This C.C. is coming on 04.06.2013 before us for final hearing in the presence of Sri Amanaganti Venkata Ramana and Sri V. Kasiviswanadha Rao, Advocates for the complainant and of Sri K. Jaganmohan Rao, Advocate for opposite parties No.1&2; upon perusing the material papers on record; upon hearing the arguments and having stood over for consideration this forum passed the following:
ORDER
(Per Sri R. Kiran Kumar, FAC President)
This complaint is filed u/s.12-A of Consumer Protection Act, 1986. The averments made in the complaint are that the complainant No.1 is the wife, complainants No.2 and 3 are the sons of the deceased Pasupuleti Jaganmohan Rao. The complainants submitted that, the deceased Pasupuleti Jaganmohan Rao had insured his life with the opposite parties, by taking a policy for Rs.80,000/- vide its No.578124978 and paid the first premium amount on 28.03.2010 and the opposite party No.1 issued policy bond in favour of the deceased. The complainants further submitted that, the insured died on 04.04.2010 due to sudden ill health, leaving the complainants as his legal heirs, though the treatment was given in time at Gandhi Hospital, Secunderabad. The complainants also submitted that after the death of Jaganmohan Rao, the complainants had informed the death information to opposite party No.1, submitted claim form along with original bond and other required papers for settlement of the claim amount. The complainants received a letter from the opposite parties vide letter dt.05.01.2011, in which it was stated that the deceased Jaganmohan Rao, had withheld material information, thereby the claim was repudiated by the opposite party No.2. The complainants further submitted that after repudiation the complainant No.1 addressed a letter on 11.03.2011 requesting the opposite parties to settle the claim, on which the Zonal Manager of opposite parties replied complainants that the higher authorities also repudiated the claim. The complainants also submitted that they issued legal notice to the opposite parties on 18.07.2011 and the same was acknowledged by the opposite parties and the opposite parties repudiated the claim of the complainants on flimsy grounds, that thereby there is deficiency of service on the part of opposite parties, for that the complainants approached the Forum.
2. On behalf of the complainant the following documents were filed and marked as Exhibits A1 to A 7.
Ex.A1:- Photocopy of First Premium Receipt.
Ex.A2:- Photocopy of Death Certificate.
Ex.A3:- Repudiation letter dt.05-01-2011, issued by the opposite parties.
Ex.A4:- Photocopy of letter dt.11-03-2011 addressed by the complainant.
Ex.A5:- Letter dt.01-04-2011 issued by Zonal Manager of the opposite party No.1.
Ex.A6:- Letter dt.12-07-2011 issued by Senior Divisional Manager of opposite party No.1.
Ex.A7:- Office copy of the legal notice, dt.18-07-2011 issued by complainant to the opposite parties No.1 & 2 with postal receipts (Nos.2) and acknowledgement cards (Nos.2).
3. On receipt of the notice, the opposite parties appeared through their counsel and filed counter. In the counter, the opposite parties admitted the taking of the policy by the deceased. The opposite parties submitted in their counter, as per the intimation received by them, the life assured died on 04.04.2010, since the claim under the policy had arisen just within 5 days of the date of commencement, treating the said claim as very early, an investigation was carried out as per the rules of the opposite parties corporation. The opposite parties also submitted that during the course of investigation certain facts came into light relating to pre-proposal critical illness and treatment of the deceased/life assured. The very date of receipt of his proposal for insurance along with the proposal deposit amount for the above said policy i.e. 31-03-2010, the deceased life assured was suffering from critical illness of “Chronic Rheumatic Heart Disease” and was undergoing treatment at Mamata Super Specialty Hospital, Khammam as in patient Reg. No.03/3223/10 and with MR. No.24078. The opposite parties also submitted that the deceased/life assured had intentionally suppressed the material facts of his chronic illness and treatment for the same. The opposite party further submitted that as per the certificate of hospital dtd.24.06.2010 of Department of Medicine, Mamata Super Specialty Hospital, Khammam the life assured was in unconscious state since 1.00 am on 31.03.2010 and also that he was a known case of Chronic Rheumatic Heart Disease with Post PBMV. And also submitted that all the reliefs prayed for by the complainants are fully untenable and far from law, since the said claim was repudiated only on the basis of direct, positive cogent evidence. For the above said reasons the claim under the said policy was repudiated for suppression of material facts. The opposite parties also relied on judgment of the Hon’ble A. P. State Consumer Dispute Redressal Commission, Hyderabad vide their order dated 17.10.2011, in F.A.No.149/2009, between Dr.PGK Murthy Vs LIC and the judgment of Hon’ble Supreme Court of India, vide their Civil Appeal No.5322 of 2007 between P.C. Chacko and Another Vs LIC of India and in Satwan Kaur Sandhu Vs New India Assurance Co. Ltd., dated 10.07.2009, in Civil Appeal No.2776/2002 and prayed to dismiss the complaint.
4. On behalf of the opposite parties, the following documents filed and marked as Exs.B1 to B5.
Ex.B1:- Proposal for Insurance dated 25.03.2010.
Ex.B2:- Photocopy of Discharge Card, dated 03.04.2010 of Mamata Super Specialty Hospital, Khammam.
Ex.B3:- Certificate of Hospital Treatment issued by the Mamata Super Specialty Hospital, Khammam.
Ex.B4:- Urine Analysis and Hematology investigation and medical reports (Nos.9) in the name of deceased/life assured.
Ex.B5:- Receipts for Investigation requisition Forms and In-patient tickets (Nos.32).
5. Counsel for complainant filed written argument.
6. Upon perusing the material available on record, now the points that arose for consideration are,
1) Whether the complainants are entitled for the claim?
2) To what relief?
Point No.1:-
The case of the complainants is that, the husband of the complainant No.1 and father of the complainants No.2 and 3, is the subscriber of insurance policy of opposite party company vide policy bearing No.578124978 for Rs.80,000/-. According to the complainants, the insure died on 04.04.2010 due to sudden ill-health. Though treatment was given in time the deceased died at Gandhi Hospital, Secunderabad. According to complainants, they immediately informed the death information to opposite party No.1 and also submitted the claim form along with original bond and other required papers of the death claim of the deceased. The opposite parties corporation failed to settle the claim of the deceased under the policy, as the opposite parties committed deficiency in service the complainants filed the present complaint. According to the opposite parties, the deceased/ life assured had intentionally suppressed the material fact of his critical illness and submitted proposal and obtained insurance policy, as such the complaint is liable to be dismissed.
From the documents and material available on record, we observed that the policy, the sum assured are not in dispute. The objection taken by the opposite parties is that the life assured had suppressed material fact of his critical illness from the opposite party corporation. For that the insurance company was bound to prove that the insured had received treatment or he was be aware from suffering of the decease before purchasing of the policy. In the present case, the documents filed by the opposite parties, Exs.B2 & B4, relating to the treatment after the policy and there is no medical record or affidavit of the Doctor that insured had taken treatment before the policy. Therefore, the opposite party corporation failed to produce direct evidence of the treatment before taking of the policy. And also the opposite party corporation had produced Discharge Card, Ex.B2, which did not support the case of the opposite parties to reveal that the insured was suffering from any decease prior to the date of obtaining the insurance policy. The Hon’ble National Commission in LIC of India Vs Shakuntala IV 2012 (CPJ) 549 (NC) observed the same.
In view of the above facts, it has been not established by the opposite party corporation that the insured had any pre-existing decease which was justify repudiation of the claim. For the reasons stated above and particularly absence of prior to the obtaining of the insurance policy was taking treatment from any Doctor/Hospital, the complainants are entitled for the claim and this point is answered according to in favour of the complainant.
Point No.2:- In the result, the complaint is allowed, directing the opposite parties to pay the Policy amount i.e. Rs.80,000/- covered under the policy bearing No.578124978, with interest @9% p.a. from the date of complaint ( i.e.11-08-2011) till the date of realization, among which, the complainant No.1 is entitled Rs.40,000/- together with accrued interest on Rs.80,000/-. The Complainants No.2 and 3 are entitled Rs. 20,000/- each. The amounts of complainants No.2 and 3 shall be kept in FDR in any Nationalized Bank till they attain the age of majority.
Dictated to steno, transcribed by her, corrected and pronounced by us in the open forum, on this 18th day of June, 2013
FAC PRESIDENT MEMBER
DISTRICT CONSUEMR FORUM, KHAMMAM
APPENDIX OF EVIDENCE
Witnesses examined for complainant: None
Witnesses examined for opposite parties: None
Exhibits marked for Complainant:
Ex.A1:- Photocopy of First Premium Receipt.
Ex.A2:- Photocopy of Death Certificate.
Ex.A3:- Repudiation letter dt.05-01-2011, issued by the opposite parties.
Ex.A4:- Photocopy of letter dt.11-03-2011 addressed by the complainant.
Ex.A5:- Letter dt.01-04-2011 issued by Zonal Manager of the opposite party No.1.
Ex.A6:- Letter dt.12-07-2011 issued by Senior Divisional Manager of opposite party No.1.
Ex.A7:- Office copy of the legal notice, dt.18-07-2011 issued by complainant to the opposite parties No.1 & 2 with postal receipts (nos.2) and acknowledgements cards (nos.2).
Exhibits marked for opposite parties:-
Ex.B1:- Proposal for Insurance dated 25.03.2010.
Ex.B2:- Photocopy of Discharge Card, dated 03.04.2010 of Mamata Super Specialty Hospital, Khammam.
Ex.B3:- Certificate of Hospital Treatment issued by the Mamata Super Specialty Hospital, Khammam.
Ex.B4:- Urine Analysis and Haematology investigation and medical reports (Nos.9) in the name of deceased/life assured.
Ex.B5:- Receipts for Investigation requisition Forms and In-patient tickets (Nos.32).
FAC PRESIDENT MEMBER
DISTRICT CONSUEMR FORUM, KHAMMAM.
