This C.C. came before us for hearing in the presence of Sri Danda Sudhakar Rao, Advocate for complainant and of Sri A. Sarath Chander, Advocate for opposite parties No.1 to 3; upon perusing the material papers on record; upon hearing arguments and having stood over for consideration, this Forum passed the following:-
ORDER
(Per Smt.V.Vijaya Rekha, Member)
This complaint is filed under section 12(1) of the Consumer Protection Act, 1986. The brief facts as stated in the complaint are that the wife of the complainant had obtained New Janaraksha Policy bearing No.688684542 for a sum of Rs.50,000/-, commencing from 26-07-2010 and matured on 26-07-2026 and she also joined in Jevan Saral (with profits) policy bearing No.688685543 for an assured amount of Rs.1,20,000/-, valid from 14-08-2010 and matured on 14.08.2025. The complainant is the nominee to the said two policies. On 07.11.2010, the life assured, Azmeera Dasamma was died due to sudden stomach and chest pain, then the complainant had submitted the claim forms to the opposite party No.2 by furnishing necessary documents, but the opposite party No.2 repudiated the claims by taking a false plea that the wife of the complainant had suffered from HTN since 15years and also suffered from Pedal Odema since 5 years. The complainant further submitted that the opposite parties issued said policies after conducting the necessary tests by their panel of doctors. The complainant also stated that at the time of taking the two policies, the life assured/ policyholder was in good health and as such the repudiation is not tenable and the complainant is entitled the all benefits being the nominee under the policy bearing Nos.688684542 and 688685543. Therefore, the complainant addressed a letter on 10-05-2011 to the opposite partyNo.1, in spite of settling the claim, the opposite parties did not respond properly, due to which, the complainant suffered a lot and after all efforts were futile, issued legal notice on 08-07-2011, even though, they failed to pay the claim amounts as assured, having no other chances, approached the Forum by alleging the deficiency of service on the part of opposite parties and prayed to direct the opposite parties to pay the assured amounts and death benefits under policy bearing Nos.688684542 and 688685543 together with interest and RS.25,000/- towards damages and costs.
2. Along with the complaint, the complainant filed affidavit and also filed the following documents, those were marked as Exhibits A1 to A8.
Ex.A1:- Original Premium receipt, dt.26-07-2010 for Rs.3,334/-.
Ex.A2:- Photocopy of New Janaraksha Policy, bearing No.688684542 with policy conditions.
Ex.A3:- Original Premium Receipt, dt.14-08-2010 for Rs.6,255/-.
Ex.A4:- Photocopy of LIC Jeevan Saral Policy (profits) with policy conditions.
Ex.A5:- Attested copy of Death Certificate.
Ex.A6:- Repudiation letter dt.29-03-2011 addressed to the complainant.
Ex.A7:- Letter dt.10-05-2011 addressed by the complainant to the opposite party No.1.
Ex.A8:- Office copy of legal notice, dt.13-06-2011 with postal acknowledgements.
3. On being noticed, the opposite parties No.1 to 3 appeared through their counsel and filed counter by denying the averments as mentioned in the complaint.
4. In the counter, the opposite parties admitted that the wife of the complainant had taken two life insurance policy bearing Nos.688684542 and 688685543 for a sum of Rs.50,000/- and Rs.1,25,000/- valid from 26-07-2010 and 14-08-2010 respectively. The opposite parties also submitted that the life assured died within 4 months from the date of obtaining the policies, therefore, investigation was done and it came to light that the life assured had suppressed the material facts related to the pre-existing illness and the complainant, who is employed with Acharya N.G.Ranga Agricultural University, Aswaraopet, availed the medical claim reimbursement for critical illness of his wife/life assured and according to the medical certificate dt.18-11-2007 issued by Dr.T. Babu Rao, M.B.B.S. of Aswaraopet, the deceased/policyholder had been suffering from acute and chronic renal ailment and was a known patient of high blood pressure and had high serum creatine levels. The opposite parties further submitted that as per the prescription dt.22-11-2007 of Vignesh Kidney Care, the wife of the complainant was suffering from HTN since 10years and advised to take renal biopsy and also submitted that as per the medical records of Charitasri and Andhra Hospitals of Vijayawada, the life assured was suffering from HTN since 15 years and dysnoea (shortness of breath) and had taken treatment for chronic renal failure. The deceased/policyholder had taken the said two policies in the year 2010 for wrongful gain and intentionally suppressed the material information related to her critical illness by giving negative answers to the Q.No.11 of her proposal forms, dt.26-07-2010 and 14-08-2010 regarding her health and as such after a careful consideration, the standing committee of the opposite parties, repudiated the claims of the complainant and the same was communicated to the complainant through a letter dt.29-03-2011. The opposite parties also stated that the life assured was suffered from pre-existing/pre-proposal illness and in support of their averments, the opposite parties quoted the judgments of higher Forums, such as P.C. Chacko and Another Vs LIC of India, in Civil Appeal No.5322, LIC of India Vs T. Venkateswarlu in Civil Appeal No.1682/2004 and in Oriental Insurance Co. Ltd. Vs Sony Cheriyan, SCC 451 of Hon’ble Supreme Court and the decisions of Hon’ble NCDRC, in LIC Vs Veerabhadraiah, in R.P. No.2922/2006, Vidyadevi etc. Vs LIC of India, CPJ 106 (NC) and Smt. Budhiben Prababhai Vs LIC of India in R.P. No.1312/2006, …… and prayed to dismiss the complaint with costs as there is no deficiency of service on the part of them.
5. Along with the counter, the opposite parties filed the following documents, those were marked as Exs.B1 to B16.
Ex.B1:- Proposal Form, dt.26-07-2010.
Ex.B2:- Photocopy of Medical Certificate, dt.18-11-2007, issued by Dr. Babu Rao, Vandana Nursing Home, Aswaraopet.
Ex.B3:- Photocopy of Prescription, dt.22-11-2007 of Vignesh Kidney Care, Vijayawada.
Ex.B4:-Photocopy of Discharge Summary, dt.10-12-2007 of Charitasri Hospitals, Vijayawada.
Ex.B5:- Photocopy of Bill Dt.10-12-2007, issued by Charitasri Hospitals, Vijayawada.
Ex.B6:- Photocopy of Essentiality Certificate, dt.12-03-2008, issued by Charitasri Hospitals, Vijayawada.
Ex.B7:- Photocopy of Medical Certificate dt.04-04-2010 issued by Dr. Babu Rao, Vandana Nursing Home, Aswaraopet.
Ex.B8:- Photocopy of Ultrasonogram Kub report, dt.05-06-2010, issued by Andhra Hospitals, Vijayawada.
Ex.B9:- Photocopy of Blood report, dt.29-06-2009 of Andhra Hospitals, Vijayawada.
Ex.B10:- Photocopy of Prescription dt.18-06-2008, issued by Dept. of Nephrology, Andhra Hospitals.
Ex.B11:- Photocopy of Prescription dt.29-06-2009, issued by Dept. of Nephrology, Andhra Hospitals.
Ex.B12:- Photocopy of Urine Analysis report, dt.29-06-2009 issued by Andhra Hospitals.
Ex.B13:- Photocopy of Letter dt.19-08-2010, addressed by the Associate Dean, Agrl. College, Aswaraopet to the D.M.H.O., Khammam.
Ex.B14:- Photocopy of letter dt.24-07-2010, addressed by the complainant to the Associate Dean, Agrl. College, Aswaraopet.
Ex.B15:- Photocopy of Essentiality Certificate dt.14-07-2010, issued by Andhra Hospitals.
Ex.B16:- Photocopy of Bills for medicines and bills for investigation reports (Nos.12).
Along with a petition, the counsel for opposite parties filed the attested copy of proposal form, dt.14-08-2010, which was marked under Ex.B17.
6. In support of his averments, the complainant filed written arguments by reiterating the same averments as mentioned in the complaint. The opposite parties filed a memo by stating that to treat the contents of their written statement as written arguments.
7. In view of the above submissions, now the point that arose for consideration is,
Whether the complainant is entitled to the relief
as prayed for?
Point:-
It is an admitted fact, during the lifetime of the deceased/policyholder, she had obtained two life insurance policy bearing Nos.688684542 and 688685543 for Rs.50,000/- and Rs.1,25,000/- on 26-07-2010 and 14-08-2010 respectively, the only dispute between the parties is with regard to the suppression of pre-existing illness at the time of submission of proposal forms for two policies. It is the version of the complainant that his wife had obtained said two policies, when she was hale and healthy and when the policies were in force, died due to stomach and chest pain, therefore, the complainant claimed for death benefits and assured amounts under the policy bearing Nos.688684542 and 688685543 being the nominee, after all efforts were in vain, the complainant filed the present complaint by alleging the deficiency of service on the part of opposite parties in settling the claim. On the other hand, the opposite parties contended that the insured had obtained said two policies by suppressing the treatment for HTN since 15years and chronic renal paranchymal disorder since 5 years i.e. prior to the date of submission of proposals. In support of their averments, the opposite parties placed Exs.B1 to B17, which contains Proposal Forms, dt.26-07-2010 and 14-08-2010, and medical record regarding the treatment, bills and tests reports Exs.B2, B3, B4, B6 & B7 reveals that the deceased/policy holder was known Hypertensive since 10 years and as on the date of said documents, she has been suffering from acute and chronic renal ailment and her health condition was managed on regular medication. Ex.B13 is the letter dt.19-08-2010, addressed by the Associate Dean of Agricultural College, Aswaraopet to the D.M.H.O. for sanction of reimbursement of medical claim of the complainant, towards medical expenses for his wife’s treatment, Ex.A14 is the letter, addressed by the complainant to the Dean of Agricultural College, Aswaraopet for consideration of his claim under reimbursement of medical expenses, incurred on his wife’s treatment and Ex.B15 is the Essentiality Certificate, dt.14-07-2010 issued by Andhra Hospitals, Vijayawada by giving particulars of the charges for usage of medicines from their Pharmacy. Upon perusing the said documents, it is a fact, the complainant had claimed the higher authorities for the amounts under medical reimbursement towards medical expenses on his wife’s treatment at Andhra Hospitals, Vijayawada. Basing on the material on record, it is clear that the wife of the complainant had suffered from HTN and renal failure before submission of proposal forms and had taken treatment for the same since 18-11-2007 till 14-07-2010 i.e. prior to date of proposals dt.26-07-2010 and 14-08-2010 and concealed her illness related to HTN and renal failure, in this regard the complainant failed to take any steps to disprove the above contentions, raised by the opposite parties by filing sufficient proof and as such we cannot come to the conclusion in favour of the complainant without the sufficient material on record. In this respect, we relied the judgments, given by the Hon’ble National commission, in LIC Vs Smt.Kempamma, decided on 24-01-2013 and in LIC of India Vs Smt. Gurvinder Kaur, decided on 30.05.2013, in the above mentioned two judgments, the Hon’ble National Commission categorically stated that “the life assured had suppressed the material facts regarding his previous treatment and operation and has furnished false answers regarding his health…. Petitioner has not committed any deficiency in repudiating the claim”. In view of the aforesaid decisions and discussions, we cannot hold that the opposite parties are liable to pay the assured amounts under policy bearing Nos.688684542 and 688685543 and as such the point is answered accordingly against the complainant.
8. In the result, the complaint is dismissed. No costs.
Typed to my dictation, corrected by me and pronounced by us, in this Forum on this 26th day of July, 2013.
FAC President Member
District Consumer Forum, Khammam
APPENDIX OF EVIDENCE
Witnesses examined for complainant and opposite parties: -None-
Exhibits marked for complainant:-
Ex.A1:- Original Premium receipt, dt.26-07-2010 for Rs.3,334/-.
Ex.A2:- Photocopy of New Janaraksha Policy, bearing No.688684542 with policy conditions.
Ex.A3:- Original Premium Receipt, dt.14-08-2010 for Rs.6,255/-.
Ex.A4:- Photocopy of LIC Jeevan Saral Policy (profits) with policy conditions.
Ex.A5:- Attested copy of Death Certificate.
Ex.A6:- Repudiation letter dt.29-03-2011 addressed to the complainant.
Ex.A7:- Letter dt.10-05-2011 addressed by the complainant to the opposite party No.1.
Ex.A8:- Office copy of legal notice, dt.13-06-2011 with postal acknowledgements.
Exhibits marked for opposite parties:-
Ex.B1:- Proposal Form, dt.26-07-2010.
Ex.B2:- Photocopy of Medical Certificate, dt.18-11-2007, issued by Dr. Babu Rao, Vandana Nursing Home, Aswaraopet.
Ex.B3:- Photocopy of Prescription, dt.22-11-2007 of Vignesh Kidney Care, Vijayawada.
Ex.B4:-Photocopy of Discharge Summary, dt.10-12-2007 of Charitasri Hospitals, Vijayawada.
Ex.B5:- Photocopy of Bill Dt.10-12-2007, issued by Charitasri Hospitals, Vijayawada.
Ex.B6:- Photocopy of Essentiality Certificate, dt.12-03-2008, issued by Charitasri Hospitals, Vijayawada.
Ex.B7:- Photocopy of Medical Certificate dt.04-04-2010 issued by Dr. Babu Rao, Vandana Nursing Home, Aswaraopet.
Ex.B8:- Photocopy of Ultrasonogram Kub report, dt.05-06-2010, issued by Andhra Hospitals, Vijayawada.
Ex.B9:- Photocopy of Blood report, dt.29-06-2009 of Andhra Hospitals, Vijayawada.
Ex.B10:- Photocopy of Prescription dt.18-06-2008, issued by Dept. of Nephrology, Andhra Hospitals.
Ex.B11:- Photocopy of Prescription dt.29-06-2009, issued by Dept. of Nephrology, Andhra Hospitals.
Ex.B12:- Photocopy of Urine Analysis report, dt.29-06-2009 issued by Andhra Hospitals.
Ex.B13:- Photocopy of Letter dt.19-08-2010, addressed by the Associate Dean, Agrl. College, Aswaraopet to the D.M.H.O., Khammam.
Ex.B14:- Photocopy of letter dt.24-07-2010, addressed by the complainant to the Associate Dean, Agrl. College, Aswaraopet.
Ex.B15:- Photocopy of Essentiality Certificate dt.14-07-2010, issued by Andhra Hospitals.
Ex.B16:- Photocopy of Bills for medicines and bills for investigation reports (Nos.12).
Ex.B17:- Attested copy of proposal form, dt.14-08-2010.
FAC President Member
District Consumer Forum, Khammam.
