LIC OF INDIA vs M.SUNITHA

FA. No. 579/97 is filed by the opposite parties 1 to 3 in CD. No. 189/95 and FA. No. 117/98 is preferred by the complainant in CD. No. 189/95.

THE complainant in the C.D. is Smt. M. Sunitha w/o late M. Ramesh. Her case in the CD is as follows : THE husband of the complainant took Jeevanmitra Policy (double cover endowment plan) bearing No. 642160781 for Rs. 25,000/- on 23.11.1991. Under Jeevanmitra policy, double the sum insured is given in case of accidental death of the insured. As per the policy Smt. Sunitha was the nominee, the subscription was deducted by the employer i.e. University of Hyderabad, at the source and paid to the opposite parties. THE maturity date for the said policy was 23.11.2016. THE insured, Sri M. Ramesh died on 8.7.1993 due to cardio-respiratory arrest. THE complainant submitted the legal heir certificate issued by the Mandal Revenue Officer, Serilingampally, Ranga Reddy District and the death certificate was issued by the Registrar, Births and Deaths, Circle-6, MCH, Hyderabad. She intimated the death of her husband to the opposite parties and later the claim form duly filled in. However, the opposite parties repudiated the claim through their letter dated 24.3.1995 (Ex. A7) on the ground that the deceased had suppressed the fact that he was suffering from Diabetes and Hypertension since a long time prior to his proposal for the policy. According to them in his application dated 6.10.1991 he had given wrong answers to question Nos. 11(a)(e) and (i). THEy also produced the discharge summary (Ex. B2) of Medwin Hospital wherein it was mentioned that he was a chronic diabetic since 12 years, that he was readmitted in May, 1991 in Medwin Hospital "with severe ''azotaemia'' and received three ''haemodialysis'' and that he had "last dialysis on 17.5.1993 on irregular dialysis". The opposite parties 2 and 3 filed their counter and contested that it was not a consumer dispute. They agreed that insurance policy was issued in the name of late M. Ramesh and M. Sunitha was the nominee under the policy. However Ramesh died on 8.7.1993 and thus the claim had arisen after one and a half years. Since it was an early claim they enquired into the genuineness of it and came to the conclusion that the deceased suppressed the material information under questions 11(a)(e) and (i). They also filed the proposal form dated 6.10.1991, original policy bond, claim forms B and B(i), and discharge summary issued by Medwin Hospital. They reiterated that the deceased was a chronic diabetic patient which fact he suppressed in the original proposal and thus violated the principle of utmost good faith. The insured underwent treatment in Medwin Hospital. Opposite party No. 4 was doctor of Medwin Hospital at the relevant time and he was a dis-interested party and hence his discharge certificate should be accepted without questioning it. They contended that on these grounds the complaint should be dismissed and the question of payment of Rs. 50,000/- with 24% per annum interest did not arise.

The opposite party No. 4, Dr. M.A. Jaleel, Junior Resident Medical Officer, Medwin Hospital in his affidavit stated that whatever he stated was based as per the records of the Medwin Hospital in this particular case. He contested that the CD was not maintainable and that it was barred by limitation because it was not filed within two years from the date of demise and hence it should be dismissed. He further mentioned that as per the case sheet late M. Ramesh was in Medwin Hospital once from 8.5.1993 to 18.5.1993, and then during the periods 17.6.1993 to 6.7.1993 and on 7.7.1993 to 8.7.1993 and he died on 8.7.1993". Dr. M.A. Jaleel mentioned further that "as per the case sheet of deceased M. Ramesh in the Medwin Hospital, late M. Ramesh husband of Mrs. M. Sunitha when admitted in this hospital in the month of May, 1993 as per the case sheet the patient i.e. the deceased was suffering with Oedema of feet for one and half years duration and diabetes mellitius for the last 12 years". He mentioned that "as per the records it is submitted here that the patient was suffering with long standing diabetes mellitius and its complications such as diabetic nephropathy with end stage renal disease, diabetic retinopathy and diabetic foot".

BOTH complainant and the opposite parties submitted exhibits in support of their respective cases. Exhibits A1 to A7 were filed by the complainants and Exhibits B1 to B6 were filed by the opposite parties. After going through all the materials presented, including affidavits of complainants, opposite parties 2 and 3 and opposite party No. 4, the District Forum observed "Ex. B2 states that in May, 1991 he was admitted and if that is correct, in Ex. B4 column No. 10 it must have been categorically mentioned and this Ex. B4 also was issued by perhaps Medwin Hospital doctor. Opposite party No. 4 signed by Mr. M.A. Jaleel". And further "these things definitely go to throw a lot of doubt about the entries and their veracity in Exs. B1, B2, B3 and B4" Forum therefore concluded that the opposite party had not provided any proof that the deceased was treated in Medwin Hospital, prior to "May, 1993" and particularly in "May, 1991" before taking the policy. It therefore directed the opposite party to pay Rs. 25,000/- to the complainant with 18% interest from the date of death namely 8.7.1993 till the time of payment. The District Forum also awarded Rs. 2,000/- as costs with 18% per annum interest from 1.4.1997, till the date of payment. In their appeal and subsequently in the arguments appellant/opposite party stressed that Ex. B2 i.e. Discharge Summary of Medwin Hospital was filed by the complainant herself and she did not deny the facts mentioned therein. They also filed the original policy (Ex. B5) and confidential medical examiners report Ex. B6. Exs. B3 and B4 are in fact original of claim form and certificate of hospital treatment. Ex. B2 dated 6.7.1993 is discharge summary issued under the signature of resident doctor who is no other than the fourth opposite party in the CD. In Ex. B2 it is noted : "Readmitted with history of pain abdomen. A case of diabetic nephropathy retinopathy, hypertension with end stage renal disease. In May, 1991, admitted with severe azotaemia and received 3 haemodialysis. Last dialysis on 17.5.1993 on irregular dialysis". This is the one they laid stress on. The same discharge certificate under Investigations mentions "investigations conducted on 17.6.1993, 26.6.1993, 17.6.1993, 18.6.1993 and 5.7.1993". It did not have any investigation report of May, 1991. In the treatment column it was stated : "Kept under dialysis bi-weekly left 4th toe amputated I. Tab. Patient was taken up for emergency dialysis and received twice a week dialysis during his stay in the hospital. Patient''s left 4th toe amputation was done under L.A. A-V fistula was made on forearm under I.A." (no date mentioned). Then there is the discharge advise, drugs and injections prescribed. This was just 2 days prior to the death of the patient on 8.7.1993, when this discharge certificate was given. Ex. B3 Column 4(a) shows that primary cause of death as "cardio respiratory arrest" and secondary cause "Diabetic Nephropathy (ESRD - end stage) Clause "C" mentions that he had been suffering from this disease from one and half years. Clauses ''d'' and ''e'' show that the symptom as ''"Oedema feet", since one and half years back and column (f) shows when he first consulted Doctor for his illness and the date was mentioned as 8.5.1993 and lastly column (g) shows answer to the question "Did you attend him during the whole of its course ?" The answer is ''yes''. That means from 8.5.1993 the patient had been under treatment till his death.

AFTER perusing the record in this case, we find that there was no dispute that the deceased was treated at Medwin Hospital on the dates from 8.5.1993 to 18.5.1993, 17.6.1993 to 6.7.1993 and from 7.7.1993 to 8.7.1993, when he expired and that the primary cause of death was ''cardio respiratory arrest''. There was also no dispute that he had taken the insurance policy on 23.11.1991 for Rs. 25,000/- which was a double benefit endowment plan. It was also agreed that in the said policy Smt. M. Sunitha, his wife, was the nominee. The subscription was deducted by the employer and paid regularly and there was no lapse. However there was dispute regarding suppression of fact by the policy holder at the time of taking policy, while the appellant/complainant was confident that there was no suppression and that the deceased suddenly became ill in the month of May, 1993 for the first time. Appellant/opposite parties repudiated the policy on the ground that he suffered from diabetes militius for the past 12 years and therefore he had Oedema of the feet for one and half years prior to his death and one of his toe had to be amputated and that the secondary cause of death was diabetic nephropath and cardio respiratory arrest was due to this secondary cause. On this ground they repudiated the claim of the appellant/complainant. In the affidavit of opposite party No. 4 it was mentioned that the patient was admitted only three times from 8.5.1993 to 8.7.1993 and there was no mention of any prior admission or treatment in 1991. However in Ex. B2 the discharge summary of Medwin Hospital dated 6.7.1993 signed by Resident Doctor (O.P. 4) it was mentioned that the patient was admitted in May, 1991 with "severe azotaemia and received three haemodialysis". Between 17.6.1993 to 5.7.1993 under ''course in the hospital and out line of treatment'' it was mentioned that left 4th toe was amputated and the patient was kept under dialysis bi-weekly during his stay in the hospital. He was readmitted on the very next day on 7.7.1993 and died on 8.7.1993. We however notice that Ex. B2 on the basis of which the claim was rejected was available immediately after the death of M. Ramesh but policy was rejected on 24.3.1995 i.e., after more than one year and eight months. We have to therefore consider whether there was any suppression of material fact by the insured at the time of taking the policy and whether appellant/opposite party was justified in repudiating the claim. If not then is there any deficiency of service by appellant/opposite party and they have to pay the insurance amount to the appellant/complainant. The Counsel for the appellant/complainant (FA. No. 117/98) based his argument on the fact that the complainant and her husband being illiterate, proposal form must have been filled by some other person who would not have explained all the clauses in the policy. Secondly such a young person could not have suffered from diabetes and that prior to May, 1993 Ramesh was never treated in Medwin Hospital and that in support of earlier haemodalysis in May, 1991 no hospital records were produced. The learned Counsel relied on the decisions of the National Commission in Anthony Rebello v. New India Assurance Co. Ltd., II (1996) CPJ 92 (NC), and Hotel Southern (P) Ltd. v. National Insurance Co. Ltd. & Ors., III (1995) CPJ 54 (NC), wherein it was held that the opposite party could not conclusively prove that the insured was suffering from diabetes at the time of proposal and that he was aware of it at that time, even if he was having that disease. On behalf of the Insurance Company, it was argued that suppression of material facts regarding health status of the policy holder would vitiate the policy. Hence there was no deficiency in service. They relied on the decisions of the National Commission in B.P.L. Ltd. v. Mrs. Regina Chritobel & Anr., and Mrs. S. Regina Chritobel & Anr. v. Sunder Home Appliances & Anr., I (1996) CPJ 122 (NC); United India Insurance Co. Ltd. v. Biman Krishna Bose, II (1995) CPJ 62 (NC); Marketing Manager, LIC of India v. Smt. S. Vijaya; and Branch Manager LIC of India & Ors. v. Smt. Vatikala Salimi, in support of their argument.

AFTER carefully perusing the material on record, we are satisfied that the insurer was well justified in repudiating the claim of the complainant and that the repudiation was not arbitrary or unreasonable and that there was no deficiency in service on its part. The Discharge Summary proves that the insured was suffering from diabetes several years prior to his death on 8.7.1993 due to ''Cardiac Arrest''. Moreover he was admitted with ''end stage renal failure'' ''ulcer in the left toe'' which was ''amputed'' subsequently and was suffering from ''odema'' in the left foot for one and half years. The District Forum erred in concluding that there was no history of illness prior to May, 1993, that opposite party faulted in repudiating the policy and hence there was deficiency in service.

IN the result, the order of the District Forum is set aside and the CD is dismissed. FA. No. 579/1997 is, therefore, allowed and FA. No. 117/98 is rejected. No costs. Appeal allowed.