BEFORE THE A.P.STATE CONSUMER DISPUTES REDRESSAL COMMISSION AT HYDERABAD.
FA 609 of 2011 against CC 28/2011 Dist. Forum, Vizianagaram
Between
1. Branch Manager,
Shriram Life Insurance Co. Ltd.,
M.G.Road, Vizianagaram.
2. The General Manager,
Shriram Life Insurance Co. Ltd.,
Regd. Office 3-6-478,
3rd floor, Anand Estate,
Liberty Road, Himayathnagar,
Hyderabad-500 029. *** Appellants/
Ops.
And
1. Ganti Nagamani
W/o. Late Umasankar
2. Ganti Srilakshmi
W/o.Ramesh,
3. Ganti Lalitha Hiravathi
W/o. Rajkumar Hiravat
4. Ganti Kalyana Chakravarthi
S/o. Late Umasankar
All are R/o. LIG 57,
Vivekananda Colony
Vizianagaram. *** Respondents/
Complainants
Counsel for the Appellants : M/s. K. Rajeshwara Rao
Counsel for the Respondents : M/s MSR Subrahmanyam.
CORAM:
SMT. M. SHREESHA, PRESIDING MEMBER
&
SRI S. BHUJANGA RAO, MEMBER
THURSDAY, THE TWENTY EIGTH DAY OF MARCH TWO THOUSAND THIRTEEN
ORAL ORDER: (Per Smt. M. Shreesha, Member)
***
1) Aggrieved by the order in C.C.No.28/2011 on the file of District Forum, Vizianagaram, the opposite parties preferred this appeal.
2) The brief facts as set out in the complaint are that the complainant No.1 is wife and complainants 2 and 3 are daughters and 4th complainant is the son of late Umasankar. The complainants submitted that during his life, the insured had taken the following Shriplus unit linked insurance plan policies with the opposite parties as follows and complainant No.1 is the nominee for the said policies.
Sl.No. Date Policy Number Sum Assured
1. 28-12-2006 L.N 110700004074 Rs.1,50,000/-
2. 20-12-2007 L.N 110700015421 Rs.1,50,000/-
3. 07-05-2007 L.N 10700062085 Rs.3,00,000/-
The complainants submitted that the above policies are in force by the time of death of the insured and the insured died of sudden ailment of acute myocardial infraction cardiogenic short (heart attack) while undergoing treatment in causality, District Head Quarter’s hospital, Vizianagaram. The complainants submit that the insured was hale and healthy and never suppressed his health conditions or was hospitalized at any time and was working as Administrator in B.S.N.L., The complainants submit that according to the terms and conditions of the said three policies, if the policy holder died when the policies were in force the opposite party should pay monthly income benefit of one per cent of the sum assured under family income benefit rider for a period of 10 years till the end of the said policy whichever is higher and also agreed to pay the unit benefit amount accrued by the date of maturity or death to his legal heirs or nominee. The first complainant immediately after the death of her husband informed the opposite parties and applied for full sum assured with all family benefits and unit benefit amount and sent the original policies and also submitted forms A, B, C & E, medical attendant certificate issued by Dr.M.Gopi Srikanth, M.D., M.R. Government hospital, Vizianagaram dt.22-6-2009. The first complainant also submitted that the opposite parties by way of letter dated 07-5-2009 requested to furnish medical reports for treatment and they acknowledged the same but failed to pay the sum assured and other benefits and repudiated the claim of the complainants stating that the deceased availed medical leave to the extent of 42 days in 2006 and 56 days in 2007. The complainants got issued a legal notice on 17-12-2010 demanding the opposite parties to pay the full sum assured under the said policies and the first opposite party issued a reply on 29-12-2010 and second opposite party on 31-12-2010 with all false allegations. Hence the complaint for a direction to the opposite parties to pay the full sum assured under the policies bearing Nos. 1. L.N.110700004074 dt.28-12-2006 for Rs.1,50,000/-, 2) L.N.110700015421 dt.20-1-2007 for Rs.1,50,000/- and 3) L.N.10700062085 dt.07-5-2007 for Rs.3,00,000/- with interest at 12% p.a. from the date of death till the date of payment together with family income benefit rider amount of 1% of the sum assured under the said three policies for a period of 10 years or till the end of the policies and also to pay the unitbenefit amount of about Rs.1,00,000/- with interest at 12% p.a. from the date of death i.e. 30-12-2008 till the date of payment together with compensation of Rs.50,000/- and costs.
3) Opposite parties filed counter resisting the complaint. Ops admitted that the first complainant’s husband took three life insurance policies under the scheme of Sri Plus bearing Nos. 1. L.N.110700004074 dt.28-12-2006 for Rs.1,50,000/-, 2) L.N.110700015421 dt.20-1-2007 for Rs.1,50,000/- and 3) L.N.10700062085 dt.07-5-2007 for Rs.3,00,000/- and the term of the policies are 15 years and mode of payment is yearly for all the three policies. Opposite party No.1 submitted that the policies were issued on good faith and after the death of the policy holder, the 2nd opposite party through private investigator, Mr.G.Rama Murthy, handed over the concerned claim forms, namely, A B C and E to nominee for processing the claim and requested the nominee to submit the filled claim forms and other documents within the stipulated period for processing the claim vide letter dt.6-3-2009 but the complainant failed to send the above documents and they reminded from time to time through letters dt.11-3-2009, 07-5-2009 and 06-3-2009 and at last the complainant sent claim forms A B C to opposite party No.2 without sending claim form ‘E’ and then opposite party No.2 sent claim form ‘E’ to the employer of the deceased by registered letter dt.19-8-09 requesting to send the leave records of the deceased. Thereafter since it was an early claim, the company made enquiry and came to know that the deceased had pre ailments prior to the commencement of policies and he availed long period of Medical leaves to an extent of 42 days in the year 2006 prior to commencement of 1st and 2nd policies and availed medical leave to an extent of 56 days prior to commencement of third policy and further availed 64 days in the year 2008 which establishes that the deceased intentionally concealed which were supposed to be disclosed at the time of taking the policy and therefore they have repudiated the policy. Opposite party No.1 submitted that it requested the insured to answer all questions fully and correctly and to disclose all material facts and not to suppress any material facts and the same were printed at the top of the proposal form in a visible manner but the insured gave answers as “no” for the questions mentioned in Q.Nos.25(c) (1 to 7) and submitted that the complaint is barred by limitation and prayed for dismissal of the complaint with costs.
4) The District Forum based on the evidence adduced i.e. Exs.A1 to A14 and B1 to B10 and the pleadings put forward allowed the complaint in part directing the opposite parties jointly and severally to pay the insured amount and directed to pay the sum with interest at 6% p.a. from the date of death till realization together with costs of Rs.3,000/-.
5) Aggrieved by the said order, the opposite parties preferred this appeal. The learned counsel for the appellants filed written arguments.
6) The learned counsel for the appellant insurance company filed written arguments and relied on following decisions:
· Dineshbhai Chandranna Vs. LIC of India reported in 2011 (1) CPR 63 (NC)
· LIC of India Vs. M. Gowri reported in 1994 (3) CPR 398 NC
· 2011 (3) CPR 148 (NC)
In the aforementioned decisions, the principle of Uberrima fide i.e., utmost good faith has been laid down and it is held that “when an information on a specific aspect is asked for in the proposal form, an assured is under solemn obligation to make a true and full disclosure of the information on the subject which is within his knowledge.” And in the instant case the opposite parties have failed to establish that the information was within the knowledge of the life assured and also that he had wilfully and wantonly suppressed the material facts in the proposal forms. Therefore the aforementioned decisions are not applicable in the facts and circumstances of case.
7) It is complainants case that complainant No. 1 is the wife, complainant Nos. 2 & 3 are daughters and complainant No. 4 is the son of late Uma Shankar who had insured his life for Rs. 6 lakhs with opposite parties and when the policy was in force he died on 30.12.2008 on account of heart attack. The opposite parties repudiated the claim on the ground that the insured had suppressed his ailments prior to commencement of the policies.
8) The appellants/opposite parties submit that the deceased had obtained three insurance policies viz., (i) for Rs. 1,50,000/- on 28.12.2006 , (ii) for Rs. 3,00,000/- on 7.5.2007 and (iii) for Rs. 1,50,000/- on 20.12.2007 totalling Rs. 6 lakhs and the term of the policies were for 15 years and the mode of payment was yearly for all the three policies. It is not in dispute that the policies commenced on 28.12.2006, 7.5.2007 and 20.12.2007 respectively evidenced under Exs. A1 to A3. It is appellant’s case that before obtaining the above policies the life assured filled the proposal forms and only basing on that information and on good faith the policies were issued. After the death of the life assured the appellant/opposite party conducted private investigation through one G. Rama Murthy who personally handed over the claim forms A, B, and C to the nominees for processing the death claim. Several reminders were sent to the complainant vide letter dt. 11.3.2009, 7.5.2009 and 19.6.2009. Ex. B3 & B4 are the letters dt. 7.5.2009 asking the complainants to send the medical reports of the life assured as they have received information that the life assured had taken treatment for diabetes and hypertension. Ex. B5 evidences that the life assured died of ‘Acute Mayo Cordial Infraction’ on 30.12.2008. The learned counsel for the appellants/Ops rely on Ex. B7 which are leave particulars of the assured and submits that the life assured was on medical leave prior to his death. We rely on the judgement in Branch Manager LIC Of India Vs. M. Parvathi @ Radha reported 1999 (2) ALD Consumer-93 wherein it was held “mere production of doctor certificate enclosed with the application for leave on medical grounds without examining the doctors does not prove that the insured was in fact suffering from the disease and that they have been suppressed by the insured. Heavy burden lies on the insurance company to prove that the insured has indeed suppressed these facts.”
9) Further, Hon’ble National Commission in case “Surinder Kaur & Ors. Vs LIC of India & Ors.”, Revision Petition No.2148 of 2003, decided on 14.02.2005, reported as 2005(2) CPC-675(NC), observed in Para-18 as follows:-
“18. The contention that the record of hospital from where the deceased got the treatment was sufficient would be too much to repudiate the claim. Without any proof of history based on statement of unspecified and unnamed person(s) on the date of admission of the deceased Manjinder Singh, LIC would not be sufficient to repudiate the claim unless it was substantiated with medical report for the treatment of a doctor prior to the submission of the proposal form”.
10) The opposite parties have to establish the suppression by way of filing the affidavit of the doctor who treated the life assured or by way of any documentary evidence like hospital treatment record. Ex. B8 is the repudiation letter dt. 28.5.2010 in which the Op repudiated the claim of the complainants on the ground that the life assured had suppressed his disease of
diabetes and hypertension and has availed medical leave to the extent of 42 days in 2006 and 56 days in 2007. Another letter is dt. 31.12.2010 evidenced under Ex. B9. The opposite parties in their reply notice reasserted that the life assured had suppressed material information with respect to his medical leaves. Ex. B10 is the investigation report. While the death of life assured by heart attack is not in dispute. The only point that falls for consideration is whether the life assured had suppressed diabetes and hypertension prior to issuance of policies. Merely because the life assured was on medical leave for a period of 42 days in 2006 and 56 days in 2007 before commencement of the policies and that he availed 98 days of medical leave between 2006 and 2008 over a period of two years, it cannot be construed that he wilfully and fraudulently suppressed diabetes and hypertension. While the opposite parties established the fact of availing medical leave however, they did not file the affidavit of the doctor who treated the life assured or medical record maintained by the hospital prior to issuance of the policies which establish that the life assured had suppressed the material facts in the proposal form.
11) Ex. A6 is the medical certificate which shows that the life assured died of “Acute Mayo cordial Infraction” and in the coloumns with respect to diseases which had existed the answer was ‘No’ and this was signed by Civil Assistant Surgeon. In the absence of any documentary evidence that the life assured had suppressed the diabetes and hypertension prior to issuance of the polices, we are of the considered opinion that keeping in view Section 45 of the Insurance Act the opposite parties have failed to establish any wilful and wanton suppression by way of hospital medical record or the affidavit of the doctor who had treated the life assured. Hence this appeal is dismissed and the order of the Dist. Forum is confirmed.
12) In the result the appeal is dismissed. No costs. Time for compliance four weeks.
1) _______________________________
PRESIDING MEMBER
2) ________________________________
MEMBER
28/03/2013
*pnr
UP LOAD – O.K.
