Andhra Pradesh
Visakhapatnam
CC/101/2013
SMT.PENTA NAGARATNAM - Complainant(s)
Versus
AGEON RELIGAR LIFE INSURANCE CO. LIMITED - Opp.Party(s)
ADARI APPA RAO
24 Nov 2014
ORDER
Date of registration : 29.04.2013
Date of order : 24.11.2014
BEFORE THE DISTRICT CONSUMERS FORUM-I,
VISAKHAPATNAM : AP
PRESENT: Smt K.V.R.Maheswari, B.A., B.L., LL.M.,
Lady Member & FAC President
Sri V.V.L.Narasimha Rao, B.A., LL.M., PGDHR,
Member
Monday the 24th day of November, 2014
Consumer Complaint No: 101 / 2013
Between:
Smt.Penta Nagaratnam, W/o Apparao (late), Hindu,
aged 46 years, Kotturu Village, Anakapalle Mandal,
Visakhapatnam District. … Complainant
And:
The General Manager, AGEON Religare Life Insurance Co. Ltd., 2nd Floor, Paranjpe’B’ Scheme, Subhash Road, Ner Garware House, Vileparle (East), Mumbai-400057.
The Branch Manager, AGEON Religare Life Insurance Co. Ltd., 2nd Floor, The Land Mark Building, Beside Airtel, Waltair Uplands, Visakhapatnam-03.
… Opposite Parties
This case is coming for final hearing on 10-11-2014 in the presence of Sri Adari Appa Rao, Advocate for Complainant and Sri K.V.S.V.Prasada Rao, Advocates for 1st Opposite party and 2nd Opposite Party set exparte and having stood over till this date, the Forum delivered the following.
: O R D E R :
(As per Sri V.V.L.Narasimha Rao, Honourable Member on behalf of the Bench)
The present Complaint is filed by the Complainant on 22.04.2013 under Sec.12 of C.P.Act against the Opposite Parties 1 & 2 and Complainant requested the forum to direct the Opposite Parties (1) to pay an amount of Rs.5,50,000/- insurance claim amount along with 24% interest from the date of claim till realization (2) to pay compensation of Rs.50,000/- for causing mental agony (3) to pay the costs for legal expenditure and any other relief or reliefs as this Forum deems fit and proper.
The brief averments are as follows: The Complainant states that her husband obtained AEGON Religare Level Term Plan Life Insurance Policy bearing No.110613135107 for an amount of Rs.5,50,000/- from the Opposite Parties on 08.06.2011 in which the Complainant is the nominee. On 14.08.2011, the Complainant husband noticed some chest pain and immediately he called Dr.T.Nagabhushana Rao for his checkup. By the time the Doctor came to his house Complainant’s husband died and Doctor stated that the insured (Complainant’s husband) died due to heart failure. Thereupon when the Complainant came to know about the Insurance policy obtained by her husband, she requested the 2nd Opposite Party on 24.09.2012 and submitted Claim Form along with original policy bond, Original Death certificate and relevant other required documents. Thereupon the Opposite Party’s employees came to the house of the Complainant and stated that both of them came for investigating about the claim and enquired about the claim of the Complainant with the neighbours and the Complainant. After that the said two investigators who has taken the Investigation report demanded the Complainant for an amount of Rs.75,000/- for settling the claim, as the Complainant refused to pay the said amount, the investigators kept quiet.
As there is no correspondence from the Opposite Parties with regarding to the settlement of the claim on 22.10.2012, she personally approached the Opposite Party and enquired about the status of the Claim Form. The Opposite Parties issued copy of the repudiation letter dt. 18.10.2012 with false allegations that insured (Complainant’s husband) suffered with Tuberculosis since year 2007. Even after that also the Complainant personally went to the Opposite Party and requested to reconsider the Insurance Claim on 3.11.2012. as there is no response from the Opposite Parties even after submitted a letter dt.3.11.2012. Having no other alternative remedy, the Complainant has filed the present Complaint before this Forum seeking reliefs as sought for.
Notices served to the Opposite Parties 1 & 2. On behalf of the Opposite Parties Sri Jatin Parekh in the capacity of Head-Legal and Company Secretary filed Counter and stated as follows: The present Complaint filed by the Complainant is not maintainable on the facts and also basing upon the law. When there is no cause of action, the issue of filing the Consumer dispute does not arise. More particularly, the District Consumer Forum is not having jurisdiction to entertain the Complaint. Even there is no deficiency of service on part of the Opposite Party, and also there is no negligence on part of the Opposite Party. The Complainant’s husband fraudulently concealed the medical record and mislead the Opposite Parties and obtained the Insurance Policy by giving wrong information. At the time of the obtaining the Policy it is the duty of the Insured to give the correct information with regarding to his medical history, further the Complainant has answered ‘NO’ for medical information pertaining to the Complainant’s husband which was revealed in the application form. The non-disclosure of the facts amounts to fraud under definition of Sec.19 of Indian Contract Act. As the Complainant’s husband is suffering with Tuberculosis since long time and also he left his Job due to the said disease which was reflected in T.B. patient No.449/207 of Primary Health Care Centre, Kasimkota, Anakapalle. The Complainant’s husband intentionally suppressed that fact and obtained the Insurance policy. “The said fact was revealed by the Investigator at the time of the Investigation about the claim”. The Proposal Form itself reveals that the Complainant’s husband has given false information about the medical information for taking the policy. As per Sec.45 of the Insurance Act, 1938, Opposite Parties can repudiate the claim and call the policy in question on the ground of concealment of material facts. As the Complainant’s husband has suppressed about his previous pre-existing disease, the Complainant is not entitled for any claim from the Opposite Parties.
Along with the Counter averments, the Opposite Parties has also discussed about 7 case laws (1) 2001 (2) SCC 160 LIF & Ors Vs Asha Goel & Anr (2) 2009 CTJ 956, Satwant Kaur Sandhu vs New India Assurance Co. Ltd. (3) 2008 CPJ 78 SC P.C.Chako and Anr Vs Chairman, Life Insurance Corporation of India and Ors (4) 1999 (3) 123 PLRD 28 Sita Holiday Resorts Limited Vs. M/s.Mohan Lal Harbans Lal Bhayana and Company (5) First Appeal No.242/2006 in Dineshbhai Chandrana Vs LIC & Anr (6) I (2003) CPJ 393 United India Insurance Co. Ltd Vs Harchand Rai Chand Rai Chandan Lal (7) II (2009) CPJ 34 Vikram Greentech (I) Ltd. & Anr Vs New India Assurance Co. Ltd. The said 7 case laws are related to the “suppression of previous medical records by the Insured and the same was proved by the Insurer and thereby the Insurance is rejected”.
To prove the allegation leveled by the Opposite Parties, the Complainant to himself filed an IA 230/2014 in CC 101/2013 under Sec.13(4)(ii) of the C.P.Act and requested the Forum to direct the Chief Medical Officer, Primary Health Centre, Kasimkota, Visakhapatnam District to produce the Revised National Tuberculosis Control Programme Treatment Card bearing T.B.No.449/2007. Observing the contentions in the I.A., the Forum has given direction to the Chief Medical Officer, Primary Health Centre, Kasimkota, Visakhapatnam to furnish the original Revised National Tuberculosis Control Programme Treatment Card. The Chief Medical Officer, Dr.J.Prasanthi, PHC, Kasimkota filed two documents dt.22.09.2014 and 23.09.2014 related to the Medical Record.
On perusing the entire pleadings of the both parties and the documents furnished by Dr.J.Prasanthi of PHC, Kasimkota, the Forum has framed the following points for consideration:- i ) Whether the complaint is within the jurisdiction of this Forum; ii) Whether there is any deficiency of service on part of Opposite parties ; iii) To what relief.
The complainant filed her Evidence Affidavit and on her behalfExs.A1 to A5 are marked. The Opposite Parties filed 5 documents in support of their defense which were marked as Exs.B1 to B5. The two documents furnished by Dr.J.Prasanthi, P.H.C., Kasimkota, were marked as Exs.C1 & C2. The Complainant and the Opposite Parties filed their Written Arguments and also adduced their oral arguments. At the time of arguments, the Opposite Parties has filed Judgement in R.P.No.380/2013 in support of their version.
Point No.1: The Opposite Parties in their counter part stated that this Forum is not having jurisdiction to entertain this Complaint. Observing the Ex.A1, Insurance Policy Schedule along with Ex.A3, Death Certificate of Complainant’s husband and the Ex.A4 Repudiation letter, Ex.A5 representation dt.3.11.2012 for claiming the insurance claim as the Complainant’s husband has paid the insurance premium for the Policy No. 110613135107 and the same was admitted by the Opposite Parties. Hence, we conclude that this Forum is having jurisdiction to entertain this complaint. Accordingly point No.1 is answered.
Point Nos.2 & 3: The present complaint is filed against the Opposite Parties 1 & 2 for claiming the Insurance claim of Rs.5,50,000/- as her husband has obtained Insurance policy No.110613135107 in which she is the nominee. The Opposite Parties in their counter and the Evidence Affidavit stated as the Complainant’s husband has suppressed the material facts i.e. Medical record and gave negative answers in the Proposal Form as ‘NO’ and also the Complaint does not falls within the jurisdiction of this Forum. The complaint is liable to be dismissed and also at the same time the Complainant is not entitled for any relief as sought for in the Complaint. Ex.A1 is the Policy Schedule of the Policy No. 110613135107 which will be valid from 8.6.2011 to 07.06.2031. In the said Ex.A1 the sum assured i.e. Rs.5,50,000/- is mentioned and the nominee’s name is mentioned as P.Nagaratnam i.e. the Complainant. Ex.A3 is the Death Certificate of the Complainant’s husband which reveals that the Complainant’s husband has died on 14.08.2011.
- The Opposite Parties in the Evidence Affidavit and Counter stated that the Complainant’s husband has taken treatment for Tuberculosis in P.H.C., Kasimkota vide Sl.No.449. To prove her genuinity and bonafides the Complainant has filed I.A.No.230/2014 in CC No.101/2013 calling for the record of T.B. patients in PHC, Kasimkota, Anakapalle. As per the request of the Complainant, the Forum gave direction to the Medical Officer, P.H.C.,Kasimkota to furnish actual records. The Medical Officer, Smt.Dr.J.Prasanthi came in person before this Forum and furnished two documents i.e. Exs.C1 & C2. Ex.C2 is the document i.e. the letter served from Medical Officer, T.B.Unit, Anakapalle to the Medical Officer, PHC, Kasimkota for giving information with regarding to the original Revised National Tuberculosis Control Programme Treatment Card bearing T.B.No.449/2007 which was allotted by the Opposite Parties 1 & 2. As per Ex.C2, it reveals thatthere were only 448 T.B. cases treated in the year 2007 and they cannot trace the Sl.No.449/2007 of the T.B.Case. Ex.C1 is the document dt.22.09.2014 served to the Medical Officer, T.B.Unit, Anakapalle, Visakhapatnam District by the Medical Officer, PHC, Kasimkota stating that “they are unable to furnish the Sl.No.449 of the T.B. case in the District Consumer Forum, Visakhapatnam”. Ex.B3 is the Revised National Tuberculosis Control Programme Treatment Card vide Sl.No.449/2007 at Kasimkota Health Centre which is on the name of the Penta Appa Rao i.e. the Complainant’s husband. Ex.B4 is the Investigation Report dt.10.10.2012 given by the Investigation Officer, who has investigated with regarding to the claim of the Complainant vide Policy No. 110613135107. In Ex.B4, the Investigator noted the death of the Complainant’s husband as place of death at his residence, date of death 14.08.2011 and cause of death reported as natural. Though the Investigator gave report vide Ex.B4, as the Complainant’s husband died Naturally which was visible on the Page No.1 (i.e. on the face of the document) in Para 9 of Page No.2 in Ex.B4, it shows “when he enquired in ART Section, it revealed that a patient bearing No.449/07 (the address and the name of the patient is matching with the claimant’s husband) states that Penta Appa Rao, Aged 50 years, S/o Appanna got treatment regarding Tuberculosis Treatment Card at ART Section”. In Para 10 of Page 2 in Ex.B4, the said Investigator states that “the medical record clearly indicates that the insured suppressed his true health status in proposal and obtained subject insurance cover on his life”.
- The Investigator in one side stating that he got information about the Complainant’s husband taken the treatment for Tuberculosis Treatment part at ART Section and on other side, he himself is stating that the Complainant’s husband died on 14.08.2011 at his residence and the cause of death is ‘natural’.
- Ex.A3 also states that the date of death of the complainant’s husband is 14.08.2011. When observing the Ex.A2, is the certificate given by Dr.T.Nagabhushana Rao, who states that “when I visited the patient’s home on 14.08.2011 at about 6 AM, there is no pulse, no Blood Pressure and already the patient is expired may be due to heart failure”.
Even observing the version of the Complainant in the Complaint, Evidence Affidavit the Complainant is stating that as the Complainant’s husband has noticed some chest pain on 14.08.2011 and called Dr.T.Nagabhushana Rao, before Doctor came to their house, he might have died and the said Doctor confronted that her husband died. So viewing the version of the Complainant in the Evidence Affidavit regarding to the death of her husband along with Investigator’s report Ex.B4 and the Ex.A2 Dr.T.Nagabhushana Rao’s certificate, we are of conclusive opinion that the Complainant’s husband died naturally may be due to the heart failure.
Observing Ex.C1 & C2 along with the Ex.B3. Ex.B3 is the copy of the record of the Tuberculosis treatment Card vide Sl.No.449/2007 of P.H.C., Kasimkota. The said exhibit is not even attested by a Doctor of the concerned P.H.C. So in our opinion there is some doubt upon the Ex.B3.
When observing the Ex.C1 & C2 basing upon the direction of the Medical Officer, T.B.Unit, Anakapalle, the Medical Officer of P.H.C., Kasimkota has given information about the Tuberculosis patients Treatment record stating that there are only T.B. cases treated in the year 2007 for about 448 only and the T.B.No.449/2007 could not be traced.
The allegation is made by the Opposite Parties is with regarding to the pre-existing disease confronting with the Sec.45 of Insurance Act, it is the bounded duty of the Insurer (i.e. Opposite Parties 1 and 2) to prove the case. Here observing the Ex.C1 & C2 when the Medical Officer is stating that T.B.No.449/2007 could not be traced and the same was communicated to the Medical Officer vide Ex.C1 to the Tuberculosis Unit, Anakapalle, Visakhapatnam District. When the Opposite Party is more particular about the Medical record of the Complainant’s husband, they could have taken further steps for directing the any other concerned Medical Officer to prove that the Sl.No.449/2007 vide Ex.B3 is correct. To that extent, the Opposite Parties has not taken any further steps to prove their contention.
As per the case law 2005 (3) ALT 9 CPJ between Oriental Insurance Co. Ltd. Vs.Ch.Venkatesam, the Hon’ble A.P.State Commission while deciding the F.A.No.930/2003 in CP No.68/2000 dt. 8.4.2014 it was held that the burden of proof with regarding to the mis-representation of the facts about the health of the insured lies upon the insurer only.
Though the case law in Civil Appeal No.2776 of 2002 between Satvant Kaur Sadhu Vs. New India Assurance Co. Ltd., the Hon’ble Supreme Court held that the Appellant has found guilty that he has misrepresented the facts about his medical records and obtained the Policy with fraudulent intention, the Opposite Parties can repudiate the claim and there is no illegality on part of the Insurance company for repudiating the claim.
Here in this case on hand: Though there is chance for proving their case, as they are stressing about the Ex.B3 document that Complainant’s husband has taken the treatment for Tuberculosis at PHC, Kasimkota vide Sl.No.449/2007 and at the same time the Complainant herself filed IA 230/2014 for calling for the Records, which was revealed by the Exs.C1 & C2 that there were only 448 cases of Tuberculosis in PHC, the Opposite Party has to take further steps to prove that the Complainant’s husband has obtained policy with a fraudulent intention by following the principle of Case Law 2005 (3) ALT CPJ (vide Para 18 supra).
More particularly their investigator himself has confronted vide Ex.B4 dt.10.10.2012 that Complainant’s husband died naturally and the same was confronted by the Ex.A2 i.e. Certificate of Dr.T.N.Bhushan Rao that, “Complainant’s husband might have died due to her failure”. So observing the facts and the circumstances of this case, we conclude that the Opposite Parties cannot rely upon the 7 case laws including Satvant Kaur Sandhu Vs. New India Assurance Co. Ltd. as they have not proved their case.
Even observing the principle of case law 2005 (3) ALT 9 CPA vide para No.18 supra) as the Opposite parties has not proved their contention, unless and until there is an authentic attestation on the Ex.A3, Tuberculosis Treatment card, we cannot come to conclusion that Complainant’s husband has suffered with Tuberculosis and obtained treatment at PHC, Kasimkota vide Sl.No.449/2007.
In the light of the facts and the pleading of the both parties and observing the Exs.C1 & C2 along with Ex.B4, Investigation Report and Ex.A2, Certificate of Dr.T.Nageswara Rao and Ex.A4 Repudiation letter of Opposite Parties dt. 18.10.2012, we are of considered opinion that the Opposite Parties repudiated the claim illegally vide Ex.A4 and thereby there is deficiency of service on part of the Opposite Parties in repudiating the Complainant’s claim. Hence, the Opposite Parties 1 & 2 are jointly and severally liable to pay Rs.5,50,000/- to the Complainant towards claim of Insurance Policy for the Policy No.110613135107 @ 6% interest from the date of repudiation letter i.e. Ex.A4 18.10.2012 till realization. As interest is awarded we hold that there is no necessity to award compensation to the Complainant. The Opposite Parties 1 & 2 are also jointly and severally liable to pay costs of Rs.3,000/- towards costs for legal expenditure. Accordingly Point Nos.2 & 3 is answered.
In the result the Complaint is allowed in part. The Opposite Parties 1 & 2 are jointly and severally liable to pay Rs.5,50,000/- to the Complainant along with interest @ 6% p.a. from 18.10.2012 till realization and also Opposite Parties are also jointly and severally liable to pay Rs.3,000/- towards costs for legal expenditure. Time for compliance within 30 days from the date of receipt of this Order.
Dictated to the Shorthand Writer, transcribed by him, corrected and pronounced by us in the open Forum on this the 24th day of November, 2014.
Sd/- Sd/-
President (FAC) Member
District Consumer Forum-I
Visakhapatnam
APPENDIX OF EVIDENCE
Exhibits Marked for the Complainant:
Ex.A1
08.06.2011
Policy Document
Photostat copy
Ex.A2
09.01.2012
Certificate issued by Dr.T.Nagabhushana Rao
Original
Ex.A3
14.08.2011
Death Certificate
Original
Ex.A4
18.10.2012
Repudiation letter issued by the 2nd Opposite Party
Photostat copy
Ex.A5
03.11.2012
Re-consideration letter submitted by the complainant to the 2nd Opposite party
Photostat copy
Exhibits Marked for the Opposite Parties:
Ex.B1
Board Resolution
Attested True copy
Ex.B2
06.06.2011
Proposal Form
Photostat copy
Ex.B3
Treatment card obtained through National Tuberculosis Control Programme
Attested True copy
Ex.B4
Investigation Report
Attested True copy
Ex.B5
18.10.2012
Repudiation Letter
Attested True copy
Exhibits Marked by Dr.J.Prasanthi, Chief Medical Officer, PHC, Kasimkota:
Ex.C1
22.09.2014
Letter addressed to the MO, TB Unit, Anakapalle by MO, PHC, Kasimkota
Original
Ex.C2
23.09.2014
Reply from MO, TB Unit, Anakapalle
Original
Sd/- Sd/-
President (FAC) Member
District Consumer Forum-I
Visakhapatnam
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