Andhra Pradesh

East Godwari-II at Rajahmundry

CC/43/2015

Chindada Nanda Kumari - Complainant(s)

Versus

Birla Sun Life Insurance Company Limited - Opp.Party(s)

P. Nanda Kishore

23 Jun 2016

ORDER

                                                                                                Date of filing:   18.06.2015

                                                                                                Date of Order: 23.06.2016

 

BEFORE THE DISTRICT CONSUMER FORUM-II, EAST GODAVARI

DISTRICT AT RAJAHMUNDRY

 

                           PRESENT:   Smt H.V. Ramana, B.Com., L.L.M.,   PRESIDENT(FAC)

                      Sri A. Madhusudana Rao, M.Com., B.L., MEMBER          

    

                  Thursday, the 23^rd day of June, 2016

 

C.C.No.43 /2015

Between:-

 

1)  Chindada Nanda Kumari, W/o. Syam Prakash (late),

      Aged 47 years, Housewife, resident of Door No.14-4-3,

      Ratnam Peta, Rajahmundry, E.G. District.

 

2)  Sayana Priyanka, W/o. Vivek Anand, D/o. Syam Prakash

      Chinada (late), aged about 25 years, resident of Door

      No.14-4-3, Ratnam Peta, Rajahmundry, E.G. District.

 

3)  Chindada Praveen, S/o. Syam Prakash Chinada (late),

      aged about 22 years, resident of Door No.14-4-3,

      Ratnam Peta, Rajahmundry, E.G. District.                                  …        Complainants

 

                                    And

 

1)  Birla Sun Life Insurance Company Limited, rep. by its

      Managing Director, G. Crop Tech. Park, 5^th & 6^th Floor,

      Kasar Vadavali, Near Hyper City Mall, Ghodbunder Road,

      Thane (West) – 400601.

 

2)  Branch Manager, Birla Sun Life Insurance Company Limited,

      Rajahmundry.                                                                               …        Opposite parties

 

 

            This case coming on 14.06.2016 for final hearing before this Forum in the presence of Sri P. Nanda Kishore, Advocate for the complainants and Sri P.L.N. Prasad, Advocate for the 1^st opposite party and the 2^nd opposite party having been set ex-parte, and having stood over till this date for consideration, this Forum has pronounced the following:  

 

O R D E R

[Per Sri A. Madhusudhana Rao, Member] 

This is a complaint filed by the complainants U/Sec.12 of Consumer Protection Act 1986 to direct the opposite parties to pay Rs.1,05,000/-; to pay Rs.5,00,000/- towards compensation for mental agony and award costs.

2.         The case of the complainants is as follows:- The 1^st complainant is legally wedded wife of Syam Prakash Chindada. The 2^nd & 3^rd complainants are the daughter and son of the 1^st complainant and Syam Prakash Chindada. Syam Praksh, S/o. Pravin during his life time obtained the Policy No.005637089 from Birla Sun Life Insurance Company Limited on the basis of application dt.25.6.2012 by furnishing true and correct facts as sought by the opposite parties. The signatures of Syam Prakash were obtained on printed formats by the opposite party. The 1^st opposite party issued policy on the life of Syam Prakash. By the date of processing and obtaining the policy, Syam Prakash (life assured) was hale and healthy and is leading his life. The deceased Syam Praksh paid updated installments to the Birla Sun Life Insurance Company Limited. There was no arrears of installment amount payable by the deceased to the opposite parties for the life policy. The husband of 1^st complainant never suffered with Cirrhosis of liver either on the date of application are 5 years prior to the said application. With Policy No.005637098, Syam Prakash by keeping the 1^st complainant as his nominee availed the policy with the 1^st opposite party and the basic sum assured is Rs.1,05,000/-. While so, Syam Prakash died on 24.9.2013 due to Cardio respiratory arrest. After the demise of Syam Prakash, the complainants applied for death benefits and claim settlements  arising out of death Syam Prakash relating to Policy No.005637089 with the opposite parties. The opposite parties intentionally not paid any amount and by the letter dt.31.3.2014, the opposite parties repudiated the claim for the benefits under the policy of life assured Syam Prakash alleging that the opposite parties were mislead to issue the policy. The complainants addressed a letter dt.6.6.2014 requesting the opposite parties to reconsider the decision and to release the benefits under the policy. For which by the letter dt.28.6.2014, the opposite parties not entertained the claim as there was no alternative, the complainant approached the Hon’ble Forum. Hence, the complaint.

3.         The 1^st opposite party filed its written version and denied all the allegations made by the complainant and the complaint is not maintainable either under law or on facts.  It is submitted that the deceased life assured late Mr. Syamprakash Chindada had availed insurance policy bearing No.005637098 with the following features:

Policy Plan	BSLI Dream Life 2010 Fav pay 5
Policy issue Date	26.06.2012
Risk Commencement Date	26.06.2012
Policy Term	Pay Term 5 years
Sum Assured	Rs.105000
Premium Paid	Rs.22500

 

This opposite party submits that the life assured expired on 24.09.2013. Subsequently, the opposite parties received Death claim intimation dt.26.12.2013 from the complainant being the nominee and wife of the deceased life assured informing therein that the deceased life assured expired on 24.09.2013. The deceased life assured expired within period of 14 months & 29 days from the date of Risk commencement, the opposite parties had conducted an investigation under the provision of clause 8(3) of the Insurance Regulatory and Development Authority (Protection of Policy Holders interest) Regulations, 2002 in order to verify the authenticity of the claim. During the course of investigation, it was found that the deceased life assured had not disclosed about his true medical history, which was material facts for the insurance company to underwrite the risk before issuance of the insurance policy. The following facts were revealed during the course of investigation which substantiate the same:

1.  Investigation Findings:

During the investigation, the investigator engaged by BSLI established and submitted the following:

Sl.No.	Documents	Description
1	The deceased life assured, Late Mr. Chindada was admitted in Andhra Pradesh Vaidya Vidhana Parishad District Hospital, Rajahmundry   Document: Case Sheet dated 10.03.2010	In-Patient No.15102 Date of admission: 10.03.2010 at 11.30 AM Present complaint and Personal history: C/O : Patient presented with C/o Vomiting episodes, Hyperpyrexia since   3 days, dysuria and anoxia, fatigue and general weakness   Personal History Patient is severe chronic alcoholic, Since 3-4 years, chronic smokers         H/o fistula & Medical
2	Document: Case Sheet titled as Physical Examination dated 11.03.2010 Pg no 2	In-Patient no. 15102 Final Diagnosis: Cirrhosis of liver

 

It is to be noted that risk commencement was 26.6.2012 and the deceased life assured was admitted at District Hospital, Andhra Pradesh Vaidya Vidhana Parishad District Hospital, Rajahmundry on 10.3.2010 i.e. prior to the issuance of the policy. Thus, the said documents clearly reveal that the deceased life assured had not disclosed about his past medical history, which was material for the opposite parties to underwrite the risk before the issuance of the insurance policy. Hence, the complainant had intentionally concealed the said information from the opposite parties. It may be noted that disclosing past medical history are material facts which are important for underwriting the risks involved in issuance of a life insurance policy. By not informing the true and correct facts, the deceased life assured took away the right of the opposite party to underwrite the correct risk involved. That the deceased life assured was duty bound to disclose all the material facts having a bearing on the insurability of deceased life assured and risk to be covered by the company. In this regard, the life assured has signed the declaration at clause of the proposal form declaring the information mentioned therein are true and correct. It is submitted on the date of submission of proposal i.e. on 25.6.2012  Que. No- 11(B) & (E) and Que No.14i (a), (b) & ii (e) in the proposal form were answered in negative by the complainant, thereby concealing the material fact related to his medical history and since the same was discovered during investigation the claim was repudiated. The non discloser of the same was material and suppressing these facts are important for the issuance of the policy and ought to have been disclosed in the proposal form. Relevant questions reads as under:

11. Insurability declaration for the life to be insured

B)  In the past five years have you undergone any surgical operation at a hospital or clinic or undergone any investigations with other than normal or negative results (including X-rays, ECG, Blood tests, biopsies, etc)?

ANS: No

E)  Have you ever been diagnosed with or treated/consulted for diabetes or sugar in urine, high or low blood pressure, chest pain, heart attack or any other heart disease, stroke, paralysis, kidney, urinary or bladder disorders, reproductive organ or prostate disorders, mental disorder, neurological disease, musculoskeletal disorders, cancer or tumour or any type, gastro – intestinal, live disease tuberculosis, asthma or any other lung disease, blood disorders, anaemia, endocrine or thyroid disorders?

ANS: No

14 Medical History

i.  Within the past 5 years have you:

(a) Consulted any doctor or health practitioner except for common cold, influenza lasting less than 4 days?

ANS: No

(b) Submitted to an ECG, X-rays, Blood tests or any other tests?

ANS: No

ii. Have you ever sought advice or suffered from any of the following?

(e) Ulcer, colitis, chronic diarrhea, hepatitis or jaundice or other liver or Digestive disorders?

ANS: No

This opposite party submits that the complaint filed by the complainant is not maintainable and the same is liable to be dismissed in as much as in accordance with the investigation report submitted by the investigator, this opposite party company repudiated the claim of complainant vide Repudiation letter dt.31.3.2014. Hence, there is no deficiency in service on the part of this opposite party and the complaint is liable to be dismissed with costs.

 

4.         The proof affidavit filed by the 1^st complainant and Exs.A1 to A6 have been marked for the complainants. The proof affidavit filed by the 1^st opposite party and Exs.B1 to B7 have been marked for the 1^st opposite party. Written arguments filed on behalf of the  1^st opposite party.

5.         Heard both sides.

6.         Points raised for consideration are:

 

1. Whether there is any deficiency in service on the part of the opposite parties?

            2. Whether the complainants are entitled for the reliefs asked for?

            3. To what relief?

 

7.  POINT Nos.1 & 2:  As seen from the record, the deceased life assured one Chindada Syam Prakash during his life time obtained Dream Life Policy from Birla Sun Life Insurance Policy vide Policy No.005637089 on 26.06.2012 for an assured amount of Rs.1,05,000/- on submission of application form and on payment of Rs.7,500/- towards first premium as per Ex.A6 = Ex.B1. Ex.B2 is the policy details of the deceased life assured issued at the time of issuance of policy. The present complaint filed by the wife and children of the deceased life assured for the claim amount on the said policy after demise of the deceased life assured, who died on 24.09.2013 as per Ex.A5 death certificate. The death claim intimation vide Ex.A4 was sent to the 2^nd opposite party along with the claim form vide Ex.A3 by the  1^st complainant herein. The complainant further submitted that the Medical Attendant’s Certificate of 24.09.2013 vide Ex.A2 issued by one Dr. B. Rambabu Naik, Civil Assistant Surgeon, District Hospital, Rajahmundry in which it was mentioned that the deceased life assured was admitted and diagnosed that the DLA suffering serious bronchitis, severe HTN, Myocardial infarction and CRA = Ex.B3 including Aadhar card and ration card issued by the A.P. Government. But, the insurance claim preferred by the complainants herein after the death of the deceased life assured is repudiated as per Ex.A1 = B7 repudiation letter dt.31.3.2014.      

            The 1^st opposite party contended that there was no deficiency in service on their part as the claim preferred by the complainants not covered under the terms of the policy as on the date of submission of proposal i.e. 25.06.2012, Question Nos.11(b) and (e) and Question No.14(a)(b) and ii(a) in the proposal form were answered in negative by the deceased life assured and concealed the material fact related to his medical history and the same was discovered during investigation at the time of claim process as per the medical treatment information furnished by the 1^st complainant. The 1^st opposite party filed Ex.B4 medical record obtained from the District Hospital, Rajahmundry under A.P. Vaidhya Vidhana Parishad pertaining to the deceased life assured Chindada Syam Prakash of Rajahmundry period from 10.03.2010 onwards till 13.03.2010 under Register No.15102. As per the said medical record, the deceased life assured was admitted in the hospital with C/o. of vomiting episodes, hyperpyrexia since 3 days, dysuria and anoxia, fatigue and general weakness and after diagnose, the doctors treated the DLA for Liver Cirrhosis and finally discharged on 13.03.2010. This information was obtained by Stellar Insurance Management Services Pvt. Limited and filed their report as per Ex.B5 and Ex.B6 is the Affidavit of the Investigator of the said Stellar Insurance Management Services Pvt. Limited along with the investigation report.

            We observed that as per the proposal/application vide Ex.B1, submitted by the deceased life assured under Clause 11 Insurability declaration for the life to be Insured, the proposer/DLA replied in negative whereas he suffered Liver Cirrhosis during 10.03.2010 and treated for the same ailment, but this was not revealed at the time of proposal to the opposite party insurance company, which ailment fall under clause 11 ii(e), but the DLA replied in negative for the same.  The opposite parties clearly established that the DLA suppressed the material fact of his past medical history with cogent documentary evidence.

            The 1^st opposite party contended that the contract of insurance is based on the foundation of principle of uberrimae fides and the life assured is under solemn obligation to make full, complete, true and correct disclosures of the material facts which is relevant for the insurer to take into account while deciding to accept the proposal. In the present case, the life assured failed to reveal his true health and concealed the material fact of past medical history.  The 1^st opposite party in support of their contention relied on Suraj Mal Ram Niwas Oil Mills (P) Ltd., Vs. United India Insurance Co. Ltd. [(2010) 10 SCC 567] and Reliance Life Insurance Co. Ltd., Vs. Madhavacharya (Revision Petition No.211 of 2009, NC), in which it was held that “since the insurance between the insurer and the insured is a contract between the parties, the terms of the agreement including applicability of the provision and also its exclusion had to be strictly construed to determine the extent of the liability of the insurer.”

            The 1^st opposite party also relied on the following citation in Satwant Kaur Sandhu Vs. New India Assurance Co. Ltd., (2009) 8 SCC 316, in which it was held that “The term material fact is not defined in the Act and therefore, it has been understood and explained by the Courts in general terms to mean as any fact which would influence the judgment of a prudent insurer in fixing the premium or determining whether he would like to accept the risk. Any fact which goes to the root of the contract of the insurance and has bearing on the risk involved would be “material”.

            The 1^st opposite party also relied on the following decisions:

1. Life Insurance Corporation of India & Ors. Vs. Smt. Asha Goel & Anr.: C.A.Nos.4186-87 of 1988 of Supreme Court of India;
2. Mithoolal Nayak Vs. Life Insurance Corporation of India: MANU/SC/0255/1962 of Supreme Court of India;
3. P.C. Chacko and Anr. Vs. Chairman, Life Insurance Corporation of India and Ors. : Civil Appeal No.5322 of 2007 (Arising out of SLP (C) No.23951 of 2005) of Supreme Court of India; and
4. Ranveet Singh Bagga Vs. M/s. KLM Royal Dutch Airlines & Anr. : C.A. No.8701 of 1997 decided on 02.11.1999 of Supreme Court of India.

The above said decisions also applicable to the present facts and circumstances of the case.

           

            With the discussion held supra, under the facts and circumstances of the case and further on perusal of the above said citations, we are in the considered opinion that the complainants are not entitled for any claim amount or other reliefs claimed in the complaint and the complaint is liable to be dismissed as we cannot attribute any kind of deficiency of service on the part of the opposite parties.      

               

8.   POINT No.3:  In the result, the complaint is dismissed, without costs.

 

 

Typed to dictation, corrected and pronounced by us in open Forum, on this the 23^rd day of June, 2016.

    

                 Sd/-                                                                                                Sd/-

              MEMBER                                                                              PRESIDENT(FAC)

 

         

APPENDIX OF EVIDENCE

WITNESSES EXAMINED

 

FOR COMPLAINANTS: None.                                      FOR OPPOSITE PARTIES: None.

 

DOCUMENTS MARKED

FOR COMPLAINANTS:

 

 

Ex.A1    Policy details issued by the opposite parties.

Ex.A2    Death certificate of Chindada Syam Prakash.

Ex.A3    Death claim intimation form.

Ex.A4    Claimant statement

Ex.A5    Medical attendant certificate.

Ex.A6    Letter dt.31.3.2014 addressed by the opposite parties to the complainant.

 

 

 

FOR 1^st OPPOSITE PARTY:-   

 

Ex.B1    Application form of deceased life assured Mr. Syam Prakash Chindada submitted to

  Birla Sun Life Insurance Company Limited along with first premium receipt.

Ex.B2    Policy details issued by the opposite parties to the deceased Ch. Syam Prakash.

Ex.B3    Death certificate of Mr. Ch. Syam Prakash and Death claim intimation form along

  with other documents.

Ex.B4    Case Sheet of deceased Ch. Syam Prakash.

Ex.B5    Investigation report of deceased Ch. Syam Prakash.

Ex.B6    Affidavit of M/s. Stellar Insurance Management Services Pvt. Ltd.

Ex.B7    Letter dt.31.3.2014 from the Birla Sun Life Insurance Company Limited to the             

  1^st complainant.

 

                 Sd/-                                                                                            Sd/-

              MEMBER                                                                              PRESIDENT(FAC)