that, complaint may be dismissed with costs.

    4. To prove the claim of complainant, himself was filed affidavit by way of evidence who examined as PW-1, documents got marked Exh.P-1 to P-10. O.Ps. also filed affidavit by way of cross of PW-1. Complainant side evidence closed. O.Ps. also filed affidavit by way of evidence, who examined as RW-1, documents got marked Exh.R-1 to R-10. Complainant filed affidavit by way of cross of RW-1. O.Ps. side evidence closed.

    5. Heard the arguments from both sides.

    6. The points that arises for our consideration are;

    (1) Whether there is a deficiency of service on the part of O.Ps?

    (2) What Order?

    7. Our answer to the above points are as under:-

    (1) Yes.

    (2) As per final order for the following;

    : : R E A S O N S : :
    8. Point No:1 :

    We have carefully perused the evidence of complainant, affidavit and documents. Complainant case is that, he is the brother of deceased Jagannath S/o P. Marappa, the policy holder and guardian of minor complainant. The deceased has taken an Endowment Assurance Policy with profits of accidental death benefits vide policy No.663371258. Unfortunately policy holder Jagannath died in an accident of murder. Complainant who is real brother of Jagannath has approached the O.Ps. and furnished all the requisite documents along with claim form. However, O.Ps. have sanctioned only Rs.57,350/- in favour of complainant, out of the above said amount, O.Ps. have deducted some amount and paid Rs.54,975/-. Therefore, O.Ps. have failed to pay an additional sum accident benefits equal to the sum assured in settlement of accidental Death Claims as per the terms of the policy.

    Further it is deposed in the evidence that, Complainant several times requested to O.Ps. to pay accidental benefits under the policy, but O.Ps. have not paid the accidental benefit. Therefore, there is a deficiency of service on the part of O.Ps. He was examined as PW-1 got marked documents Exh.P-1 to P-10 they are Exh.P-1 is FIR, Exh.P-2 is death certificate of deceased Jagannath, Exh.P-3 is letter issued by Sr. Surgeon, Raichur to PSI, Netaji Nagar P.S., Exh.P-4 is P.M. Report, Exh.P-5 is affidavit, Exh.P-6 is discharge voucher, Exh.P-7 is letter issued by O.P. to complainant, Exh.P-8 & P-9 are notices issued by complainant to O.P., Exh.P-10 is insurance policy. On careful perusal of the affidavit of O.Ps. who deposed in their evidence that, deceased life assured Jagannath S/o P. Marappa was issued the policy brg. No.663371258 for sum assured for Rs.50,000/- with the mode of payment being yearly. Master Pandu S/o Late Jagannath (Minor) was a nominee with P. Narasappa as appointee. O.P. has received intimation regarding death of P. Jagannath.

    In this case contention of O.P. is that, life assured died due to over consumption of alcohol as is evidence from the police records but not due to any bodily injury as claimed by complainant. Thus complainant is not eligible to claim the accidental benefits as the death does not due to accident as explained under clause 10.2(b)(i)(iv) of the terms and conditions of the policy. He examined as PW-1 documents got marked Exh.R-1 to R-10 they are Exh.R-1 is policy bond, Exh.R-2 is statement recorded by police, Exh.R-3 to Exh.P-5 are case diary, Exh.R-6 is arrest warrant, Exh.R-7 is report sent to Human rights commission, Exh.R-8 is FIR, Exh.R-9 is panchanama, Exh.R-10 is letter issued by Sr. Surgeon, Dist. Hospital Raichur. On careful perusal of the documents filed by the complainant i.e Exh.P-3 and P-4 are letter issued by Sr. Surgeon, Dist. Hospital Raichur and P.M. Report goes to show that, death of life assured is accidental one. Even on going through the document Exh.R-3 to R-5 which are case diary clearly goes to show that, life assured had accidental death. In the present case complainant has prayed for awarding Rs.20,000/- towards loss of earning, Rs.15,000/- towards mental agony and cost of proceedings & Rs.5,000/- towards other expenses. But these claims are abnormal, therefore without adducing cogent and convince evidence, these amounts cannot be awarded. Though in this case, O.Ps. have taken contention in their evidence and also in their affidavit that, life assured Jagannath died due to over consumption of alcohol. To prove this aspect, O.Ps. have not examined any independent witnesses nor materials placed before this Forum. On going through the evidence of complainant, affidavit and documents, in our considered opinion, there is a deficiency of service on the part of O.Ps., accordingly we answered this point in affirmative.

    9. Point No.2 :

    In view of the discussions made on point No.1, we also answered this point in affirmative. Hence we proceed to pass the following;

    : : O R D E R : :
    Complaint is allowed. Complainant is entitled to recover a sum of Rs.60,000/- with interest @ 6% per annum from the date of filing of this complaint, till the date of realization from O.Ps. Further complainant is entitled to recover a sum of Rs.2,000/- towards mental agony and cost of this proceedings from O.Ps.

  15. #45
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    Default Life Insurance Corporation

    Sri.Gopal Chawan
    S/o Narasing,
    Aged about 52 yers,
    Busienss,
    R/o 5th Ward,
    Sri.Rama Swamy Extenion,
    Hivina Hadagali Town,
    Bellary District.
    (By Sri.D.H.Gazeiyappa Advocate )
    V/s
    OPPONENTS:
    (1) The Zonal Manager ,
    Life Insurance Corporation
    South Central Zonal Office,
    Saifabad, Hyderabad-500 063.
    2. The Divisional Manager,
    Life Insurance Corporation
    Divisional Office,
    Post Box No.43 , “Jeevan Prakash “
    Station Road, Raichur.
    (By Sri.N.Ramadas Advocate )
    3. The Branch Manager,
    Life Insurance Corporation
    Branch Office,
    Harapanahalli.



    JUDGMENT

    The complainant Sri. Gopal Chawan has filed this complaint against the OPs 1 to 3 Usec.12 of the Consumer Protection Act to direct the OPs to settle the claim of the complainant to the extent of Rs.1,01,500/- along with accrued benefits and litigation expenses.

    2. The facts of the case in brief are as follows :-

    Smt. Channamma Chawan was the legally wedded wife of the complainant . The OPs 1 to 3 have issued a policy bearing No.664020336 , dated:30-03-2007 , Plan –Term ( PPT) 180-20 in the name of complainant’s wife, Smt.Channamma Chawan. The said Channamma Chawan has nominated the complainant as nominee . On 17-06-2007 at about 3-50 pm., the policyholder died due to ill health in Bapuji Hospital Davangere. The complainant being nominee has every right to claim benefits under the above said policy . After the death of policy holder, the complainant has submitted claimant’s statement in form “A” and “C” .

    The OPs have repudiated the claim of complainant stating that policy holder has suffered CVA + J2 DM + HTN since two years, prior to proposing for insurance. The OPs are in wrong conception and they have repudiated the claim of the complainant. The said Channamma was in good health prior to proposing for insurance. After verifying the health status of deceased Channamma , the OPs have accepted the proposal and issued policy in the name of wife of the complainant. The OP-2 as per letter dt:2-5-2008 stating that the complainant may send his representation for consideration of claim to OP-1 with in 30 days from the date of receipt of the said letter.


    The complainant ‘s son Sri. Suresh Chawan has issued a letter to OP-1 claiming the benefits under the above said policy. In spite of service of letter issued by the complainant’s son , the OPs have failed to settle the claim of the complainant . The complainant has issued legal notice dt:24-10-2008 calling upon the OPs for disbursement of Rs.1,00,000/- along with other benefits as per the terms and conditions of the policy, within 15 days from the date of receipt of said legal notice. In spire of service of legal notice, the OPs neither replied nor complied with said notice demands .Now the OPs are liable to pay a sum of RS.1,01,500/- i.e. policy amount , legal notice charges , miscellaneous charges . Under the above said facts and circumstances of the case , the complainant has filed this complaint for the above said reliefs.

    3. In pursuance of statutory notice issued by this forum the OPs 1 and 2 entered appearance through their advocate. In spite of notice , the 3rd OP remained absent and it was placed exparte . The 2nd OP has filed its version contending that :-

    The complainant has come forward with a false complaint to make a wrongful gain . He has also suppressed the material facts. Before adverting to mischief played by the deceased. The procedures involved before issuing a policy. Whenever a person want to go for any insurance that person is required to make a proposal .

    As per the proposal that person has to give certain declaration and answer certain questions. The person is also required to give a declaration as to the state of his good health. He has also required to reveal personal information which is in his special knowledge. He is required to do because the corporation can assess the risks involved before accepting proposal. At the same time the person who is giving the proposal is also required to state that in case if any of the information given by him is found to be incorrect , the insurance company is at liberty to repudiate the claim. In the present case , the deceased while giving such a proposal for the policy had declared that she is having a good health . She had also answered the following questions as to her health .

    11 a) During the last five years did you consult a medical practitioner for any ailment requiring treatment for more than a week ?-NO

    c) Are you suffering from or have you ever suffered from Diabetes, Tuberculosis, High blood pressure , Low blood pressure, Cancer, Epilepsy, Hernia, Hydrocele , Leprosy, or any other diseases ?- No.

    i) What has been your usual state of health ? Good.

    As could be seen from the above answers , the declaration given by the deceased was totally false, as could be made out from the records of Bapuji Hospital. The proposal for the policy was made by the proposer i.e. during the year 2007 . The Policy bearing No.664020336 was issued to her on 30-3-2007 .

    When the OPs received intimation that Channamma died on 17-6-2007 and that claim application was also received, the OPs had to start an investigation , because it was an early claim. During the course of investigation it was revealed to the OPs that actually Channamma was admitted to the Bapuji Hospital on:13-6-2007 . At the time , when she was admitted she had complaints of giddiness and vomiting. It was also stated that she has been suffering from Hypertension and was on regular treatment since 2 years . When the OPs came to know that the deceased had not disclosed this fact of herself suffering from Hypertension, they called upon the attending doctors to give certificate .

    The doctor who was attending to her has given a statement stating that her condition was Left Ventricular Angina , type 2 Diabetes Mellitus and Hypertension and that since 2 years she was on medication . If the deceased channamma had disclosed this material fact at the time she proposed for the policy , the OPs would not have ventured to issue a policy to her . Since the same amounts to non disclosure of material particulars. The deceased had committed breach and thus this disentitled to her nominee to receive any amount. Consequently the OPs had no other go except to repudiate the claim of the complainant. The repudiation of the claim by the OPs is legal , lawful and in accordance with prescribed procedures . There is no deficiency in service and the complaint is misconceived. The OPs put the complainant in strict proof of the some of the averments and the allegations made in the complaint . Hence the complaint should be dismissed.

    4. The complainant has filed his affidavit evidence and has

    produced several documents . The 2nd OP –Umesh Shastry , Administrative Officer , LIC of India , Davangere Branch has filed his affidavit evidence for and on behalf of insurance company and the OP-2 has produced several documents .

    5. Both the parties have submitted their written arguments.

    6. Now, the points that arise for consideration of this Forum are as follows:-

    i). Whether there is any deficiency in service on the part of

    the OPs ?

    ii) If so, whether the complainant is entitled to the reliefs as sought?

    iii) What Order?

    7. Our findings on the above points are as follows:-

    i) Point No.1: In affirmative .

    ii) Point No.2: As entitled to the extent stated below.

    iii) Point No.3: See, as per order below:

    for the following:-

    REASONS
    Points 1 and 2 :-

    8. It is undisputed fact that Smt.Channamma Chawan was the wife of complainant. It is an admitted fact that the OPs have issued policy on 30-3-2007 and they insured the life of deceased Channamma in a sum of Rs.1,00,000/- . It is also not in dispute that the said Channamma appointed or nominated the present complainant , her husband as nominee. It is also an admitted fact that on 17-6-2007 at about 3-50 pm., the policy holder Channamma died due to ill health in Bapuji Hospital , Davangere. No doubt as a nominee the complainant is entitled to receive the benefits of the said policy. It is also an admitted fact that the complainant being nominee has submitted claim form , claiming the policy amount. According to the complainant that the health of the deceased Channamma was good prior to issuance of policy or on the date of issuance of policy .

    According to the complainant that after verifying the health status of deceased Smt.Channamma, the OPs have accepted the proposal and issued policy in the name of complainant’s wife. It is also not in dispute that the OPs repudiated the claim of the complainant stating that the policy holder has suffered CVA + J2 DM + HTN since two years, prior to proposing for insurance. According to the complainant that the OPs are in wrong conception and they have repudiated the claim of the complainant. According to the complainant that the OP-2 as per letter dt:2-5-2008 informed the complainant that the complainant may send his representation for consideration of claim to OP-1 within 30 days from the date of receipt of the said letter.

    The complainant ‘s son Sri. Suresh Chawan has issued a letter to OP-1 claiming the benefits under the above said policy and in spite of service of letter issued by the son of the complainant, , the OPs have failed to settle the claim of the complainant . It is not in dispute that the complainant got issued legal notice dt:24-10-2008 , but the OPs neither replied the said notice nor complied with the notice demands . According to the OPs that the said Channamma has submitted proposal for issuance of policy and declared that she is having a good health and she had also answered the following questions as to her health .

    11 a) During the last five years did you consult a medical practitioner for any ailment requiring treatment for more than a week ?-NO

    c) Are you suffering from or have you ever suffered from Diabetes, Tuberculosis, High blood pressure , Low blood pressure, Cancer, Epilepsy, Hernia, Hydrocele , Leprosy, or any other diseases ?- No.

    ii) What has been your usual state of health ? Good.

    9. No doubt within few months from the date of issuance of policy by the OPs, the deceased Channamma died and the death was within 2 years from the date of issuance of policy and the above said circumstances the OPs started investigation as it was an early claim. According to the OPs that during the course of investigation it was revealed to the OPs that actually Channamma was admitted to the Bapuji Hospital on:13-6-2007 and at the time , when she was admitted she had complaints of giddiness and vomiting.

    It was also stated that she has been suffering from Hypertension and was on regular treatment since 2 years . When the OPs came to know that the deceased had not disclosed this fact of herself suffering from Hypertension and they called upon the attending doctors to give certificate and the doctor who was attending to her has given a statement stating that her condition was Left Ventricular Angina , Type 2 Diabetes Mellitus and Hypertension and that since 2 years she was on medication and if the deceased channamma had disclosed this material fact at the time she proposed for the policy , the OPs would not have ventured to issue a policy to her


    10. No doubt the OPs repudiated the claim of the complainant on the ground of suppression of material facts about her health while submitting proposal form for issuing of policy . The complainant has filed his affidavit evidence reiterating the averments and the allegations made in the complaint in his affidavit evidence . Further the 2nd OP has filed his affidavit evidence for and on behalf of the OPs LIC of India reiterating the contention taken by the OP-2 in its version, in his affidavit evidence.

    11. As we have already stated above , the case of the complainant and also the case of the OPs. Therefore it is not necessary to re-iterate the said facts stated by the complainant in his complaint and affidavit evidence and also narrate the contentions taken by the OPs in their version and the affidavit evidence of OP-2 . Now heavy burden is on the OPs to establish that the complainant suppressed the material information with regard to her health . While submitting proposal form for issuance of policy. The OPs must establish that the deceased was suffering from such a disease prior to issuance of policy and that she suppressed the said material information.

    12. The complainant has produced certificate of identity and burial of Smt.Channamma wife of the complainant . From this certificate , it is found that the deceased died on 17-6-2007 . The complainant has produced the claimants statement given under form ‘A’ . The complainant has produced the letter written by the LIC to Suresh Chawan son of the complainant . It is dt:2-5-2008 . According to the OPs that the deceased withheld the material information regarding her health at the time of effecting the assurance with them by giving answers to the questions .

    11 (a) During the last 5 years did you consult a Medical

    Practitioner for any ailment requiring treatment for more than a week ?- NO

    (e) Are your suffering from or have you ever suffered from Diabetes, Tuberculosis, High Blood Pressure , Low Blood Pressure , Cancer , Epilepsy, Hernia , Hydrocele, Leprosy or any other disease ? - NO

    (i) What has been your usual state of health ? Good

    From this letter it is found that , the above answers given by the said deceased Channamma were false as they hold in-disputable proof to show that before issuance of the policy she was suffering from CVA+ J2DM + HTN since two years prior to proposing for insurance. The OPs must established that the deceased was suffering from such a disease prior to issuance of policy. Further they must prove that she was under going any treatment for such a disease continuously since 2 years. If the OPs established that the above said facts then only the complainant is not entitled to any policy amount, otherwise the OP company is bound to pay the policy amount.

    14. The complainant has produced the letter written by Suresh son of complainant to the Zonal Manager LIC of India , South Central Zonal Office, Saifabad, Hyderabad in connection with the policy issued by the OPs in respect of Channamma . The complainant has produced the office copy of legal notice . It is clear from the postal acknowledgements, postal receipts that in spite of service of said notice, the OP’s neither replied nor complied with the said notice.

    15. The OP-2 has produced admission record of Bapuji Hospital, Davangere . In this document , date of admission of deceased shown as 13-6-2007 and discharged on 17-6-2007 . Further from the document issued by Bapuji Hospital Davangere that the said patient Channamma admitted to said hospital with the history of giddiness and vomiting since yesterday i.e. on 12-6-2007. It is mentioned in this history sheet that K/C of MTN on regular treatment since 2 years. Absolutely there is no material on record to show that the patient was taking treatment since 2 years . The OP has not examined the said physician who record the history . The examination of the said doctor who recorded the history is absolutely material to establish or to prove that the said patient was taking treatment since 2 years regularly . The OP-2 has produced the progress sheet right from 13-6-2007 to 18-6-2007 . Further the OPs have produced the doctor treatment chart. Graphic Chart (T.P.R) taken on 13/6 and 14/6 . Urine Sugar Chart and other reports of the test conducted by various departments . It is clear from this document ECG was done in the said hospital and other tests . The OP-2 has produced the report of the blood bank issued by Bapuji Hospital; the result , which reads as follow :-

    HIV I & II NON- REACTIVE ,

    RAPID SPOT TEST ( BIOSING)

    (BY IMMUNOCHROMATOGRAPHIC ASSAY)
    NOTE : NEGATIVE REPORT DOES NOT RULE OUT THE

    POSIBILITY OF SUSPECTED DISEASE.

    HBSAg – NON REACTIVE .
    RAPID SPOT BIOSIGN

    BY ( IMMUNOCHROMATOGRAPHIC ASSAY)
    NOTE : NEGATVIE REPORT DOES NOT RULE OUT THE

    POSIBILITY OF SUSPECTED DISEASE .

    The said reports given by Bapuji Hospital issued only after the admission of the patient to hospital on 13-6-2007 . The said policy was issued on 30-3-2007. She was admitted to hospital on 13-6-2007. These medical reports are issued only after the issuance of the policy .


    16. There is no single document to show that prior to issuance of policy she was admitted to any hospital and taken treatment to any of the disease. There is no material on record to show that the complainant was suffering from such disease since 2 years and was taking any treatment by going to any hospital . There is no material evidence on record to show that before issuance of policy and acceptance of proposal at any time the complainant took treatment by going to any hospital in order to say positively that she was suffering from some disease and was taking treatment regularly . In the absence of any such medical records it is impossible to believe the case of the OP’s that the complainant was suffering from such disease since 2 years prior to acceptance of proposal and issuance of policy and that the complainant suppressed the material information regarding her health.


    16. The OP-2 has produced the medication chart. The OP has produced Ex.R.2 – proposal for LIC’s MONEY PLUS PLAN . The OP-2has produced the identity card issued by Election Commission of India in respect of Channamma . It is found that she was aged about 35 as on 1-1-2002 .

    The OP.No.2 has produced policy issued on 30-3-2007 and deceased insured her life for Rs.1,00,000/- . The OP-2 has produced the letter written by the LIC to the Suresh Chawan s/o Gopal Chawan . In this letter the insurance company informed the said Suresh that “ In case you are not satisfied with the above decision you may send your representation for consideration of your claim to our Zonal Manager at the following address within 30 days from the date of receipt of this letter. It is clear from this letter that the deceased suppressed the material information regarding her health and on account of the said reason they repudiated the claim of the complainant. No doubt the policy of insurance is evidence a contract based on good faith. There is no any documentary evidence to establish that the assured suppressed the material fact about her sickness before purchasing of the policy.


    17. After careful scrutiny of the evidence on record it can be stated that the repudiation of the claim by insurer merely on the ground that the deceased withheld the correct information regarding her health at the time of effecting insurance with corporation is not proper . In a decision reported in AIR 2001 , Supreme Court page 549 wherein head-note (B) , it is held that :-

    (B) Insurance Act (4 of 1938), S.45- Life Insurance Corporation Act (31 of 1956), S.30- Repudiation of claim by insurer-Merely on grounds that deceased had withheld correct information regarding his health at the time of effecting insurance with corporation-Not proper- Matter of repudiation of policy should not be dealt with in a mechanical and routine manner but should be one of extreme care and caution.

    18. In the instant case the insurance company has failed to establish that the complainant withheld the material information by orally and documentary evidence. From the evidence on record that it can be stated that the OPs repudiated the claim without conducting proper investigation . Of course the doctor has issued certificate that the deceased was suffering from several diseases as mentioned in the certificate since many years prior to acceptance of proposal and issuing of policy. The OP-2 has not taken any steps to examine the said doctor. The contents of the said certificate are not duly proved by examining the said doctor . From the evidence on record it can be stated that such alleged pre-existing disease was not known to the patient till she was taken to Hospital, etc. Till the presence of such symptoms like giddiness and vomiting she was not taken to any Hospital. Apart from it the deceased Channamma never hospitalized or treated for any disease or diseases.

    19. There is no material on record to show that the deceased had any knowledge of existence of such disease prior to submitting of proposals or before issuance of policy . In the absence of any such knowledge of existence of such disease it cannot be said that the complainant deliberately suppressed the material information regarding her health. In the instant case, the OP-2 has not produced any moral hazard report .


    20. We have gone through the evidence on record carefully , the OPs have failed to establish that the diseased was suffering from any disease prior to submitting of proposal and issuance of policy . Further the OPs have failed to establish that the deceased had taken any treatment since 2 years by going to any hospital or admitted to any hospital . All the medical records produced by the OPs are all subsequent to acceptance of proposal and issuance of policy. Only on the basis of the said certificate and after enquiry with the doctor, the OPs repudiated the claim of the complainant . There is no any investigation report. Apart from it the OPs have not examined the doctor who issued the said certificate .

    There is no material on record to show at any point of time the deceased admitted to any hospital and taken treatment by going to any hospital in respect of any disease prior to acceptance of proposal and issuance of policy . The repudiation of the claim made by the OPs is not based on any reliable documentary medical evidence. At the out set., it can be stated the OPs have failed to establish that the deceased was suffering from any disease prior to issuance of policy and the deceased knowing fully well suppressed the said material information regarding her health .

    21. In view of the same , the repudiation of the claim is not in accordance with law or the repudiation of the claim by the OPs is illegal. The repudiation of the claim by the OPs are nothing but deficiency in service on the part of the OPs . In view of the same, the OPs are bound to pay the policy amount to the complainant i.e nominee, nominated by the deceased . The OPs forced the complainant to file this complaint without honouring the claim of the complainant caused mental agony to the complainant. After taking in to consideration, all the above said facts and circumstances , we feel it just and proper to direct the OPs to pay a sum of Rs.1,01,500/- to the complainant together with interest at 10 % p.a., from the date of filing of this complaint i.e. 31-12-2008 till realization. In our view the ends of justice would be adequately met with, if the above said compensation is awarded to the complainant .Accordingly, we answer Point No.1 in Affirmative, Point No.2 as entitled to the extent stated below.

    Point No.3:

    22. In view of our findings on Points 1 and 2 the complaint filed by the complainant has to be allowed in part. In the result we pass the following order.

    : O R D E R :

    o The complaint filed by the complainant against the opponents is partly allowed.

    o The OPs are hereby directed to pay a sum of Rs. 1,01,500/- to the complainant together with interest at 10 % p.a., from the date of filing of this complaint i.e. 31-12-2008 till realization .

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