::BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AT BIDAR::
C.C. No.14/2017.
Date of filing: 13.02.2017.
Date of disposal: 31.03.2018.
P R E S E N T:-
(1) Shri. Jagannath Prasad Udgata, B.A., LL.B.,
President
(2) Shri. Shankrappa (Halipurgi),
B.A.LL.B.,
Member.
COMPLAINANT/S: 1. Smt. Shantamma W/o Late Veerayya Swamy,
Age: 45 years, Occ: household,
R/o H.No.19-5-66,
Raghavendra Colony Naubad Bidar.
(By Sri. D.M.Swamy, Adv.)
VERSUS
OPPONENT/S: 1) The Manager LIC of India,
LIC Building Near Railway Station
Jeevan Beema Road, Bidar.
2) The Senior Divisional Manager,
LIC of India Jeevan Prakash,
Station road Raichur.
(By Sri. Vijay Udgir, Adv.)
:: J UD G M E N T ::
By Shri. Jagannath Prasad Udgata, President.
The present complaint is by a bereaved widow, u/s 12 of the Consumer Protection Act, 1986, alleging deficiency of service by the opponents.
The contents of the complaint is as follows:-
2 That, her late husband by name Veeraya, during his life time had obtained two policies from the opponents bearing Nos.6662911220 and 666300396 each for a sum of Rs. 2,00,000/- on 19.04.2015 and 15.07.2015 respectively by paying the regular premiums.
3. That, the late policy holder aforesaid died on 16.11.2015 while under treatment at Government Hospital, Bidar, wherein he was admitted for stomach pain and other accessory complaints. Consequence upon the death, the complainant filed claim with opponents on 12.08.2016, but the same was refuted by the laters on 08.11.2016, on the ground that, the deceased policy holder was alcoholic since thirty years and he has suppressed such material facts from the insurer.
4. The opponents, upon receipt of Court notice, have entered appearance through their counsel and have filed versions, stating that, at the time of the submission of proposals, the deceased proposer was not truthful, and further that, the papers obtained from BRIMS, belie his claim of good health and hence u/s 45 of the Insurance Act, they are competent to deny the claim (s) of the complainant.
5. Both sides have led their evidence, produced documents trying to justify their respective claims and also written arguments. The parties have also filed rulings relied upon by them rendered by the higher foras described here afterwards.
6. Considering the rival contentions of the feuding parties, the following points arise for our consideration:-
- Does the complainant prove that, there has been a deficiency of service in the part of the opponents?
- Do the opponent prove that, they were justified in repudiating the claim?
- Does the complainant prove that, she is entitled for the relief (s) claimed?
- What order?
7. Our answers to the points stated above are as follows:-
Point No.1. In the affirmative.
Point No.2. In the negative
Point No.3. Affirmative in part.
Point No.3. As per the final orders owing to the following:-
:: REASONS ::
8. Point No.1&2- The opponent L.I.C. has been well aware of the fact that, two policies were obtained by the late policy holder over a period of two months for identical sum. The agent or the representative or the field officer while closing the business at the relevant time, must have observed the external health conditions of the proposer at those times. If at all cirrhosis of lever was existing at the time of proposal, it would depict an unusual appearance of the individual. A non medical man may not be in a position to observe and consider an alarming health condition, but obtainment of policies in a quick succession should have caused a bell of alarm to sound in the minds of the officers of the corporation, which has not happened.
9. Next, the opponent corporation, has relied on the medical papers allegedly provided by the medical superintendent, BRIMS teaching hospital, Bidar.
10. While the document at Annexure-R2 is an admission slip, evidencing the admission of one Veeraya Swamy on 15.11.2015, Annexures R1 and R3 are the treatment records and death certificates respectively. Prima facie, we are at loss to understand, how at all such documents could be provided to a third party (L.I.C.) ignoring the ethics of patient- doctor fidelity. Is not a violation of Hippocrates oath taken by the doctors? A million dollar question itself.
11. Next, we observe document Annesure-R3 is only partially legible. There in, the cause of death (immediate) is cirrhosis of liver. Thereafter another two causes of death has certified as pleural effusion (affliction of lungs) and Alcoholism. The next cause is not legible to naked eye. This document is purported to have been originated in BRIMS. Per centra, the certificate of death produced by the complainant vide Annexure-D, describes the condition of the patient at the time of admission as (a) Breathlessness and (b) Distension of abdomen. It has been further mentioned cirrhosis of liver as the cause of death. There is no mention of alcoholism in this document. Now the question rises, as to how some doctors could observe the alcoholic syndrome and others could not. Who revealed this information to whom and at what point of time?
12. There after, a through glance into the contents of the document relied upon by the opponents placed at Annexure R2 reveal still surprising entries in the case sheet. We observe, the entries are not signed by any doctor. Even though K/C/o (Known case of ) alcoholic liver disease is mentioned, together with distension of abdomen and breathlessness since 10days, there is no mention of pleural effusion any where in the case sheet. Much before the investigation of LFT (Liver Function Test-Comprising of Bilirubin test, S.G.O.T., S.G.P.T. and alkalyne phosphate) as suggested at the second page of the case sheet, purely on guess, it was inferred that, the patient admitted was suffering from alcoholic liver disease. Cannot the liver be afflicted due to attack of Hepatitis- A, B, C, or E viruses? Where is the proof of alcoholism?
13. Strangely, the opponent has not preferred to examine any doctor from BRIMS, Bidar to substantiate the claim of cirrhosis of liver due to chronic alcohol consumption.
14. The complainant has submitted before us a case law of the Hon’ble National Commission reported in II (2009) CPJ 186 (NC)-L.I.C. of India and Anr v/s Kamla Devi, in which it has been held as follows:-
Consumer Protection Act, 1986 Section 21 (b) Insurance Suppression of material facts Contention, Insured consuming alcohol for a decade in high doses Bed Head Ticket of hospital relied by insurer Statement of history of deceased not given by insured, as insured admitted in unconscious state a certificate given by doctor indicating how he elucidated information Record produced cannot be relied upon as admission of Insurer held liable under policy.
15. Next, the complainant has also submitted a copy of judgement delivered by us in C.C.No.53/2015 (D.O.D.21.11.2016) in which discussing various case laws as mentioned underneath we had passed an award in positive.
i. 1(2012( CPJ 378 (RAJ)
Consumer Protection Act, 1986 Sections @(1)(g) 14(1)(d), 15 Insurance (Life) Suppression of material facts Death of insured claim repudiated on ground of concealment of previous disease Alleged deficiency in service District forum allowed complaint Hence appeal A common man is not supposed to know all the niceties and technicalities of law once accepting the premium and having entered into agreement without verifying the facts, Insurance Company cannot wriggle out of liability merely by saying that contract was made by misrepresentation and concealment Insurance policies should not be issued and repudiated in such casual mechanical manner Policy entails liability on both sides It is rather exploitation of customer and more or less fraud on public respondent has been put to great inconvenience in contesting present appeal Costs of Rs.5,000 awarded Impugned order upheld.
ii. 2013(1) CPR 150 CPR 150 (DEL).
Once Insurance Company has accepted proposal it cannot go behind the same even if proposal is in violation of criteria mentioned in insurance policy.
iii. IV (2008) CPJ 89 (NC)
Consumer Protection Act,1086- Section (1)(g) and 2(1)(b) Insurance Repudiation of claim Suppression of disease at time of revival of policy alleged No document produced in support of allegation History recorded in hospital’s bed ticket, not to be treated as evidence as doctor, recording history not examined Suppression of disease not proved Insurer liable under policy.
iv. III (2009) CPJ 91 (NC)
Consumer Protection Act 1986 Section @(1)(b).
Insurance suppression of material facts Claim repudiated Contention, insured suffering from Hypertension, L.S. Hemiplesia, Diabetes, Inter Cerebral Haemorrhage, not disclosed complaint allowed by Forum Order set aside in appeal relying upon report of Sr. Consuldtant doctor Hence revision Affidavit of concerned doctor filed Report of Sr. Consultant remains unsubstantiated, unproved State Commission erred in relying upon unproved document order of Forum restored.
16. The complainant has also submitted another decision of the Hon’ble National Commission reported in III (2009) CPJ 91(NC) Rasheeda Khatoon V/s L.I.C. of India, in which the ratio decedent is as follows:-
Suppression of material facts Claim repudiated Contention, insured suffering from Hypertension, L.S. Hemiplesia, diabetes, Inter Cerebral haemorrhage, not disclosed Complaint allowed by Forum. Order set aside in appeal relying upon report of Sr. Consultant doctor Hence revision Affidavit of concerned doctor not filed Affidavit of concerned doctor not filed Report of Sr.Consultant remains unsubstantiated, unproved State commission erred in relying upon unproved document Order of Forum restored.
17. As a whole, we infer that, the documents relied upon by the opponents are not complementaries to each other, obfuscated, not proved by any cogent evidence and it would be unwise to place any reliance upon them.
18. It may further be seen, the deceased proposer was Veeraya, 48 years, whereas the hospital records pertain to Veeraya Swamy, aged 50 years.
19. We may further mention here that, the Hon’ble Apex Court in a far fetching decision reported I III (2007) CPJ-3 (S.C.) united India Ins. Co. Ltd. v/s Great Eastern shipping Co. Ltd. has been pleased to hold that “where two views are possible, the one which favours the consumer should be accepted”.
20. This dicta, binds us under Article 141 of the Constitution of India.
21. We therefore hold that, by refuting the claim Settlement, the opponents have indulged into deficiency of service and hence we answer point No.1 & 2 accordingly.
22. Point No.3. Having proven her entitlements by the documents submitted and our inference of deficiency of service practised by the opponents, the complainant deserves to be awarded as per her prayer and hence, we proceed to pass the following:-
::ORDER::
- The complaint is allowed..
- The opponents are hereby jointly and severally directed to pay a sum of Rs.4,00,000/- (total sum assured in two policies bearing Nos. 666300396 and 666291220) with all accrued benefits with 6% interest per annum, calculated from the date of claim i.e. 12.08.2016, till the date of realisation;
- The opponents are further saddled with a compensation of Rs.5,000/- and a further sum of Rs.5,000/- towards litigation expenses.
- Four weeks time granted to comply this order.
(Typed to our dictation then corrected, signed by us and then pronounced in the open Forum on this 31st day of March 2018).
Sri. Shankrappa H. Sri. Jagannath Prasad
Member. President.
Documents produced by the complainant
- Annexure. A- Copy of policy No.666300396.
- Annexure. B- Copy of Policy No.666291220.
- Annexure. C– Copy of repudiation letter of the opponents
date: 08.11.2016.
- Annexure. D— Copy of certificate of hospital treatment.
- Annexure. E – Copy of claimants’ statement. (claim application).
- Annexure. F – Death certificate in original.
- Annexure. G - Copy of Medical attendants’ certificate.
- Annexure. H- Original letter of opponents date. 26.05.2016.
Document produced by the Opponents.
- Annesure.R1- copy letter of Medical Superintendent, BRIMS
teaching hospital, Bidar date: 22.06.2016 together
with copies of case sheet. - Annexure.R2- Copy of admission ticket.
- Annexure.R3- Copy of Medical certificate of cause of death.
NIl
Witness examined.
Complainant.
- P.W.1- Smt. Shantamma (Complainant).
Opponent No.1
- R.W.1- Sri. K. Parashurama, officer of L.I.C. and authorised
signatory.
Sri. Shankrappa H. Sri. Jagannath Prasad
Member. President.
