State Consumer Disputes Redressal Commission
The Senior Divisional Manager, vs Mother Superior, Sacred Heart ... on 21 March, 2011
Daily Order
First Appeal No. A/09/655 (Arisen out of Order Dated 22/04/2009 in Case No. OP 17/01 of District Idukki) LIC of India Vs. Mother Superior BEFORE: SRI.S.CHANDRAMOHAN NAIR PRESIDING MEMBER PRESENT: Dated : 21 Mar 2011 ORDER Disposed as Allowed
KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION VAZHUTHACAUD, THIRUVANANTHAPURAM.
APPEAL No. 655/2009
JUDGMENT DATED: 21-03-2011
PRESENT:
SMT. VALSALA SARANGADHARAN : MEMBER
SHRI.S. CHANDRA MOHAN NAIR : MEMBER
APPELLANTS
1. The Senior Divisional Manager,
LIC of India, Divisional Office,
Ernakulam, Kochi - 11.
2. The Zonal Manager,
LIC of India, Southern Zonal Office,
Anna Sali, Chennai - 2.
(Rep. by Adv. Sri. G.S. Kalkura )
Vs
RESPONDENT
Mother Superior, Sacred Heart Hospital,
Paynkulam, Myloombu P.O., Idukki, Pin - 685 584.
(Rep. by Adv. Sri. S. Reghu Kumar)
JUDGMENT
SHRI.S. CHANDRA MOHAN NAIR : MEMBER This appeal is filed by the opposite parties in CC No. 17/2001 of CDRF, Idukki. By the impugned order dated 22-04-2009, the appellants are under orders to pay to the complainant the sum of Rs. 50,000/- with 12% interest from the date of complaint till payment which is the insurance amount of the deceased Sister Clemencia as per policy No. 770900995. The appellants are also under directions to pay Rs. 2,000/- as cost to the complainant.
2. The case of the complainant before the Forum is that she is the nominee of Sister Clemecia who had an insurance policy with the opposite parties and that the insured passed away on 29-12-1994 due to heart attack. The complainant has approached the opposite parties for getting the insurance amount of Rs. 50,000/- and it is the case of the complainant that the opposite parties denied the claim and it was only on reconsideration that the opposite parties agreed to pay a sum of Rs. 25,000/- on ex-gratia basis. The complainant submitted before the Forum that she is entitled to get the full amount of Rs. 50,000/- with interest, compensation and costs.
3. Resisting the complaint the opposite parties filed version wherein it was stated that Sister Clemencia had taken an insurance policy from the opposite parties for a sum of Rs. 50,000/- and the policy had lapsed due to nonpayment of premium on 14-09-1992 onwards. However, the insured had revived the policy after submitting the personal statement regarding health and the policy was revived. The opposite parties submitted that the insured was admitted in Holy Family Hospital, Muthalakkodam, Thodupuzha and was in treatment as inpatient from 08-05-1983 to 16-05-1983 and was admitted again for a week in March 1989 and then again from 12-05-92 to 18-05-92 and the treatment was for multiple fibroid uterus and had done a total abdominal hysterectomy in 1986 and also that she had undergone treatment for asthmatic bronchitis and its connected diseases. It was the contention of the opposite party that the policy was revived suppressing material facts and within a short time of revival the complainant had passed away. However, on a reconsideration of the claim the opposite parties were willing to pay a sum of Rs. 25,000/- as ex-gratia payment which the complainant did not accept. Thus, contending for the position that there was no deficiency in service, the opposite parties prayed for the dismissal of the complaint.
4. Evidence consisted of the oral testimony of PWs 1 and 2 and Exts. P1 to P6 on the side of the complainant and the oral testimony of DW1 and Exts. R1 to R21 on the side of the opposite parties.
5. Heard both sides.
6. The learned Counsel for the appellant vehemently argued before us that the Forum below had failed in appreciating the real facts of the case in its correct perspective. It is his very case that the Forum ought to have relied on Exts. R1 to R21 produced by the opposite parties and also that the Forum ought to have appreciated the facts that the complainant had concealed vital information about her health while giving the statement of health for reviving the policy. The learned Counsel has relied on Ext. R1 and argued before us that the Forum has given a total goby to the said evidence while passing the impugned order. The learned Counsel has also attacked the percentage of interest awarded by the Forum below and it is his very case that the Forum ought to have dismissed the complaint. He has also relied on Section 45 of the Insurance Act 1938 and argued before us that the opposite parties/appellants have discharged their burden by producing the treatment records of the hospital where the insured was treated on different occasions.
7. On the other hand, the learned Counsel for the respondent/complainant supported the findings and conclusions of the Forum below and submitted before us that it was the agent who had filled up the proposal forms of 8 persons including the insured and the insured had not concealed any material facts to the questions made by the agent. He has also submitted that the agent and the Development Officer came to the hospital where the insured was working and it was at the instance of the agent that the proposal for revival was filled up and the insured had not suppressed any of the information regarding her health. He has relied on the decision of the Hon'ble Supreme Court in Harshad J Shah and Another Vs LIC of India and others reported in 1997(5) SCC 64 and argued before us that the agents are expected to render all reasonable assistance to the claimants in filling claim form and also that the agents are expected to guide the policy holders while filling the forms and get all the details from them while filling the forms. He has also argued that the action of the opposite parties in expressing their willingness to pay Rs. 25,000/- on ex-gratia basis would show that the opposite parties were at fault and the complainant was entitled to get the full amount as per the policy. Thus, he argued for the position that the appeal is to be dismissed with compensatory cost.
8. On hearing the learned Counsel for the appellants, respondent and also on perusing the records, we find that it is the admitted case of both sides that the complainant/respondent had taken an insurance policy from the oppose party and due to lapse of the policy the same was revived on presenting the statement of health regarding the health conditions of the insured and also that the policy was revived on the basis of the proposal form. It is also found that the complainant has claimed the amount consequent to the death of the insured as she is the nominee of the deceased Sister Clemencia, the insured. The learned Counsel for the appellants placed much reliance on Ext. R1 which is the proposal form wherein the statement of health is given in column 11 - personal history. On an appreciation of the said documents marked as Ext. R1, we find that the insured had answered 'no' to the questions
(a) During the last five years did you consult a Medical Practitioner for any ailment requiring treatment for more than a week?
(b) Have you ever been admitted to any hospital or nursing home for general check-up, observation, treatment or operation? (c) Have you remained absent from place of work on grounds of Health during the last 5 years? (d) Are you suffering from or have you ever suffered from ailments pertaining to Liver, Stomach, Heart, Lungs, Kidney, Brain or Nervous system?
The learned Counsel for the respondent would argue that these columns were filled up by the agent. Even if admitting that it was filled up by the agent, it is to be noted that the insured is not an illiterate woman and that it was without knowing the contents in the proposal form that she had signed the proposal for reviving the policy. On a perusal of Ext.R19 series, we find that the insured had been treated on various occasions in Holy Family Hospital, Muthalakkodam, Thodupuzha which the complainant had not disputed. It is also to be found that the revival was on 12-12-1994 and the insured had died on 29-12-94 ie, within a short time after reviving the policy. We find that the complainant has answered 'no' to the important questions regarding her treatment within 5 years prior to the date of revival. It is evident from Ext.R19 series that the complainant was admitted and treated for asthmatic bronchitis and multiple fibroid uterus etc. We find force in the arguments of the learned Counsel for the appellant that the insured had suppressed the material facts regarding her treatment while reviving the policy. However, it is also seen that as per Ext.R21 the opposite parties have offered the sum of Rs. 25,000/- as ex-gracia payment and it is seen that the sum was not paid so far. We are of the opinion that the opposite parties/appellants are liable to pay the said amount with interest from the date of complaint till date of payment. The Forum below had awarded 12% interest for the insurance amount. However, we feel that interest at the rate of 9% would be sufficient to meet the ends of justice. The cost awarded by the Forum below is sustained.
In the result, the appeal is allowed with the modifications indicted above. Thereby the appellants are liable to pay Rs. 25,000/- with 9% interest from the date of complaint till the date of payment with cost of Rs. 2,000/-. In the facts and circumstances of the present appeal, the parties are directed to suffer their respective costs.
S. CHANDRA MOHAN NAIR : MEMBER VALSALA SARANGADHARAN : MEMBER Sr. [ SRI.S.CHANDRAMOHAN NAIR] PRESIDING MEMBER