DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, Civil Station, Palakkad 678001, Kerala
Dated this the 23rd day of February, 2010
Present: Smt.Seena.H, President Smt.Preetha.G.Nair, Member Smt.Bhanumathi.A.K, Member
C.C.No.106/2007
Leela, W/o.Late Dr.Mohandas, Mangattil House, Thattampadi, Edappal, Malappuram Dist. - Complainant (By Adv.Showkketh Babu.R.K & U.Muhammed Musthafa) Vs
1. Bajaj Allianze Life Insurance Company Ltd. 5th Floor, Ashok Plaza Corporate, Software Park, S.N.32/3, Nayar Road, Varriar Nagar, Pune 411 006.
2. The Branch Manager, Bajaj Allianze Life Insurance Company Ltd. Amritha Towers, Mele Pattambi, Pattambi. - Opposite parties (By Adv.K.S.Menon) O R D E R
By Smt.Seena.H, President
Case of the complainant in brief:- Complainant herein is in the capacity of legal heir of her deceased husband who was a policy holder bearing No.0016168692 issued by the 1st opposite party by paying a premium of Rs.20,000/-. Complainant's husband has applied for the said policy through the 2nd opposite party. As per the terms of insurance coverage, the 1st opposite party has to pay an amount of Rs.1,00,000 in the event of death of the policy holder. Policy commenced on 20.02.2006. The complainant's husband expired on 17.09.2006. Thereafter complainant claimed for the insurance amount, but the same was repudiated by the opposite parties stating that as per the investigation and hospital records, the insured had history of diabetes millitus since six
years and hypertension since seven years. The insured knowingly suppressed these facts at the time of taking policy. According to the complainant her husband was healthy and had no disease at the time of applying or registering the insurance policy. After receiving the letter of repudiation the complainant sent a registered lawyer notice dt.4.2.2007 to the opposite parties stating her grievance. Opposite parties has not replied for the same. According to the complainant, the repudiation of claim and the irresponsible attitude of the opposite parties amounts to clear deficiency of service. Complainant prays for an order directing the opposite parties to pay an amount of Rs.1,00,000 the insurance amount and Rs.50,000 as compensation for the mental agony and loss sustained on account of the deficiency of service.
Earlier opposite parties were set ex-parte and complaint was allowed by the forum. Thereafter it was taken up in appeal by second opposite party. Complaint was remanded back to the forum for fresh disposal.
Second opposite party filed version with the following contentions. Issuance of the policy and happening of death within the period of policy is not disputed. According to 2nd opposite party the said policy was issued only on the basis of disclosure of the facts stated in the proposal form. Later the opposite parties were informed that the policy holder expired on 17.09.06. The claim for the amount insured was received from the complainant on 13.10.2006 and the same was investigated by the officers of the opposite party. The investigation report revealed that the policy holder has suppressed material and true facts regarding pre-existing diseases and had obtained policy by misrepresentation and fraud. The insured had uncontrolled diabetes mellitus for over six years and was having hypertension for over 7 years. The insured was a Homoeo Doctor and he was taking his own medicines. These facts which were in the exclusive knowledge of the insured had been suppressed by him at
the time the proposal was filled. The investigation conducted by the opposite party revealed that as a Homoeo Doctor the insured was reluctant to take any medicines or treatment other than his own. He has not kept any records regarding his treatment. It is understood that the deceased had contacted Dr.Narayanan of Sukapuram Hospital on 31.08.06 with complaint of decreased urine out put and generalised oedema. The said Doctor has diagnosed acute nephritis with renal failure. The death summary issued from Amrita Institute of Medical Science and Research Centre clearly indicates that Dr.Mohandas is a diabetic for six years and hypertensive for more than 7 years and was on regular medication. According to opposite party, the complainant herein who is the wife of the insured has already admitted the fact that the insured was suffering from diabetics. The claim was therefore repudiated due to non disclosure of material fact and the same was informed to the complainant by letter dt.4.2.07. According to opposite party repudiation of the claim is entirely on just and sufficient reason. Second opposite party denies the say of the complainant that one Alex.P.Sakaria, Sales Representative of the company requested the complainant to give exaggerated description about the disease of her husband so that she will get more benefit. Complainant herself has admitted the fact in the statement given by her to the investigator that the insured was suffering from diabetics. Further in the proposal form against the enquiry whether the insured is a diabetic patient or not. The answer given is in the negative. The policy is obtained clearly on misrepresentation of facts and as such the rejection of the claim is just and proper.
The evidence adduced by the complainant consists of the chief affidavit and Exts.A1 to A7. Second opposite party filed affidavit and Ext.B1 to B12 were marked. Complainant and 2nd opposite party were cross examined as PW1 and DW1.
Issues for consideration;
Whether there is any deficiency in service on the part of opposite parties? If so, what is the relief and cost?
Heard both parties in detail and gone through the entire documents on record.
The definite case of the complainant is that the opposite parties without any sufficient reason has repudiated the insurance claim of the complainant. Second opposite party on the other hand contented inter alia that the insured has suppressed material facts regarding his pre-existing disease and hence the repudiation is just and proper. On going through the records it can be seen that the only documents in favour of the opposite party is Ext.B5 which is the statement given by the complainant regarding disease of her husband. In the said statement complainant has stated that her husband was a diabetic. Further personal statement regarding the disease of the insured has stated by her relative and neighbour also reveals that the insured was diabetic patient. Marking of the said documents was strongly objected by the complainant. It is true that the complainant has contrary version regarding the said statement in the complaint and in her deposition. In the complaint she has stated that the statement was given by her as per the request of the investigator that giving exaggerated description of the disease will entitle her more benefits under the insurance coverage and therefore she herself has given a self written statement to the opposite party. While cross examining she has deposed that she has only given signed blank papers to the investigator. Other than the said evidence, no other supporting documents were produced by the opposite party to prove that the deceased has pre-existing disease. In the version opposite party has stated that the Death Summary issued from Amrita Institute of Medical Science and Research Centre clearly indicates that the insured was a diabetic for six years and hypertension for over seven years and was on regular medication. No supporting documents were produced by the opposite party to substantiate the said contention. In the
absence of solid evidence regarding the pre-existing disease we are not in a position to accept the contention of the opposite party. Further opposite party has not proved the nexus between the disease alleged to be concealed by the insured and the reason for death of the insured. No documents has been produced by the opposite party to substantiate this aspect. It is settled position that the onus to prove that there has been suppression of material fact with regard to pre-existing disease rest heavily on the Insurance Company.
In view of the above said facts and circumstances of the case we are of the view that complaint be allowed. In the result complaint allowed.
Opposite parties are directed to pay an amount of Rs.1,00,000/- (Rupees One lakh only) being the policy amount and Rs.5,000/- (Rupees Five thousand only) as compensation for mental agony and Rs.1,000/- (Rupees One thousand only) as cost. The order shall be complied within one month from the date of communication of the order failing which the whole amount shall carry an interest of 9% per annum from the date of order till realisation.
Pronounced in the open court on this the 23rd day of February, 2010 Sd/- Seena.H, President Sd/- Preetha.G.Nair, Member Sd/- Bhanumathi.A.K, Member Appendix Witnesses examined on the side of complainant PW1 – Smt.Leela Witnesses examined on the side of opposite parties DW1 – Shri.Suresh.K.U, the Branch Manager, Bajaj Allianz, Palakkad
Exhibits marked on the side of complainant Ext.A1 – First premium receipt dt.20.02.2006 issued by opposite party Ext.A2 – Letter dt.21.02.2006 sent by opposite party to complainant Ext.A3 – Copy of Death Certificate Ext.A4 – Repudiation letter dt.04.02.2007 sent by opposite party to complainant Ext.A5 (Series) 3 Nos. - Copy of lawyer notice, postal receipt Ext.A6 – Acknowledgement card Ext.A7 – Acknowledgement card dt.23.03.2007 Exhibits marked on the side of opposite party Ext.B1 – Proposal Form for Life Insurance given by Dr.Mohandas.M Ext.B2 – Letter dtd.11.10.06 sent by complainant to 2nd opposite party Ext.B3 – Authorisation to Shri.Sunil Kumar.P.G Ext.B4 – Investigation report Ext.B5 – Statement dt.17.12.06 given by the complainant Ext.B6 – Statement dt.17.12.06 given by sister of the insured Ext.B7 - Statement dt.17.12.06 given by Shri.Ratheesh.A, neighbour of complainant Ext.B8 – Death Summary Ext.B9 – Certificate issued by Dr.K.Narayanan Ext.B10 – Photo copy of Death Certificate of the insured Ext.B11 – Photo copy of rejection letter dt.04.02.07 sent by 1st opposite party to complainant Ext.B12 – Rejection letter dt.04.02.07 sent by 1st opposite party to complainant Costs (Allowed) Rs.1,000/- (Rupees One thousand only) as cost
| | HONORABLE Smt.Bhanumathi.A.K, Member | HONORABLE Smt.Seena.H, PRESIDENT | HONORABLE Smt.Preetha.G.Nair, Member | | 
