BEFORE THE A.P STATE CONSUMER DISPUTES REDRESSAL COMMISSION AT HYDERABAD
CC 214 of 2014
Between:
Smt. M. Krishna Veni
W/o. Late Mallidi Srinivas Reddy
D.No. 2-60, Ramavanam
Anaparthy Mandal
East Godavari Dist. A.P. Complainant
And
1) AVIVA Life Insurance Company Ltd.
Rep. by its Manager
AVIVA Towers, Sector Road,
Opp: Golf Course, DLF Phase-V, Sector-43
Gurgeon, Haryana-122 003.
2) AVIVA Life Insurance Company Ltd.
Rep. by its Branch Manager
3rd Floor, Isnar Saryasree Complex
Dwaraka Nagar, Visakapatnam
Andhra Pradesh-530 016. Opposite Parties
Counsel for Complainant: M/s. K.R.R. Associates
Counsel for Opposite Parties: M/s. Naspuri Mahender (Not appeared)
Oral Order: 19/08/2015
(Per Honble Justice Noushad Ali, President)
1) This complaint is filed claiming Rs. 30 lakhs towards death benefits under the insurance policy issued by the Opposite Parties with interest to refund the premium amount paid on the policy and to award compensation of Rs. 1 lakh towards mental agony and costs.
2) Complainant is the wife of Mallidi Srinivas Reddy who obtained a life insurance policy during his life time from the Opposite Parties AVIVA Life Insurance Company Ltd., for an assured sum of Rs. 30 lakhs. The policy term was 30 years commencing from 6.5.2013. On 14.9.2013, the Insured was hit by a lorry driven in a rash and negligent manner and sustained severe multiple injuries. The police registered a crime on 15.9.2013 against the lorry driver and filed charge sheet against him for the offence u/s 304A of IPC.
3) The insured was shifted in an unconscious state to a hospital by name Safe Hospital, Kakinada by one of his relatives. From there he was taken to Medi Care Hospital, Rajahmundry on the same day. On 5.10.2013, he was shifted to another hospital, Navin Emergency Hospital, Rajahmundry as the insured had electrolytes imbalance. He was shifted back to Medi Care Hospital, Rajahmundry on 9.10.2013. The insured was re-admitted into Navin Emergency Hospital on 19.10.2013 with severe breathlessness and metabolic acidosis and shock etc. He died on 21.10.2013.
4) The complainant being the wife and nominee of the insured claimed the insurance amount from the Opposite Parties. The claim was repudiated under letter dt. 23.12.2013 on the ground that the policy was obtained by suppressing the health status of the insured. The insured was said to be diabetic and a pulmonary tuberculosis patient since March, 2013, and obtained the policy in the month of May, 2013 by suppressing the said fact. The Opposite Parties refused to review their decision and finally rejected the claim under letter dt. 26.6.2014. Therefore, the complainant has filed the complaint in question urging that the repudiation is not sustainable.
4.1) In her complaint, the complainant has averred that the deceased was hale and healthy prior to the accident, and he did not take any treatment for the ailments before his death. There was no suppression of any material fact as alleged by the Opposite Parties. She has further averred that the death was caused due to the accident and not due to diabetes or pulmonary tuberculosis. Therefore, the claim cannot be repudiated as the alleged ailments have no nexus to the death.
5) The Opposite Parties did not choose to deny the averments made in the complaint by filing their written version. However, they filed their evidence affidavit denying their liability on the same lines as mentioned in the repudiation letter dt.23.12.2013 that the policy was obtained by suppressing the ailments being suffered by the insured at the time of obtaining the policy.
6) Ex. A1 to A23 are marked on behalf of complainant andExs. B1 to B9 are marked on behalf of the Opposite Parties.
7) Heard Sri K. Rajeswara Rao, learned counsel appearing for the complainant.
8) Counsel for the Opposite Parties is absent. He was absent even on the previous occasions on 10.7.2015, 14.7.2015, 24.7.2015 and the matter was posted to today for orders which too did not sensitize the learned counsel to be present.
9) In the light of the claim made by the complainant vis-à-vis the stand of the Opposite Parties and the material brought on record, the following points arise for consideration:
i) Whether the repudiation of claim is justifiable?
ii) To what relief?
Point No. 1 :-
10) Ex. A1 and A2 (Ex. B2) are the insurance policy and the schedule issued by the Opposite Parties in favour of the deceased. The term of the policy was 30 years commencing from 6.5.2013. Ex. A3 is the FIR dt.15.9.2013 registered by the police against the driver of the vehicle which hit the deceased. Ex. A4 is the accident report of the Motor Vehicles Inspector and Ex. A5 is the intimation letter dt.14.9.2013 addressed by Safe Hospital, Kakinada to the police. Ex. A6 is the Inquest Report and Ex. A7 is the Charge Sheet filed against the driver in the Court of Judicial First Class Magistrate, Alamuru. Ex. A11 is the Death Certificate. These documents are not in dispute.
11) It is also not in dispute that the insured was met with an accident as reflected in Exs. A3, A4, A6 and A7. Similarly, there is no dispute with regard to the letter of repudiation Ex. A22 dt. 23.12.2013 and Ex. A12 letter dt.6.4.2014 addressed by the complainant to the Opposite Parties for review and rejection letter Ex. A23 dt.26.6.2014.
12) Ex. A13 are bunch of reminders sent by the complainant for review of the decision. Ex. A14 are postal receipts and Exs. A15 are postal acknowledgements relating to the correspondence of the complainant for settling the claim. These documents are also not in dispute. Ex. A24 photographs are filed to show amputation of leg of the deceased.
13) Ex. B1 is the proposal form submitted by the deceased. Ex. B2 policy schedule of the conditions attached thereto, Ex. B3 death claim, Ex. B4(Ex.A5) intimation to the police about the admission of the deceased as Medico Legal Case, Ex. B5 letter dt. 5.4.2014 addressed by the surveyors to the Medical Superintendent, Naveen Trauma & Emergency Hospital, Rajahmundry, Ex. B7 (Ex. A22) repudiation letter dt. 23.12.2013, Ex. B8 (Ex. A23) review order, are also not in dispute. Ex. B9 is the affidavit of the Investigator who was deputed to conduct enquiry with regard to the claim.
14) There is no controversy with regard to the principle that the contracts are based on mutual trust and there should be utmost honesty in the matters relating to insurance contracts. A person who intends to take a policy of whatsoever nature is under an obligation to disclose true and correct facts. If the policy is a life insurance policy or a medi-claim policy, the beneficiary should disclose the true status of his health with regard to the ailments he is suffering from on the date of submitting the proposal.
Upon such disclosure the insurer will have a choice either to accept the proposal or reject the same. The proposal submitted with all disclosures becomes a contract after it is accepted, and it becomes binding on the insurer and the conditions thereof become binding on the insured. The insurer will not be liable in case false information is furnished by the insured in the proposal or if the policy is obtained by suppressing the material facts.
15) Therefore, the question in the instant case is whether there was suppression of material facts by the insured with regard to his health status when he obtained the policy.
16) Ex. B1 proposal form shows that the deceased answered in the negative, the questions relating to his health. He answered No to the questions, whether he had suffered any medical or surgical treatment, including investigations, tests, scans or X-Ray for any illness or medical conditions. He gave the same answer whether he was currently receiving any treatment or awaiting medical or surgical consultation tests or investigations including for Diabetes, Tuberculosis, Asthma or any other respiratory or lung disease. Therefore the deceased declared that he was hale and healthy and the policy was issued on that basis.
17) The stand of the Opposite Parties is that the insured was a known diabetic since six years and a pulmonary tuberculosis patient since March, 2013. Therefore the burden to prove the allegation is on the opposite parties. To discharge the burden they seek to rely on the discharge summary issued by the Safe Emergency Hospital. The said document is marked on behalf of the complainant as Ex. A8. They also seek to rely on the discharge summary issued by Medi-care Hospital Ex. A9 and the treatment summary issued by Naveen Trauma & Emergency Hospital Ex. A10 marked on behalf of the complainant. According to these documents the deceased was diabetic and a pulmonary tuberculosis patient. They also disclose the treatment given to him in the said hospitals.
18) But the question is whether these documents can be treated as proof of the allegation of suppression. Suppression pre-supposes knowledge. When a person knows a fact, it means that he has knowledge of the same. He should disclose it whenever it is necessary and required to do so. On the other hand, if a fact is not known to him, knowledge cannot be attributed to him, and no inference of suppression can be drawn merely because the fact was known at a later stage.
19) In the case on hand, though there is a mention in Exs. A8 to A10 about the deceased being diabetic and pulmonary tuberculosis patient, nothing is mentioned about the treatment received by the deceased prior to the date of accident. Mere treatment given to the insured for these ailments in these hospitals would not lend support to the fact that insured had knowledge of the same in the past.
20) In the context other evidence on record assumes importance. Ex. A16 is a certificate issued by the family doctor G. Suryanarayana. According to it the deceased did not have ailments and he was hale and healthy and that he was maintaining good health in his life time. Dr. M.V.V. Anand, a doctor of Safe Emergency Hospital who issued Ex. A17 and Ex. B4 certificates stated that one K. Koteswara Reddy who accompanied him informed that the deceased was never admitted in the hospital before his admission after the accident. Ex. A18 certificate issued by Dr. V. Ganga Kishore of Medicare Hospital also discloses that the deceased was not given treatment for diabetes in the hospital before the accident. To the same effect Naveen Trauma Emergency Centre has issued Ex. A10 certificate. K. Koteswara Reddy who got the deceased admitted into the hospital gave his affidavit Ex. A20 in which he stated that the deceased was hale and healthy and not diabetic and he gave the statement on the spur of moment to
answer the queries of the hospital staff. These documents Exs. A16 to A20 would clearly demonstrate that at no point of time before the accident, the deceased received any treatment either for diabetes or Pulmonary Tuberculosis.
21) The Opposite Parties made a probing enquiry through their investigating agency. The agency left no stone unturned and submitted Ex. B6 report. The agency enquired into several aspects of the life of the deceased. It enquired as many as four relatives of the deceased, four neighbours besides the government officials such as Anganwadi worker, Auxiliary Nurse Midwifery (ANM) and the Panchayat Secretary. None of them stated that the deceased was suffering from any ailment. They uniformly stated that the insured met with an accident and died during the course of treatment. The investigating agency did not even leave the medical shops to ascertain whether the deceased had purchased medicines before the accident. But it could not find any information. The agency enquired with the complainant also who in her statement categorically stated that her husband had no vices or health problems before the unfortunate accident. The investigating agency could not find any incriminating material with regard to the past history of health of the deceased. A cumulative consideration of Exs. A 16 to A20 and Ex. B6 investigation report would only lead to the inference that the deceased had no knowledge of the ailments. It may be noted that diabetes and tuberculosis are known to be silent killers and one does not know until they strike. Ex. B6 investigation report discloses that the deceased owned two rice mills and was running another mill on lease. The deceased being considerably rich would not have failed to take treatment if he had really known that he was afflicted with diabetes and tuberculosis. In this view of the matter there is no material to show that the deceased had prior knowledge, hence it cannot be said that he obtained the policy by suppressing the fact.
22) As already noted, the claim was repudiated on the sole ground of suppression of material fact. Since it is held that there is no suppression of fact, repudiation of the claim must be held unjustifiable.
Point No. 2 :
23) The assured sum under the policy is Rs. 30 lakhs which is claimed in the complaint. Hence, the complainant is entitled to receive the said amount. Since the repudiation is held to be unjustified, the amount should carry reasonable interest at 9% p.a., from the date of repudiation till payment.
24) The complainant is also entitled for premium amount as per the policy condition. An amount of Rs. 17,389/- was paid as premium but after deducting the taxes from the said amount, the complainant is entitled for Rs. 16,860/-. The complainant is also entitled for costs quantified at Rs. 10,000/-. No amount need be awarded towards compensation.
25) In the result, the complaint is allowed in the following terms:
i) The Opposite Parties shall pay Rs. 30 lakhs towards policy amount with interest @ 9% p.a., from the date of repudiation i.e., 23.12.2013 till payment.
ii) The Opposite Parties shall also pay a sum of Rs. 16,860/- towards the premium amount and
iii) Rs. 10,000/- shall be towards costs.
Three months time reckoned from the date of receipt of this order is granted for compliance
_______________________
PRESIDENT
pnr
APPENDIX OF EVIDENCE
WITNESSES EXAMINED FOR
COMPLAINANT OPPOSITE PARTIES
None None
DOCUMENTS MARKED FOR COMPLAINANT:
Ex. A1: 06.05.2013 Policy document copy
Ex. A2: 06.05.2013 Policy schedule.
Ex. A3: 15.09.2013 FIR copy
Ex. A4: 18.09.2013 Accident report from Motor Vehicles Inspector
Ex. A5: 14.09.2013 Police intimation of MLC case of Safe Emergency
Hospital
Ex. A6: 22.10.2013 Inquest report copy.
Ex. A7: 10.11.2013 Charge sheet filed before the Judicial First Class
Magistrate, Alamuru.
Ex. A8; 02.10.2013 Discharge summary of Safe Emergency Hospital
Ex. A9: 19.10.2013 Discharge summary of Medicare Hospitals.
Ex. A10: 21.10.2013 Treatment summary of Naveen Trauma &
Emergency Centre, Rajahmundry.
Ex. A11: 21.11.2013 Certificate of Death issued by Municipal
Corporation, Rajahmundry.
Ex. A12: 06.04.2014 Letter addressed by complainant to O.P.
Ex. A13: - Copies of bunch of e-mails
Ex. A14: - Postal receipts.
Ex. A15: - Postal acknowledgements.
Ex. A16: - Certificate issued by Dr. G. Suryanarayana as to the
health status of life assured.
Ex. A17: - Certificate issued by Safe Emergency Hospital.
Ex. A18: - Certificate issued by Medicare Hospital.
Ex. A19: - Certificate issued by Naveen Trauma & Emergency
Hospital.
Ex. A20: - Affidavit of Karri Koteswara Reddy
Ex. A21: - Colour Photographs showing injuries (4 Nos)
Ex. A22: 23.12.2013 Repudiation letter of Opposite Parties along with
Letter dt. 26.6.2014 intimating the decision of
Claims Review Committee declining the claim.
DOCUMENTS MARKED FOR OPPOSITE PARTIES:
Ex. B1: 30.04.2013 Proposal form of the life assured.
Ex. B2: 06.05.2013 Policy schedule.
Ex. B3: 23.12.2013 Death Claim Form.
Ex. B4: 14.09.2013 Police intimation of MLC case of Safe Emergency
Hospital
Ex. B5: 05.06.2014 Letter of Stellar Insurance Management Services to
Naveen Trauma & Emergency Hospital, Rajamundry.
Ex. B6: 21.10.2013 Treatment summary of Naveen Trauma &
Emergency Centre, Rajahmundry.
Ex. B7: 23.12.2013 Repudiation letter of Opposite Parties addressed to
Complainant.
Ex. B8: 26.06.2014 Letter of Opposite Parties to complainant intimating
the decision of Claims Review Committee declining
the claim.
Ex. B9: 29.11.2014 Affidavit of PSS Prakash, Investigator of M/s. Stellar
Insurance Management Services Pvt. Ltd.,
_______________________
PRESIDENT
pnr
