Date of filing      :   24-08-2012

                                                                       Date of order     :   26-08-2015

IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD

                                             CC.249/2012

                      Dated this, the 26th      day of  August  2015

PRESENT:

SMT.P.RAMADEVI                                         : PRESIDENT

SMT.K.G.BEENA                                          : MEMBER

SMT.SHIBA.M.SAMUEL                               : MEMBER

1 K.C.Joseph Alias Jose.K.C, S/o.Chako,                          : Complainants

   Kunnath Veedu, Vellarikundu.Po. 671533

   Kasaragod.Dt.

2 Alice Joseph  alias Tressiamma, W/o.Joseph,

    Kunnath Veedu, Vellarikundu.Po. 671533

   Kasaragod.Dt.

   (Adv.A.K.V.Balakrishnan, Hosdurg)

1 Branch Manager, L.I.C of India,                                                 : Opposite  parties

   New Happy Shopping Complex, Market  Road,

   Nileshwar. 671314.

 2 Divisional Manager, LIC of India, Kozhikkode Division,

    Po. Calicut. 673001.

3 Zonal Manager, LIC of India, South Zonal Office,

   LIC Building, Anna Salai, Chennai. 600002.

   ( Ops 1 to 3 Adv.P.V.Jayarajan, Kasaragod)

                                                                        O R D E R

SMT.K.G.BEENA, MEMBER  

            Complainant’s son late Jijo Joseph had taken a policy from opposite parties covering the risk for Rs.3,50,000/- after paying the premium amount.  Opposite party No.1 issued the policy.  On 10-11-2010 complainant’s son Jijo Joseph was suffering from fever and was treated at PHC Vellarikundu and CMC Vellor but unfortunately Jijo died on 22-01-2012.

2.         Opposite party filed written version stating that the policy was issued under non Medical general scheme i.e. without medical examination of the proposer. Opposite parties accepted the risk under the policy on the basis of the proposal form and declaration  given by the proposer.  Opposite parties perused the Hospital records and found that the deceased suffered from fever on 10-11-2010 and admitted at PHC, Vellarikundu and discharged on 15-11-2010 and for better treatment he was referred to CMC Vellore and admitted thereon 2-12-2010 from there it is revealed that he was suffering from severe   aplastic  anemia for which he had taken treatment from CMC Vellore on 12-10-2010 onwards i.e, before the date of commencement of the policy.  The certificate dated 7-7-2011 issued by Dr. Aby Abraham Department of Hematology, CMC Vellore shows that the deceased has consulted in the OP department on 8-10-2010.  The treatment records of the same hospital reveals that the treatment was started from 12-10-2010 onwards for aplastic anemia which is prior to the date of commencement of the policy and the claim under the policy was repudiated vide opposite parties letter dated 28-09-2011.  The claim was repudiated on the ground of suppression of material facts and informed the same to the complainant vide letter dated 28-09-2011.  As per the appeal of the claimant the claims review committee considered the case once again and detail and implied the decision for repudiation OP (LIC of India) is a statutory body under  the control of Government of India is expected to hold in trust the money collected  as premium from the public and every claim has to be judicially valued to confirm that the payments are made to the genuine claimants only.  In the claim form the occupation is shown as  student.  The immediate cause of death is septic shock and the antecedent cause of death is  severe  aplastic  anemia. The decision of the opposite parties to repudiate the claim made by complainant is taken as per the prevailing rules and regulations pertaining to the policies and based on sound principles and welfare legislations and legally valid.  Hence the complaint may be dismissed.

3.         Complainant filed proof affidavit.  Exts A1 to A13 marked.  Opposite parties counsel submitted that they have no oral evidence.  Exts B1 to B3 marked.  Both counsels filed argument notes.

4.         The question raised for consideration are:

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

              repudiating the claim submitted by the complainant?

            2 If so what is the relief?

            For convenience the issues 1 & 2 can be discussed together.

5.         Issues 1 & 2  :  The complainant’s son Jijo Joseph was taken a new Bhima policy for 16 years on 21-10-2010.  But the assured expired within 3 months of joining in policy i.e on 22-01-2011.  After the death of the assured, Nominee his father K.C.Joseph has given death intimation on 8-5-2011 with death certificate issued by Commissioner Vellore City Municipal Corporation.  Complainant submitted  claim form but opposite party repudiated the same on the ground of cancelment of pre-existing disease.  By this complaint, complainant alleges deficiency in service on the part of opposite parties in repudiating the claim of the complainant.  The complainant in his cross-examination denied the suggestion that the deceased  has prior knowledge  that he is suffering from some serious disease  and in order to obtain the policy he filed Ext.A2 proposal form before LIC.  Once again PW1 vehemently denied the suggestion of opposite parties counsel that his son obtained the Ext.A1 policy by suppressing material facts with an intention to grab some money from opposite parties.   By analyzing the attitude of PW1, in the box and the response for each questions proves that he is innocent  regarding the serious nature of the disease of his son at the time of availing policy. The cause of death shown in Ext.A6 Medical Certificate of  ‘Septic Shock’.  He was suffering from aplastic anemia.  The deceased Jijo Jospeh was only 25 years of age in Ext.A2.  Usually no one will expect a severe disease during that age we cannot expect that  parents  are trying  to grab money assuring the life of son.    In Ext.A3 it is stated that duration of last illness is 2-12-2010.  But the policy is issued on 21-10-2010 42 days after the issuance of policy.  Jijo Jospeh was suffering from fever and was treated at PHC Vellarikundu on 10-11-2010 to 15-11-2010.  If the deceased had prior information regarding any serious illness they would have gone to better treatment in the initial stage itself.  Ext.B1 produced by opposite party only certifies that Jijo Joseph, CMC Hospital No.802305D was seen in the OPD on 8-10-2010.  In Ext.B1, nowhere states the severe nature of the disease of the deceased.  As per Ext.B3, the deceased was referred to CMC Vellore for expert  management. None of these documents states that the deceased was suffering from serious illness prior to the issuance of policy  the actual cause is septic shock while undergoing treatment for aplastic anemia.  No material evidence is produced before the Forum that the deceased has pre-existing serious ailment which can cause death.  aplastic anemia as per Wikipedia and free encyclopedia is a disease in which the bone marrow and the blood stem cells that reside there are damaged. This causes a deficiency of all three blood  cell types.  It is a rare but serious blood disorder that the affected persons bonemarrow doesn’t make enough new blood cells.  Septic shock is what happens as a complication of an infection where toxins can initiate  a full body inflammatory response.  National Commission in United India Insurance Company V Smt. Shavinder Kaur 1986-2002 Consumer  6522(NS) held that there is a no material on record to show that the deceased had a disease at the time of taking the policy and secondly that this fact was within his knowledge.  Inorder to learn on the fact of cancelment, the insurance company has to prove its knowledge which is not proved by any material on record.  This itself is a clear case of deficiency in service.

            Hence the complaint is allowed directing the opposite parties to  pay Rs.3,50,000/- with a compensation of Rs.10,000/- and Rs. 5000/- as cost.  Failing which opposite parties bound to give 12 percent interest for Rs.3,50,000/- from the date of claim application till payment.  Time for compliance is 30days from the date of receipt of copy of this order.

Sd/-                                                                   Sd/-                                                    Sd/-

MEMBER                                                                             MEMBER                                                             PRESIDENT

Exts.

A1. 21-10-2010 Photo copy of New Bhima gold Policy

A2. 21-10-2010 Photo copy of Proposal Form

A3. Photo copy of  Claimant’s Statement

A4. 22-01-2011 Photocopy of Death certificate

A5. 22-01-2011 Photocopy of Medical  Certification of Death: International

A6.22-01-2011 Photocopy of Medical Certificate of cause of death

A7. 11-04-2011 Photocopy of Certificate of Identity and Burial or Cremation

A8. Photocopy of Medical Attendant’s Certificate.

A9. 22-1-2011 Photocopy of Death Summary.

A10.28-9-2011 Photocopy of letter issued by LIC

 Sd/-                                                                                          Sd/-                                                                      Sd/-

MEMBER                                                                             MEMBER                                                             PRESIDENT

Pj/                                                                                Forwarded by Order

                                                                            SENIOR SUPERINTENDENT