Complaint is filed on 24-2-2009
Compliant disposed on 5-11-2012
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM::AT:: KARIMNAGAR
PRESENT: HON’BLE SRI K. DEVI PRASAD, B.Sc., LL.B., PRESIDENT
SMT. E. LAXMI, M.A.,LL.M.,PGDCA, PGDIM, MEMBER
SRI. K. CHANDRA MOHAN RAO, B.Com., LL.B., MEMBER
MONDAY, THE FIFTH DAY OF NOVEMBER,
TWO THOUSAND TWELVE
CONSUMER COMPLAINT NO. 38 OF 2009
Between:-
Lingempally Rajamma @ Lingampally Rajamani W/o. Late Lingampally Krishna Reddy, Age 38 years, Occ House hold, R/o. Lambadipally (v) of Mallial T.Q. of Karimnagar district.
... Complainant
AND
- The Branch Manager, Reliance Life Insurance Company Ltd., Vamandas Complex, 5-6-291, First Floor, Saraswathi Nagar, Nizamabad – Town proper and district.
- The Branch Manager, Reliance Life Insurance Company Ltd., Karimnagar proper and district.
…Opposite parties
This complaint is coming up before us for final hearing on 29-10-2012,in the presence of Sri M.Mahender, Advocate for complainant and Sri V.Srinivas, Advocate for opposite party no.1 and 2, and on perusing the material papers on record, and having stood over for consideration till this day, the Forum passed the following:
::ORDER::
1. This complaint is filed under Section 12 of C.P.Act, 1986 praying this Forum to direct the opposite parties to pay the complainant a sum of Rs.1,00,000/- towards sum assured and other benefits with interest along with compensation, damages and costs of the proceedings.
2. The brief averments of the complaint are that the complainant’s husband during his life time obtained Reliance Endowment Plan (Regular) Policy bearing no.10372934 by paying first premium of Rs.5,774/- for an assured sum of Rs.1,00,000/- commencing from 18.11.2006. As per the terms and conditions of the policy in case of death of the policy holder the nominee will get an assured sum of Rs.1,00,000/- along with all other benefits.
3. The complainant further submitted that her husband i.e. Lingampally Krishna Reddy died on 21.01.2008. After death of her husband the complainant informed the same to opposite party no.1 along with required documents and requested to settle the claim. After receipt of claim from complainant, the opposite party repudiated the claim on the ground that “non disclosure of heart disease in the proposal form”. But at the time of obtaining the policy, the policy holder was hale and healthy. The Panel Doctor of opposite parties also examined the policy holder and after thorough check up only the opposite parties issued the policy to the deceased. Therefore, the opposite parties repudiated the claim of complainant in a routine manner and without any valid reason hence, filed this complaint for redressal of her grievances.
4. The opposite party no.2 filed Written Version of it’s Territory Manager denying the averments made in the complaint and submitted that on receipt of claim from complainant, an investigation was carried out by the opposite party and it was found that the deceased policy holder was hospitalized on 01.08.2005 at Krishna Institute of Medical Sciences with shortness of breath and was diagnosed to be suffering from dialated cardio-myopathy and severe LV disfunction and he was discharged on 02.08.2005. The same was confirmed by the Hospital vide Claim Form-B. The policy holder suppressed the material facts at the time of obtaining the policy. As per Sec 45 of the Insurance Act, if there is any mis-statement or suppression of material facts, the policy can be cancelled in question.
5. The opposite party no.2 further submitted that there is no negligence or deficiency of service on their part, hence the complainant is not entitled for any death benefit as the policy was void ab initio as the deceased policy holder had suppressed material facts regarding his health. Therefore, prayed for dismissal of the complaint.
6. The complainant filed Proof Affidavit reiterating the averments made in the complaint and the documents filed by her are marked as Ex.A1 to A8. Ex.A1 is the original copy of Residence Certificate of complainant issued by Surpanch, G.P.Lambadipally Dt: 30.10.2008. Ex.A2 is the original Policy Schedule issued by opposite parties Dt: 20.11.2006. Ex.A3 is the original 1st premium Receipt bearing no.R9003783 issued by opposite parties Dt: 20.11.2006. Ex.A4 is the original Deposit Acknowledgment for Rs.5,774/- issued by opposite parties Dt: 31.10.2006. Ex.A5 is the original policy document issued by opposite parties Dt: 20.11.2006. Ex.A6 is the original Benefit Illustration for Endowment Plan (Regular) – with Profiles issued by opposite parties Dt: 20.11.2006. Ex.A7 is the photo copy of Proposal for Insurance Dt: 03.11.2006. Ex.A8 is the original copy of Repudiation Letter issued by opposite parties Dt: 19.02.2008.
7. The opposite party no.2 filed Proof Affidavit on his behalf and on behalf of opposite party no.1 and the documents filed by them are marked as Ex.B1 to B9. Ex.B1 is the photo copy of Discharge Summary of deceased issued by Department of Cardiology Dt: 02.08.2005. Ex.B2 is the photo copy of Patient Information Form issued by Krishna Institute of Medical Sciences, Secunderabad Dt: 01.08.2005. Ex. B3 is the photo copy of authorization for Investigations, Procedures, Surgical Operations and Treatment. Ex.B4 is the photo copy of Admission Slip issued by Krishna Institute of Medical Sciences, Secunderabad Dt: 01.08.2005. Ex.B5 is the photo copy of History and Physical Examination Report issued by Krishna Institute of Medical Sciences, Secunderabad. Ex.B6 is the photo copy of Claim Form B – Medical Attendant Certificate of opposite parties Dt: 02.08.2005. Ex.B7 & A8 are one and the same documents. Ex.B8 is the original Policy Schedule issued by opposite parties. Ex.B9 & A7 are one and the same documents.
8. The point for consideration is whether there is any deficiency of service on the part of opposite parties, if so, to what relief the complainant is entitled?
9. The records and documents reveal the admitted facts that the complainant’s husband L.Krishna Reddy had obtained Reliance Endowment Plan (Regular) policy from opposite party no.1 bearing no.10372934 for an assured sum of Rs.1,00,000/- commencing on 18.11.2006 with yearly premium of Rs.5,774/- for a term of 21 years.
10. The life assured died of heart attack on 21.01.2008. Subsequently the complainant being the nominee lodged her claim with opposite party no.1 along with required documents for settlement of her claim as entitled under the said policy.
11. But her claim evoked a reply from opposite parties Head Office, Chennai under Ex.A8 Dt: 19.02.2008 repudiating the claim of the complainant on the ground of non-disclosure of heart disease and hospitalization in the proposal form under question 54 (a) and 54 (s) which are material to the issue of policy in terms of Sec 45 of the Insurance Act 1935.
12. Aggrieved by this rejection the complainant has approached this Forum seeking the desired relief.
13. The opposite parties have filed counter and Proof Affidavit justifying their repudiation of the claim of the complainant reiterating the same ground mentioned in the letter of repudiation Dt: 19.02.2008 under Ex.B7 i.e. non-disclosure of Heart disease and hospitalization, in the Proposal Form with regard to his health condition especially against the question no.54(a) & 54 (s). In support of this contention opposite parties filed the Medical Records including Discharge Summary gathered from KIMS, Secunderabad under Ex.B1 in which it was mentioned that life assured was treated for Cardio Myopathy and severe LV disfunction from 01.08.2005 to 02.08.2005 pleading that it was confined by S.Remedy Hospital Karimnagar. In addition to this the opposite parties filed Claim Form B (Medical Attendant Certificate) Dt: 02.02.2008 marked as Ex.B6 which reveals that the life assured was admitted in Sreem Remedy Hospital on 20.01.2008 and that the life assured was suffering from the earlier disease for last two years. Ex.B6 contains answer to
Q.No.6: What was the diagnosis?
Ans: K/c of Dialated Cardio Myopathy with acute left verticular failure.
Q.No.7: Date when diagnosed first?
Ans: Two years back suggesting that the life assured was treated at Sreem Remedy Hospital, Karimnagar two years back.
Opposite parties thus relied on this report to substantiate their allegation of suppression of material facts that the life assured had pre-existing disease on the date of obtaining the said insurance policy i.e. 20.11.2006. But Ex.B6 is only Medical Attendance Certificate which is not credible. Only Medical Records and Discharge Summary are authentic documents. Even in case of mention of any pre-existing disease in Discharge Summary, the affidavit of the doctor who treated the life assured is essential to establish the fact of pre-existing disease as observed by Hon’ble State Commission of Rajasthan in Appeal No.1601/2011 reported in II 2012 CPJ 41 cited by the complainant.
14. In that case the Hon’ble State Commission upheld the order of District Forum on the ground that the affidavit of Investigator as also of any person who could have proved documents in respect of previous disease of the insured have not been filed. The Hon’ble State Commission opined that Insurance Company is supposed to verify all the facts mentioned in Proposal Form before issuing the policy. Common man is not supposed to know all the niceties and technicalities of Law.
15. In the case on hand the affidavit of Investigator nor the doctor who examined the life assured was filed. There is no evidence to shat the life assured was subjected to Medical Check up before issuing the policy for verifying the information given in the proposal form. Thus the above authority is relevant to the present case.
16. More over Ex.B6 contains the date of admission but not the date of discharge or death. The complainant denied through her Proof Affidavit all the pleadings opposite party based on the documents Ex.B1 and B6 and contends that the life assured was hale and healthy at the time of obtaining the said insurance policy and that he died of Heart Attack subsequently on 21.01.2008. In the absence of evidence from the concerned doctor who said to have treated in S.Remedy Hospital, the pleadings of opposite parties that the life assured furnished incorrect information in the Proposal Form stands disproved.
17. The Insurance Company repudiated the complaint on the ground of suppression of material fact by taking shelter U/s. 45 of Insurance Act, 1948 which reads as follows:
“every fact of materiality must be disclosed; otherwise there is good ground for recession of the contract. The duty to disclose material facts continues right up to the conclusion of the contract and also implies any material alteration in the character of the risk which may take place between proposal and acceptance. If there is any mis-treatment or suppression of material facts, the policy can be called in question”.
As such in the present scenario there is every reason to belief that the life assured was hospitalized at KIMS, Secunderabad from 01.08.2005 to 02.08.2005 was totally cured of the said heart disease and liver disfunction and in that healthy state he obtained the said insurance policy on 20.11.2006 and subsequently died on 21.01.2008 i.e. one year two months from the date of inception of the said policy.
The learned counsel for the complainant cited the decisions rendered by
The Hon’ble National Commission, New Delhi, 2010 (3) CPC in RP No.1516/2006 held that “ CP Act, 1986 – Section 14 & 15 _ Medi-claim Policy – Insured underwent Artery By Pass Grafting on 15.07.1998 during subsistence of mediclaim policy – Claim was repudiated on the ground that insured had suppressed the fact that the he was having a heart problem when policy was taken – it was pleaded that insured was suffering from Chronic State Angina for last 10 years – But no evidence including affidavit of doctor was produced in support of this allegation, except discharge summary – Concealment of material disease not proved – Relief granted by For a below amounting to Rs.,1,73,850/- with 9% P.A. interest and costs of Rs.15,000/- upheld – Revision dismissed”.
The Hon’ble State Commission of Punjab at Chandigarh 2011 (1) CPC 77 in FA No.664/2007 held that “the insurance company has not led any evidence to prove that the complainant was having any heart problem at the time of taking the mediclaim policy. The insurance company has examined doctor Hatim to substantiate its claim. But he did not examine the complainant of the record of Escort Heart Institute and Research Centre. Mere producing the copies of the clinical summary allegedly issued by Escort Heart Institute and Research Center is not sufficient to exonerate the Insurance Company from its liability”.
The Hon’ble National Commission, New Delhi, 2012 (1) CPR 232 (NC) in RP No.2992 of 2011 held that “Borrower life assured died due to heart attack – alleged pre-existing disease – photocopies purporting to be out-patient tickets/cards of deceased at Government Hospital did not bear signature of any attending physician at OPD nor was any Doctor produced before District Forum to prove these documents – it was also necessary for petitioner to examine Investigator who had signed Investigator’s report and ask him to produce statement attributed to complainant that her husband used to got to Government General Hospital for check-up of BP – Order of State Commission not suffering from any jurisdictional error, legal infirmity or material irregularity”.
18. In this case also the opposite parties failed to prove that the life assured had pre-existing disease mentioned in Ex.B6 by filing the Discharge Summary of S.Remedy Hospital along with affidavit of doctor who treated the life assured at Sreem Remedy Hospital, Karimnagar As such the allegation made by opposite parties taking shelter under U/s.45 of Insurance Act vide Ex.B7 stands disproved and consequently the repudiation of the claim of the complainant is considered unjustified amounting to violation of principles of Uberrimafides.
19. In the light of the above decisions and in view of the above observations we hold that the opposite parties deficient in service and so liable to pay the assured sum of Rs.1,00,000/- to the complainant.
20. In the result the complaint is allowed in part and the opposite parties are directed to pay the complainant a sum of Rs.1,00,000/- with interest @ 9% P.A. from the date of filing the complaint i.e. 24.02.2009 and Rs.1,000/- as costs within one month from the date of receipt of this order.
Dictated to Stenographer and transcribed by her, after correction the orders pronounced by us in the open court this the 5th day of November, 2012.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
