Andhra Pradesh

Nellore

CC/124/2013

Munjuluru Nagaraju - Complainant(s)

Versus

1.The Branch Manager Tata AIA Insurance Co.Ltd - Opp.Party(s)

D.Balagopalreddy

04 Jun 2015

ORDER

Date of filing      : 11-12-2013

Date of Disposal : 04-06-2015  

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

           :: NELLORE ::

                                                       

Thursday, this the 4th day of JUNE, 2015.

 

          PRESENT:  Sri P.V.Krishna Murthy, B.A., B.L., President

                                      Sri M.Subbarayudu Naidu, Member

                              

                      C.C.No.124/2013

 

Munjuluru Nagaraju,

S/o.Late Ramanaiah Setty,

Hindu, aged about 28 years,

Business,

Residing at Sripuram Village

Dakkili Mandal,

Sri SPSR Nellore District,

Andhra Pradesh                                                             …  Complainant

 

                      Vs.

                                                                            

1. The Branch Manager,

Tata AIA Insurance Co.Ltd.,

Hotel Surya complex Near Madras Busstand,

Nellore.

 

2. The Claims Manager,

Tata AIA Insurance Co.Ltd.,

2^nd Floor, My Home Tycoori,

Kundhanabag

Begumpet,

Hyderabad 500016

 

3. Tata AIA Life Insurance Company Ltd.,

Rep. by its Managing Director,

14^th floor, Tower A

Penusila Business Park

Senapari Depat Marg

Lower Parel

Mumbai – 400013.                                          … Opposite parties

 

This matter coming on 15-04-2015 before us for final hearing in the presence of Sri D.Bala Gopal Reddy, Advocate for the complainant and  Sri P.Sreenivasa Rao, Advocate for the opposite parties and having stood over for consideration till this day, this Forum passed the following:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          

                                                                                                                                                                                                                         ORDER                                                                                                                                                                                                                          (BY SRI M.SUBBARAYUDU NAIDU, MEMBER ON BEHALF OF THE BENCH)

 

     This consumer case is filed by the complainant against the opposite parties 1 to 3 to direct them to pay an amount of Rs.10,00,000/- being the assured amount under the policy along with interest at 12% p.a., from the date of repudiation of the claim dt.05-03-2013 till its payment; to pay Rs.50,000/- towards damages for causing mental agony and deficiency in service and to pay the costs of the complaint and also to grant such other and further reliefs as the Hon’ble Forum may deem fit and proper in the circumstances of the case.

 

     The factual matrix leading to filing of this consumer case is as stated hereunder:

 

1.    It is the case of the complainant that he is the son of late Ramanaiah setty and the said Ramanaiah settee who obtained a policy from the opposite parties/respondents.  The said Ramanaiah Setty, is the son of late Venkataswamy, insured his life for Rs.10,00,000/- with the 1^st opposite party under policy no:C198347073 in the year 2010 and the said policy plan name, is health protractor.  The said Ramanaiah setty had paid the premium.

 

2.   It is further submitted that the insured nominated the name of his son who is the complainant herein as per policy.  It is further submitted by the complainant in para-4 of his complaint that his father unfortunately died at Narayana General Hospital, Nellore on 24-11-2012 with acute cordial arrest i.e., heart attack.  He had submitted the claim in Chennai, 2013 along with necessary documents to the first opposite party requesting to pay the amount in due under the policy.  The opposite parties according to their letter dated   5-3-2013 repudiated the claim of the complainant by stating that the insured has suppressed the material facts of his earlier disease and their investigation was established that the life insured  was on medication dilated cardio – myopathy left ventricular dysfunction diabetes mellitus and hypertension since prior to the application for insurance according to their records such information was not disclosed in reply to  the specific questions in the application dated 18-05-2010 for the above said policy, after carefully evaluation of all facts and documents  submitted to them circumstances in this case, they have come to the conclusion that the replies for the above aforesaid questions in the application form are false as such information prior to the application for insurance.  The complainant after receiving the reply, the complainant once again issued another reply notice stating that the insured never suffered any ailment by the date of submission of nomination for obtaining the said policy.

 

3.       It is further submitted by the complainant that there is no proof that the insured has suffered the disease, as mentioned   in the letters of repudiation of the claims.  Mere allegations are made by the complainant against the opposite parties for repudiation of the claim.  So, the mere ailments made by the opposite parties repudiation of the claim, will not sustainable for the reasons after repudiation, is only to avoid the payment of the said policy.  If any insured is suffered such ailment is alleged by the opposite parties they ought to have cancelled the policy prior to his death.  It is clearly shows that their defense is only invented for the purpose of avoiding the payment of insurance amount with a malafied intention without proper application of mind which is not reasonable, justifiable both in principle and doctrine.  There is clear negligence and deficiency of service on the part of the respondent in not paying the policy amounts.  Hence, they (opposite parties) are liable to pay damages for causing mental agony to the complainant. They are also liable to pay interest at 12% p.a. from the date of submission of claim forms on the policy amount.  Hence the complaint.  

   

II.    In response, the opposite parties were resisted the complaint by filing a counter/written version on 21-07-2014 before this Hon’ble Forum, denied the allegations of the complainant, in the complaint and further stated that the complaint is false, concocted and untenable.  They are all invented only to get illegal benefits by throwing the blame on the opposite parties by the complainant.

    

     (i) The opposite parties are submitted that their counter/written version and further stated at page no.1 that the opposite parties (respondents) have no knowledge about the relationship of the complainant and late Ramanaiah setty.  It is true that the said Ramanaiah setty, obtained said policy from the opposite parties herein.  The said Ramanaiahsetty, is son of late Venkataswamy insured his life for Rs.10,00,000/- with the 1^{st  opposite party (}respondent) under policy No.C198347073 in the year 2010 and the said policy plan name is Life Raksha.  Ramanaiah setty paid the said premium amount.  It is humbly submits that the insured nominated the name of his son as nominee under the said policy.

 

   (ii)   It is further submitted that it is false to state that the complainant’s father unfortunately died at Narayana General Hospital, Nellore on 24-11-2012 with acute cardiac Arrest, i.e., heart attack.  It is true that the complainant herein submitted the claim in the month of January, 2013 to the 1^st opposite party herein requesting him to pay the amount due under the policy.  It is true that the opposite parties herein under their letters dated 05-03-2013 repudiated the claim of the complainant stating that insured has suppressed the material facts of his earlier diseases and their investigation is established that the life insured was on medication dilated cardio-myopathy left ventricular dysfunction diabetes mellitus and hypertension since prior to the application for insurance according to their records such information  was not disclosed in reply to the specific questions in the application dated 18-05-2010 for the above policy, after careful evaluation of all facts and documents submitted and for the circumstances in this case(opposite parties), they have come to the conclusion that the replies for the above aforesaid questions in the application form are false as such information prior to the application for insurance.  It is true that on receiving the said reply, the complainant again issued another reply notice stating that the insured never suffered any ailment by the date of submission of nomination for obtaining the said policy.  It is false to state that there is no proof that the insured has suffered the disease, as mentioned in the letter of repudiation of the claims.  It is not true to say that mere allegations made by the opposite party for repudiation of the claim is not sustainable in law and the reasons for repudiation are only to avoid the payment of the policy amounts.  It is false if really the insured had suffered such ailment as alleged by the opposite parties they ought to have canceled the policy prior to his death.  These opposite parties came to know about the diseases of the insured only after his death when they made investigation of the death of the insured.  It is not true that it clearly shows their defense is only invented for the purpose of avoiding the payment of insurance amount.  It is not true to say that with a malafide intention without proper application of mind which is not reasonable, justifiable both in principle and doctrine.  There is no clear negligence and no deficiency of service on the part of the opposite parties (respondents) in not paying the sai policy amounts.  It is not true to say that the opposite parties are liable to pay damages for causing mental agony to the complainant.  They are also not liable to pay interest at 12%p.a. from the date of submission of claim forms on the policy amount.

 

(iii) It is submitted that the deceased policy holder had suppressed material facts regarding his health condition as the deceased policy holder was on the treatment for medication dilated cardio-Myopathy left ventricular dysfunction diabetes mellitus and hypertension and the treatment was given but the same was not disclosed by the deceased policyholder at the time of filling up the proposal form for the said policy.  It is further submitted that upon a detailed investigation by (opposite parties) our company the aforementioned fact came to light and hence the opposite parties were right in repudiating the claim as the deceased policy holder had suppressed/not disclosed material facts about his health condition from (opposite parties) our company and as such claim was rightly repudiated as per sec.45 of the insurance Act, 1938.

 

(iv)  The medical records of Narayana medical college hospital dated 23-06-2010 states that the deceased life assured was a known diabetic since 3 years and was on regular treatment with insulin, ex-smoker & alcoholic.  The DLA had also undergone ECG on 19-05-2009 which was not disclosed in the application form.  Further the deceased had filled the authorization form for medical and/or surgical treatment of Narayana General Hospital on               12-05-2009.

 

(v) It is further submitted that one of the most important principles of insurance including the life insurance is Uberrimae fides i.e., ‘utmost good faith’ wherein every fact material to contract must be disclosed and the concealment of material information regarding one’s health condition, it can lead to the violation of the insurance contract.

 

(vi) It is further submitted that as per the terms and conditions of the policy contract, since the deceased policyholder had suppressed material facts so all claim benefit shall cease and all monies that have been paid shall be forfeited to the company.

 

(vii)  It is further humbly submitted that there is no unfair trade practice or deficiency of service as alleged in the complainant and hence the complainant is not entitled for a sum assured amount as well as any compensation as prayed in the complaint as the deceased policyholder had suppressed material facts about his health at the time of availing the policyholder, had suppressed material facts about his health at the time of availing the policy, hence there is no contract of insurance between the deceased policyholder and the opposite party company and the opposite party company has rightly repudiated the claim of the complainant, and the complainant is not entitled for any compensation or relief as prayed in the instant complaint and the complaint is liable to be dismissed with heavy costs.  The rest of the contents are denied in entirely and the complainant is put to strict proof of the same.

 

The complainant has filed his affidavit on 06-08-2014 and the documents which are marked as Exs.A1 to A4, on the other hand, an authorized signator and Assistant Manager –legal Sri P.B.Ganapathy has filed his affidavit on behalf of the opposite parties and documents which are marked as Exs.B1 to B4.  Both of them are not filed their written arguments in support of their case.

 

IV. Basing on the pleadings such as the complaint and counter/written version of opposite parties and the documentary evidence of the complainant and his written arguments of the case, the following issues/points that arise for our determination of the consumer case.

 

(a)Is there any deficiency in service on the part of the opposite parties towards the complainant?

(b) Whether the complainant is entitle to get the reliefs as prayed in the complaint, if it is so, to what extent?

( c ) To what relief?

 

 V. Issues Nos.1 and 2 :  In view of interdependence of these two issues with each other on the subject-matter which involved in this consumer case as, we have taken up together for discussion and determination of the case. 

  

      Sri D.Balagopal Reddy, the learned counsel for the complainant has vehemently argued that the complainant, being a nominee of the policy submitted a claim to the 1^st opposite party with necessary documents and requested to pay the amount due as per the policy.  But the opposite parties have repudiated the claim by stating that insured had suppressed the material facts  of his earlier diseases by a letter dt. 5-3-2013 (Ex.A2).  He has further argued that the complainant had sent a letter dt.7-8-2012 by stating that the insured had never suffered any ailment by the date of submission of nomination for the policy.  He has also further contended that there is no proof that the insured has suffered the diseases as mentioned in the repudiation of the claim.  If really the insured had suffered such ailments as alleged by the opposite parties, they ought to have cancelled the said policy prior to his death.

 

2.     The said learned counsel for the complainant urged that the defence set up by the opposite parties, is only invented for the purpose of avoiding the payment of insurance amount.  There is a deficiency in service and negligence on the part of the opposite parties towards the complainant. So, the complainant is entitled to get the reliefs as prayed for.  Hence, the said learned counsel for the complainant has prayed that the Hon’ble Forum may pleased to allow the complaint with costs.

 

3.   On the other hand, the learned counsel for the opposite parties Sri P.Sreenivasa Rao has also vehemently argued that the complainant has suppressed the material facts and not disclosed the ailments suffered by him while obtaining the said policy.  He has further argued that it is true that the letter dt.5-3-2013 (Ex.A2 issued to the complainant by the opposite parties and mentioned the reasons for rescinding his claim under the policy, Exs.B1 is the application of the insured dt.18-05-2010; Exs.B2 is the bunch of medical records of the insured.  He has also further argued that it is revealed that during investigation of the claim and it is a clear proof that the record of medical history of the insured which established that insured had suppressed many ailments he had, prior to obtaining of the said policy from the opposite parties.

 

   The said learned counsel for the opposite parties has further contended that there is no deficiency in service and negligence on the part of the opposite parties towards the complainant. It is totally a false claim as per the medical record.  The complainant is, in order to get wrongful gain from the opposite parties, filed a false complaint against the opposite parties and it should be summarily rejected in view of the facts and circumstances of the case.  Finally, he has prayed that the Hon’ble Forum may be pleased to dismiss the complaint with costs.

 

Forum’s Findings and observations

      We have heard the case and perused the record very carefully.  Parties led their evidence by way of affidavits.  Both of them have not filed their respective written arguments in support of their case.

 

     Basically, the complainant has to prove his case beyond reasonable doubt.  He who seeks equity from the Forums/courts must come with clean hands.

 

     It is crystal clear as per the record i.e., Exs.B1 and B2 that the insured had prior to the policy, is clearly suppressed the material facts.  The very essence of the contract of insurance, requires bonafide statements and goodfaith between the parties.  But here, insured had several ailments as per Exs.B2 and that has been purposefully avoided to mention them in the application for insurance (Exs.B1).  Actually, the policy is obtained from the opposite parties, the insured is not fair enough to disclose correct facts at the time of application.  We need not much to look into the details, primafacie, it is evident clearly that the insured had played foul play to get wrongful gain from the opposite parties.  The claim of the complainant, is correctly negatived by the opposite parties in view of the facts and circumstances.  There is no deficiency in service and negligence on the part of the opposite parties towards the complainant.  Every case has to be judged on its own facts.  The claim of the complainant is not at all justified.  The complaint of the complainant is liable to be dismissed without costs.

 

 

Point No.3:  In the result, the complaint is dismissed but without costs.

 

Typed to the dictation to the stenographer and corrected and pronounced by us in the Open Forum this the 4th day of JUNE, 2015.    

 

 

 

         MEMBER                                                                 PRESIDENT

  APPENDIX OF EVIDENCE

 WITNESSES EXAMINED FOR COMPLAINANT:

 

PW1

06-08-2014

:

Manjuluru Nagaraju, S/o.Late Ramanaiah setty, Hindu, aged about 29 years, business, residing at Sripuram village Dakkili Mandal, Sri S.P.S.R.Nellore District.

 

WITNESSES EXAMINED FOR OPPOSITE PARTIES:

 

RW1

06-01-2015

:

P.B.Ganapathy, S/o.P.S.Bheemaiah, Hindu, aged about 35 years and authorized signatory of the respondent company residing at Bangalore.

                                                                              

EXHIBITS MARKED FOR COMPLAINANT:

 

Ex.A1	02-04-2013	:	Photostat copy of letter addressed by the opposite party to the complainant.
Ex.A2	05-03-2013	:	Photostat copy of letter addressed by the opposite party to the complainant.
Ex.A3	24-11-2012	:	Photostat copy of Medical certificate for cause of death given by Narayana General Hospital Nellore along with statement of death and death particulars.
Ex.A4	13-08-2013	:	Photostat copy of letter from the office of the insurance Ombudsman to the complainant.

 

EXHIBITS MARKED FOR OPPOSITE PARTIES:                      

 

Ex.B1	18-05-2010	:	Photostat copy of application Form of policy of Ramanaiah Manjuluru
Ex.B2	-	:	Photostat copy of case record of the Ramanaiah Manjuluru.

         

 

                                                                                Sd/-

                                                                      PRESIDENT

Copies to:

1)Sri .D.Balagopal Reddy,Advocate,D.No.24-2-405, Near Magunta    

   Statue,Opp: Santhi Apartments, Dargamitta,Nellore- 524 003.

 

     2)Sri P.Srinivasa Rao,Advocate,Flat No.502, KAC, Celestial,

    Muthyalapalem,Ramalingapuram,Nellore-3.