BEFORE THE DISTRICT CONSUMER FORUM AT NALGONDA
PRESENT: SRI MAMIDI CHRISTOPHER,
PRESIDENT.
SMT.S.SANDHYA RANI,
FEMALE MEMBER.
. . .
MONDAY, THE THIRTIETH DAY OF DECEMBER, 2019
CONSUMER COMPLAINT No. 31 OF 2015
Between:
- Kanamala Venkatamma W/o Late Venkata Ramulu,
Age: 40 years, Occ: Household,
- Kamnamala Madhusudan S/o Late Venkata Ramulu,
Age: 25 years, Occ: Pvt.Employee,
- Kanamala Naresh, S/o Late Venkata Ramulu,
Age: 22 years, Occ: Student,
- Kanamala Mounika D/o Late Venkata Ramulu,
Age: 20 years, Occ: Student,
All R/o Srirampuram Chandrugonda, Ganugapadu, Khammam Dist.
…COMPLAINANTS.
]
AND
- Bajaj Allianz Life Insurance Co.Ltd., H.No.1-6-60, Ground floor, Srilekha Complex, Nallabavi Road, Opp: Yepur Bus stop, Suryapet, Suryapeta (Mandal), Nalgonda District-508213.
- Bajaj Allianz Life Insurance Co.Ltd., H.No.1078, II nd Floor, United Chamber Sati Road, Ganapathi, Coimbatore, Tamilnadu-641006.
…OPPOSITE PARTIES.
This complaint coming on before us for final hearing, in the presence of Sri G.Srinivas Chakravarthy, Advocate for the Complainants, and Sri K.Anantha Reddy, Advocate for the Opposite Party No.1, and the Opposite Party No.2 having been called absent, and on perusing the material papers on record, and having stood over for consideration till this day, the Forum passed the following:
ORDER OF THE FORUM DELIVERED
BY SMT.S.SANDHYA RANI, FEMALE MEMBER
1. The Complainants filed this complaint Under Section 12 of Consumer Protection Act, 1986 to direct the Opposite Parties to pay a sum of Rs.2,08,000/- towards death benefits of K.Venkata Ramulu with costs.
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2. The facts leading to the filing of this complaint as follows:
The husband of the Complainant No.1 K.Venkata Ramulu had taken a policy under the name and style of Bajaj Allianz Invest Gain Economy Regular Premium Policy from the Opposite Party No.1 on 30/03/2013. He paid an amount of Rs.10,601.78 Ps. towards regular premium to the Opposite Party No.1. The mode of payment of the premium is Rs.10,284/- per year, commencing from 31/03/2013 for a period of 20 years, i.e. till 28/03/2032. The Opposite Party No.1 issued Policy, vide Policy No.0298745344 to the insured. The deceased was hale and healthy at the time of taking the policy. On 11/08/2013 after attending agricultural operations at his fields he came to his house and due to chest pain he died on the spot. As per the policy, the Opposite Party No.1 is liable to pay the minimum death benefits amounting to Rs.2,08,000/- in case of death of the policy holder. After death of the deceased life assured, the Complainants have approached the Opposite Party No.1 on 27/09/2013 for the death benefits of the deceased Venkata Ramulu being his legal heirs and successors. On 15/04/2015 the Opposite Party No.1 sent a letter stating that the deceased died due to chronic kidney disease at stage-5 and due to hypertension he was hospitalized and taken medical aid during the period from 10/09/2012 to 14/09/2012 and the claim was repudiated due to non-disclosure of material facts. The Opposite Party No.1 invented the story of kidney disease in order to avoid the payment of policy benefit claim of the deceased. In fact, the deceased died due to chest pain and there is no problem of his health at any point of time and never take any medical aid from any doctor at any time. As such, the Complainants are entitled for the death benefits of
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Rs.2,08,000/- from the Opposite Party No.1 payable on account of death of the deceased. Therefore, the Complainants filed this complaint.
- The Opposite Party No.1 filed his written version by denying all the
averments of the complaint. The Opposite Party submitted that the deceased life assured has not disclosed the diagnosis undergone by him during 10/09/2012 to 14/09/2012 for Chronic Kidney Disease Stage-5, Chronic Glomerulonephritis, Hypertension and Anaemia and put on haemodialysis while submission of proposal form, dated 30/03/2013. The deceased life assured was under obligation to mention the actual illness or disease in the proposal form at the time of applying for the insurance policy from the Insurance Company. The insurance is based upon contract whereby the proposal along with the first insurance premium is received from the Proposer, who intends to take the insurance policy from the Insurance Company. The proposer who intends to procure an insurance policy, has to fill in the material details in the proposal form, amongst which the medical, income details, as well nomination details have to be provided. The Opposite Party No.1 made an investigation and found that the life assured had taken treatment towards the said disease at Andhra Hospital, Vijayawada. The investigation report along with discharge summary of Andhra Hospital, Vijayawada, dated 14/09/2012 reveals that the life assured was taking treatment for the said disease. The above facts amounts to non-disclosure of material facts and hence the present complaint is not maintainable on the ground of suggestio vari supresso falsi. The life assured had knowledge that he was suffering from the above said disease even at the time of making proposal to the
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opponent company. The life assured is guilty of suppressing the material facts at the time of making proposal for insurance. The life insurance policy issued to the life assured is based on the principles of “Uberimma Fidei”, i.e. utmost good faith and accordingly rely on the declarations and statements made in the proposal form, the company has issued the policy in the name of the life assured. The life assured must disclose to the insurer all facts material to an insurer’s appraisal of the risk, which are known or deemed to be known by the assured. The deceased had knowledge of his particular pre-existing disease and other matters, he is obliged to disclose it particularly while answering questions in the proposal form. Non-disclosure or in case of any inaccurate answer will entitle the insurer to repudiate his liability as there is clear presumption that any information sought for in the proposal form is material for the purpose of entering into a contract of insurance. The Discharge Summary, dated 14/09/2012 clearly states that the life assured was admitted on 10/09/2012 and underwent surgery on 13/09/2012 and discharged on 14/09/2012 for the above said ailments suffered by him. Further, the Ultra Sonogram Abdomen Report, dated 10/09/2015 shows that the life assured was suffering from Bilateral Chronic Medical Renal Disease and the said documents were procured during investigation officer Mr.Kollipara Pratap Rudra Kumar. Therefore, there is no deficiency in service on the part of the Respondents as per Ranveet Singh Bagga Vs.KLM Royal Dutch Airlines (2000) 1 SCC 66. The Complainant No.1, who is the wife of the deceased policy holder aware of her husband’s pre-existing disease and the treatment he had undergone, had failed to disclose these facts in her claim form, only on the investigation made by the Opposite Party No.1, the said material fact was found out and the rejection of
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the claim was made on valid grounds and reasons. The Opposite Party No.1 has rightly repudiated the claim of the Complainants and prayed for the dismissal of the complaint. In support of their contention, the Opposite Party No.1 filed the following citations:
- IV (2009) CPJ 8 (SC).
[Between: Satwant Kaur Sandu Vs.New India Assurance Co.Ltd.]
- III (1996) CPJ 9 (SC)=(1996) 6 SCC 428
[Between: United India Insurance Co.Ltd. Vs.M.K.J.Corporation].
- In spite of receiving the notice, the Opposite Party No.2 failed to
appear before this Forum and was called absent.
5. The Complainant No.1 filed her proof affidavit and marked Exs.A-1 to A-6. The Opposite Party No.1 filed his proof affidavit and marked Exs.B-1 to B-5.
6. The points for consideration are:
1) Whether there was deficiency in service on the part of the
Opposite Parties No.1 and 2?
2) Whether the Complainants are entitled for the claims
they made in their complaint?
3) If so, to what extent?
7. POINT No.1:
It is not in dispute that the husband of the Complainant No.1 K.Venkata Ramulu had obtained a policy, vide Policy No.0298745344. from the Opposite Party No.1 on 30/03/2013, which was commencing from 31/03/2013 to 28/03/2032 and he paid an amount of Rs.10,601.78 Ps. towards regular premium to the Opposite Party No.1. According to the Complainants, the deceased was hale and healthy at the time of taking the policy. On 11/08/2013 after attending
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agricultural operations at his fields he came to his house and due to chest pain he died on the spot. After death of the deceased life assured, the Complainant No.1 approached the Opposite Party No.1 on 27/09/2013 for the death benefits of the deceased Venkata Ramulu. On 15/04/2015 the Opposite Party No.1 sent a letter stating that the deceased died due to chronic kidney disease at stage-5 and due to hypertension he was hospitalized and taken medical aid during the period from 10/09/2012 to 14/09/2012. As the deceased was suffering from kidney disease, the Opposite Party No.1 repudiated the claim of the Complainants due to non-disclosure of material facts. The deceased died only due to chest pain and there was no health problem and he never take any medical aid at any time from any doctor and as such the Complainants are entitled for the death benefits of Rs.2,08,000/- of late Venkata Ramulu. The Opposite Party No.1 repudiated the claim of the Complainants in order to avoid the payment of death benefits.
8. Ex.A-1 is the Death Claim Notification of Policy No.0298745344, along with Regular Premium Receipt and Proposal Form. Ex.A-2 is the Death Certificate of the deceased K.Venkata Ramulu. Ex.A-5 is the Repudiation Letter issued by Opposite Party No.1. Ex.A-6 is the original Policy Payment Receipt for Rs.10,387/- issued by Opposite Party No.1. As per the facts, it is evident that the Complainants have approached the Opposite Party No.1 for the death benefits of the deceased, who is the policy holder of the Opposite Party No.1 and who died on 11/08/2013 at his house due to chest pain. The Complainants denied that the deceased undergone treatment for kidney problem, in fact he never took any treatment for any disease. The Complainants
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submitted that there was no non-disclosure of material facts to the Opposite Party No.1 regarding the health of the deceased and that the Complainants are entitled for the death benefits of Rs.2,08,000/- and the Opposite Parties are liable to pay the same. The Opposite Party No.1 placed the claim of the Complainants before the Claims Review Committee and they have denied the death claim for the reason of non-disclosure of material facts of the deceased. Ex.B-1 is the original Policy Bond. Ex.B-2 is the letter of intimation of death. Ex.B-3 is the Discharge Summary of the deceased, issued by Andhra Hospital, Vijayawada. Ex.B-5 is the Repudiation Letter. Ex.B-3 Discharge Summary of the deceased pertains to the year 2012, but the deceased died on 11/08/2013. The Opposite Party No.1 had repudiated the claim of the Complainants on the ground of suppression of material facts and pre-existing illness without any substantial legal proof. The Opposite Party No.1 neither filed any documents nor examined any doctor who treated the deceased to prove that the deceased had suffered from the diseases stated above. There is no nexus with regard to the death of the deceased and the diseases as stated by the Opposite Party No.1.
9. The Hon’ble National Commission had occasion to consider a case where the deceased died on account of a disease not related to the treatment he had taken earlier to signing the proposal form. In the case reported in Chinnamma Vs.Divisional Officer, LIC of India ( 1996 (3) CPR 229 (NC) ) the assured underwent treatment for peptic ulcer and died of heart attack. In the said case, the Hon’ble National Commission held that peptic ulcer has no nexus with the heart attack with which the deceased suffered and that the repudiation of the claim
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made on the ground of suppression of his treatment of peptic ulcer was found not justified. In a decision reported in P.Venkat Naidu Vs.LIC of India and another ( IV (2011) CPJ 6 (SC) ) the Hon’ble Supreme Court had similar question before it. In the said case, the deceased had undergone prior treatment for abdominal pain, but after obtaining the policy he died of cardiac problem. A perusal of the said decision shows that the deceased in the said case had taken treatment for abdominal pain and after obtaining a policy signing good health declaration he died of heart attack. On the LIC of India repudiating the claim on account of suppression of treatment taken by the deceased for abdominal pain, the nominee approached the District Forum which allowed the complaint and directed payment of amount of policies and the same was upheld by the Hon’ble State Commission. On a revision being filed the Hon’ble National Commission allowed it and reversed the order of the District Forum and State Commission. Thereupon the nominee carried the matter in civil appeal to the Hon’ble Supreme Court and the Hon’ble Supreme Court allowed the complaint and affirmed the order of the District Forum. The Hon’ble Supreme Court had extracted the evidence of the doctor examined in the said case who stated that he treated the deceased for abdominal pain but the deceased died of cardiac problem. Agreeing with the findings of the District Forum and the Hon’ble State Commission who held that the suppression of treatment for abdominal pain cannot be a ground for repudiation of the policy where the deceased died on account of cardiac problem, a disease which has no relation to abdominal pain with which the deceased was suffering, the Hon’ble Supreme Court had allowed the appeal filed by the nominee.
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10. In a decision reported in IV (2019) CPJ 93 (Har.), between Exide Life Insurance Company Limited Vs. Ishrat and others, the Hon’ble Haryana State Consumer Disputes Redressal Commission observed that repudiation is not justified as no doctor or any expert had been examined to show that life assured had been suffering from cancer of throat earlier to taking of policy.
Consumer Protection Act – Sections 2(1)(g), 15 Insurance (Life) – Death Claim – Suppression of pre-existing disease alleged – Claim repudiated – Deficiency in service – District Forum allowed complaint – Hence appeal – Medical Certificate relied upon by insurer is a fabricated document – It does not bear signature of person who had issued the same – Way in which it has been recorded indicates that some quack has fabricated the same – No doctor or any expert had been examined to show that life assured had been suffering from cancer of throat earlier to taking of policy – Repudiation not justified.
11. The deceased in this case died due to chest pain, but not due to sufferance of diseases as stated by the Opposite Party No.1. Hence, we hold that the repudiation of the claim of the Complainants is illegal and is not tenable. In repudiating the claim the Opposite Parties exposed themselves to the finding that they are guilty of deficiency of service and negligence on their part.
12. POINTS No.2 & 3:
In the light of findings under Point No.1 and in the light of the observations of the observations, we are of the opinion that the Opposite Parties are liable to pay an amount of Rs.2,08,000/- towards the death benefits covered under the policy along with interest and costs.
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In the result, the complaint is allowed, directing the Opposite Parties No.1 and 2 to pay to the Complainants No.1 to 4 jointly and severally, a sum of Rs.2,08,000/- (Rupees Two Lakhs and Eight Thousand only) covered under the Policy bearing No.0298745344 with interest @ 9% p.a. from the date of the complaint, i.e. 11/08/2015 till realization and a sum Rs.20,000/- (Rupees Twenty Thousand only) towards deficiency of services and mental agony and a sum of Rs.2,000/- (Rupees Two Thousand only) towards costs. Out of the awarded amount of Rs.2,08,000/- (Rupees Two Lakhs and Eight Thousand only) and 9% p.a. interest amount, the Complainant No.1 shall be paid Rs.82,000/- (Rupees Eighty Two Thousand only) along with entire interest amount and costs. The balance amount of Rs.1,26,000/- (Rupees One Lakh and Twenty Six Thousand only) shall be equally apportioned between the Complainants No.2 to 4, i.e. at the rate of Rs.42,000/- (Rupees Forty Two Thousand only) each. Time for compliance one month from the date of receipt of this order.
Dictated to Steno-Typist, transcribed by him, corrected and pronounced by us in the open Forum on this 30th day of December, 2019.
FEMALE MEMBER PRESIDENT
APPENDIX OF EVIDENCE
WITNESSES EXAMINED
For Complainants: For Opposite Parties:
Affidavit of the Complainant No.1. Sri V.Suresh, Asst.Branch
Manager of Opp.Party No.1 Co.
filed his affidavit on behalf of
Opposite Party No.1.
EXHIBITS MARKED
For Complainants:
Ex.A-1: Dt.27/09/2013 Xerox copy of Death Claim Notification,
Insurance Policy along with Proposal Form.
Ex.A-2 Dt.11/08/2013 Xerox copy of Death Certificate.
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Ex.A-3 Xerox copy of Aadhar Card of the
Complainant No.1.
Ex.A-4 Dt.15/12/1995 Xerox copy of Voter ID Card of the deceased.
Ex.A-5 Dt.15/04/2015 Copy of Repudiation Letter issued by the
Opposite Parties.
Ex.A-6 Original Policy Payment Receipt for
Rs.10,387/-.
For Opposite Party No.1:
Ex.B-1: Dt.01/04/2013 Original Policy Bond.
Ex.B-2: Dt.27/09/2013 Original Death Intimation Letter.
Ex.B-3 Dt.14/09/2012 Xerox copy of Discharge Summary,
issued by Andhra Hospitals, Vijayawada.
Ex.B-4 Dt.10/09/2012 Ultra Sonogram Abdomen Report,
issued by Andhra Hospitals, Vijayawada.
Ex.B-5 Dt.14/02/2014 Xerox copy of Repudiation Letter.
PRESIDENT
DISTRICT CONSUMER FORUM
NALGONDA
