Andhra Pradesh

Nellore

CC/10/2015

Doniparthi Harshitha Daughter of Raja Rao - Complainant(s)

Versus

1.Manager ICICI Prudential Insurance Trend set Towers - Opp.Party(s)

N.Mohandas

29 Jan 2016

ORDER

Date of Filing     :07-02-2015

                                                                                                Date of Disposal:29-01-2016

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM:NELLORE

Friday, this the 29^th day of  January, 2016

 

PRESENT: Sri M. Subbarayudu Naidu, B.Com.,B.L.,LL.M.,President(FAC) & Member                             

                   Sri N.S. Kumara Swamy, B.Sc.,LL.B., Member.

 

C.C.No.10/2015

 

1.	Doniparthi Harshitha,  D/o.Raja Rao, Aged 6  years,  Being minor, Represented by father         and next friend and guardian Doniparthi Raja  Rao,
2.	Doniparthi Sujathamma, W/o.Doniparthi Ramanaiah, Hindu, Aged 50 years, Both are residents of D/o.4/8/282, Thummaguntavari Veedhi, Ramachandrapuram, Nawabpet, Near Saibaba Temple, Nellore, S.P.S.R.Nellore District-524  002.                                               ..…Complainants

                                                                           Vs.

 

1.	The Manager, I.C.I.C.I. Prudential Insurance        Trend set towers,  Ramalingapuram, Main Road, Nellore-2, S.P.S.R.Nellore District.
2.	The  Vice President Claims, ICICI Prdudential  Life      Insurance Company Limited,  Claim Cell,  Vinod Silk Mills Compound  Chakravarthi Ashok Road,   Ashok Nagar, Kandivali  East, Mumbai-400 101.                     …..Opposite parties

                                                                 

            This complaint coming on 20-01-2016 before us for hearing in the presence of                Sri N. Mohandas, advocate for the complainants and                                                                 Sri Dasu Guru Kumar and  M. Sravan Kumar, advocate for the opposite parties  and having stood over for consideration till this day and this Forum made the following:

 

ORDER

(ORDER BY  Sri N.S. KUMARASWAMY, MEMBER)

 

This complaint is filed under Section-12 of Consumer Protection Act, 1986 prays to  direct the opposite parties to pay Rs.7,17,875/- towards  the sum assured  as per the policy issued to the deceased with 12 %  interest from the date of death, costs of Rs.20,000/- for deficiency in services and such other further reliefs.

 

2.         The brief averments of the complaint are that the deceased namely Doniparthi Ramanaiah while he was alive insured his life with the 1^st opposite party i.e ICICI prudential Insurance, Nellore. The policy by name “ICICI PRU CASH ADVANTAGE” obtained on 1-2-2014 after paying Rs.1,03,090/- towards first installment including service charges. The policy number was assigned vide no 18444510.He nominated his granddaughter namely Harshitha who is the first complainant herein. The complainant further submitted that as per the scheme of the policy a sum of Rs.1,00,000/- was paid under annual scheme for a period of 10 years starting at the age of 55 and from the 11^th year by which time the insured attains 65 years the insured will be given annualized guarantee cash benefit of Rs.60,459/- for life term per annum till 75 years of his age. In any case if death occurs premature the death benefit is to be paid at Rs.7,17,875/- to the nominee who is the first complainant herein.               On 28-6-2014 the said Doniparthi Ramanaiah expired and immediately the second complainant informed the same to the first opposite party in writing by surrendering his policy with a request to pay insured amount as per terms of the policy. On 4-10-2014 the 2^nd complainant received a letter from the 2^nd opposite party stating in that the claim was repudiated on the ground that the deceased was diagnosed of “left bundle branch blockage” since august 2010 and on account of that the assured was hospitalized in a local hospital for dialated cardio myopathy with dyslipedemia with ejection fraction 25 % on February 2013 for treatment of severe mitral regurgitation with moderate pulmonary hypertension with chronic obstructive pulmonary disease with congestive heart failure as per the investigation revealed. Further the 2^nd opposite party stated that the questionnaire no 5c and 5f given to the deceased in the proposal forum and the deceased replied negatively. Had the correct medical history been disclosed by the deceased in the proposal forum for insurance the company would have declined the proposal in respect of issuance of policy. Further the complainant submitted that the said Donaparthi Ramanaiah never admitted in any hospital at any point of time during his life time and he was hail and healthy his death was not connected to any ailments as mentioned in the letter sent by the opposite party on 4-10-2014 and the diseases mentioned in the letter are imaginary and invented for the purpose of repudiating the claim. The complainant further submitted that a premium of Rs 1,03,090/- collected from the deceased which deemed that the opposite party accepted the health condition of the deceased and the policy issued without any hesitation. As such the repudiation is unjustified and complainant prays for relief as claimed in the complaint. Hence the complaint.

3.         The opposite partied filed written version denying all allegations made in the complaint except that of admitted certain facts.

            The life assured  namely Ramaiah Doniparthi, who is the husband of the complainant insured I.C.I.C.I. Pru Cash Advantage E10 for a sum of Rs.7,00,000/- by paying  annual premium of Rs.1,00,000/- amount.  The risk commenced from the date of  27-02-2014.  After receipt of proposal form from the life assured believing correctness of material facts, the insurance authorities  issued policy No.18444510 in favour of life assured with instructions to return the policy within 15 days  under the  free look period provision, if the policy holder is not satisfied with the features or the  terms  and conditions of the policy.  Further, the opposite party submitted that they have given opportunity to the life assured / policy holder  to reexamine the  replies  made by him in the proposal  and get the details rectified in case of any  discrepancy in the replies to the questions in the proposal form.  The opposite parties further contended that insurance is a contract of utmost good faith requiring of the proposer and the life  to be assured not only to disclose all material facts but also not to suppress any material facts in response to the questions in the proposal form.  Further stated that in case of  any mis-statement or suppression or non-disclosure of material information,  the company has the right  to repudiate the claim under the policy  void  in accordance with Section-45 of Insurance Act.  The opposite parties stated  that the  insured has given negative answers for the following questions Nos.5(C) with regard to health details of life assured.

 

            4.         It is pertinent to note that the deceased Life Assured, despite being specifically asked about the material information, had not disclosed his details of previous  ailments related to Dilated   Cardiomyopathy and that   he got hospitalized in Bollineni Superspeciality Hospital, Nellore on February 5, 2013 till February 11, 2013 for the treatment of Mitral regurgitation with moderate pulmonary hypertension with chronic Obstructive Pulmonary disease (severe blockage of arteries) with Congestive Heart Failure and Dialated  Cardiomyopathy (DCm) which was prior to the issuance of the subject policy.  Dilated  Cardiomyopathy is  a condition in which the heart becomes weakened and enlarged  and cannot pump blood efficiently.   The decreased heart function can affect the lungs, liver, and other body systems.  Dilated Cardiomyopathy is one of the cardiomyopathies, a group  of diseases that affect primarily the  myocardium (the muscle of the heart).  It is pertinent to note that the Life Assured  deceived the company into believing that he was  a healthy individual and thus obtained life insurance by misrepresentation.  Had the Life Assured disclosed the stated history at the proposal stage, the Company would not have issued the subject policy under any condition.  Further submitted that the life assured was expired on 28-06-2014 i.e., within 4 months of issuance of policy.  Subsequently, claim application received from the complainant.  The  claim was repudiated on the ground of suppression of pre-existing diseases and a letter to that effect  dated 04-10-2014 was sent to the complainant in accordance with terms and conditions of the policy documents.  Further the opposite parties received legal notice dated 18-10-2014 from the complainant and the same was duly replied by the opposite party vide letter dated 31-10-2014 giving correct reasons for repudiation of the claim.  The opposite parties further submitted number of reliances  in support of their contention.  In view of the above facts the present complaint is not maintainable and is liable to be dismissed.  Hence, complaint may be dismissed with exemplary costs.

5.         The points for determination would be:

1. whether there is any deficiency of service on the part of the opposite parties

for non-settling the claim of the complainants, if so whether the complainants are entitled for the reliefs as prayed for in the complaint and for costs?

 

2.  To what relief?

 

            6.         In order to substantiate the complainant averments, the complainant filed evidence on affidavit as P.W.1 and no documents marked on their side.  On the other hand, the opposite parties  filed  only written version with supported affidavit. The opposite parties  did not file  chief affidavit inspite of giving opportunities.  Hence, treated as no evidence on the side of  opposite parties and the complainant did not file written arguments as stipulated under provisions of  Consumer Protection Act.  Hence, the case is proceeded with  the material available on record.

 

            7.         POINT No.1:  It is an admitted fact that the deceased life  assured namely Doniparthi Ramanaiah obtained ICICI Pru Cash Advantage, E10  policy for a sum of Rs.7,00,000/- by paying premium of Rs.1,00,000/-  and the frequency period of premium is annual vide policy No.18444510.  It is also admitted fact  that the deceased life assured  died on 28-06-2014 leaving behind the L.Rs. of Kum.Doniparthi Harshitha and  Smt.Doniparthi Sujathamma.  The complainant No.1 is the grand daughter of deceased Ramanaiah nominated her as nominee  in the said policy. 

 

            8.         The main grievance of the complainants are that the deceased life assured obtained the above policy for a sum of Rs.7,00,000/- by paying annual premium of Rs.1,00,000/- to the opposite parties.  On sudden death of  the Doniparthi Ramanaiah                             dated 28-06-2014,the complainants preferred a claim form in writing by surrendering the policy to the opposite parties  with a request to  pay assured amount as per the  terms of the policy.  Subsequently,  on 04-10-2014  a letter was received from the  opposite parties  stating in that the claim was repudiated on the ground that deceased was diagnosed  of left bundle branch blockage in August, 2010 and that the assured was hospitalized in a local hospital  for diolated  cardio myopathy with dyslipedemia with ejection fraction 25% on February, 2013 for treatment of severe Mitral Regurgitation with moderate pulmonary hypertension with chronic obstructive pulmonary disease with congestive heart failure,  as if their investigation revealed.  The complainants are further alleged that the repudiation letter is an imaginary one  and invented for the purpose of  repudiating the claim.  Hence, the repudiation of claim is unjustified.  Since, the deceased life assured was never admitted in any hospital and he was hale and healthy  and also not suppressed anything at the time of taking the policy.  As such, the opposite parties are liable to pay the insured amount  alongwith  damages  and for costs. 

 

            9.         On the other hand, the opposite parties  admitted  that the deceased life assured was  obtained policy  from them.  When the questionnaire framed  in the proposal form before issuing the policy, the policy holder gave negative replies by  suppressing the material facts and when the claim made by the complainant consequent  on  diseased died, the claim was repudiated on the ground of suppression of  material facts and violation of  terms and conditions of the policy. 

 

            10.       The  policy of  insurance  is a bilateral contract.  The parties to the contract are bound by the  terms and conditions of contract.  One of the terms of contract is to the effect that the opposite parties are entitled to disown their liability if  on the future occasion, it comes to  light that there was  suppression  of earlier  diseases  suppressed by the insured. In present case it is the  clear  and categoric contention of the opposite parties are that  the insured while entering  into the policy suppressing the  fact of his sufferings from the diseases  described in the  repudiation letter.  In view of the said stand taken by the opposite parties, the burden lies on the complainant to  disprove the said contention.  In the present case, the complainant  was except filing chief affidavit did not produce any evidence to refute the contents of the opposite parties.  If the deceased life assured  that  he was not  suffered the earlier diseases, the complainant would be  entitled for the benefits accruing under the policy.   Merely, because the opposite parties have not filed chief affidavit and have not filed any document in support of their contentions, the complainants would not be automatically entitled to win the  case.  It is well settled principle of law  that  she, who assets  a fact  has to establish the same by producing cogent and  convincing evidence.  The complainant has to win or loose  on the strength of her own case and  she cannot depend upon the weakness of the  case of the opposite parties.  In this case, complainant was given  ample opportunities to produce evidence in support of her case, which she did not  properly utilized  and not evincing any interest  to get on with the case.   As the complainants failed to establish their case  in support of their  allegations, the complainants are not entitled any relief  as claimed for  in the complaint.  Thus, no deficiency can be attributed to the opposite parties.  Accordingly, point No.1 is answered.

 

  11.     POINT No.2:  In the result, the complaint is dismissed, without costs.

 

Typed to the dictation to the Stenographer, corrected  and pronounced by us in the open  Forum, this the  29^th  day of  January, 2016.

 

 

                 Sd/-                                                                                          Sd/-

           MEMBER                                                                               PRESIDENT(F.A.C.)

 

                                                APPENDIX OF EVIDENCE

 

Witnesses Examined for the complainants

 

P.W.1  -

24-06-2015

Smt.Doniparthi Sujathamma, W/o.Ramanaiah, Nellore, S.P.S.R.Nellore District. (Chief Affidavit filed)

 

Witnesses Examined for the opposite parties

-Nil-

 

                             EXHIBITS MARKED FOR THE COMPLAINANTS

-Nil-

 

                         EXHIBITS MARKED FOR THE OPPOSITE PARTIES

-Nil-

                                                                                                                               Id/-

 

                                                                                                         PRESIDENT(F.A.C.)

 

Copies to:

 

1.	Sri N. Mohandas, Advocate, Ongole.
2.	Sri Dasu Guru Kumar and  M. Sravan Kumar, Advocates, 15/619-2, James Garden, Nellore-524 002.

 

Date when free copy was issued: