BEFORE THE DISTRICT CONSUMERS FORUM: KURNOOL
Present: Sri. M.Krishna Reddy, M.Sc., M.Phil., Male Member, PRESIDENT (FAC)
And
Smt. S.Nazeerunnisa, B.A., B.L., Lady Member
Friday the 8th day of February, 2013
C.C.No.98/2007
Between:
D. Anjali Devi, W/o. Late D.Subba Seshaiah,
Shaik palli Maddileti building, Dwarka Nagar, Velgodu, Kurnool District.
… Complainant
-Vs-
1. Branch Manager, Life Insurance Corporation of India Limited,
Atmakur, Kurnool District.
2. Divisional Manager, Life Insurance Corporation of India Limited,
P.B.No.10, College Road, KADAPA - 516 004.
… Opposite parties
This complaint is coming on this day for orders in the presence of Sri.P.Siva Sudharshan, Advocate, for the complainant, Sri.I.Anantha Rama Sastry, Advocate, for the opposite parties and upon perusing the material papers on record, the Forum made the following.
ORDER
(As Sri. M.Krishna Reddy, Male Member, PRESIDENT (FAC))
C.C.No.98/2007
1. This complaint is filed under section 11 and 12 of C. P. Act, 1986 praying:-
(a) To direct the opposite parties to pay the policies Nos.652176099 Rs.20,000/-, 650474520 for Rs.1,00,000/- and 652179312 for Rs.50,000/- amount to the complainant with interest at 24% per annum from the date of death of the deceased i.e., 18-05-2005 till the date of realization, along with benefits;
(b) To grant a sum of Rs.20,000/- towards mental agony;
(c) To grant a sum of Rs.2,000/- towards cost of the complaint;
And
(a) To grant any other relief as the Honourable Forum deems fit and proper in the circumstance of the case.
In F.A.No.125/2009 against C.C.No.98/2007, District Consumer Forum, Kurnool, State Commission remanded the matter to the District Consumer Forum, Kurnool, setting aside the previous order of District Forum, giving liberty to the parties adduce evidence. Hence the matter is restored and issued notices to counsels of both parties.
2. Persuent to the notice of this Forum Counsels of the parties filed their memo of continuation. Additional sworn affidavit and documents marked as Ex.A1 to Ex.A7 are filed on behalf of the complainant. From opposite parties side documents marked as Ex.B1 to Ex.B7 are filed. Deposition of Dr.Ram as RW1 and Ex.A8 to Ex.A11 are also on the file and they were marked by Advocate Commissioner.
3. The case in brief is that the complainant is widow and nominee of deceased D.Subba Seshaiah who insured his life under five policies bearing Nos.650474520, 652179312, 652176099, 650365141 and 650466690. After the death of insured on 18-05-2005 the complainant submitted necessary documents to claim the insured amount from opposite parties insurance Company, which in turn settled only two policies. The remaining three policies were kept pending on the ground that the insured suppressed his health conditions at the time of revival from lapsed position. The original complaint filed by the widow of insured was dismissed in this Forum on the premise that the complainant’s husband suppressed material facts concerning his health at the time of revival of three policies. The unsuccessful petitioner filed on appeal before State Commission. The appeal was allowed setting aside the order of the District Forum. The State Commission had remarked that the District Forum erred in deciding the case because to repudiate the claim the Insurance Company has not produced any documents except setting that the deceased had under gone treatment at APSRTC Hospital, Taranka and NIMS, Hyderabad, and it is the duty of opposite parties Insurance Company to support repudiation of claim on the basis of legally tenable evidence. Insurance Corporation could have obtained a certificate from the Doctor who had purportedly treated the insured. State Commission also expected the submission of Form – E from the employer of the complainant’s husband. Hence the case was remanded to the District Forum giving liberty to the parties adduce evidence.
4. Both parties filed their written arguments and submitted oral arguments.
5. The points for consideration are:
i. Whether opposite parties Insurance Corporation has rendered deficiency service by neither repudiating nor settling the claim in respect of the three insurance policies?
ii. Whether the complainant is entitled for relief?
iii. To what relief?
6. The complainant or the nominee of insured contended that her husband took five insurance policies from opposite parties corporation bearing Nos.650474520, for Rs.1 lakh, 652179312 for Rs.50,000/-, 652176099 for Rs.20,000/-, 650365141 for Rs.20,000/- and 650466690 for Rs.25,000/- and died on 18-05-2005 due to fever, and his death is natural. The complainant as nominee of the above said five policies submitted claim form for settlement. The opposite parties corporation settled two policies bearing Nos.650365141 for Rs.20,000/-, 650466690 for Rs.25,000/-. The remaining three policies were kept pending and were neither settled nor repudiated. The complainant denied that opposite parties sent claim forms B and B1 earlier to the filing the complaint. Further complainant avered that opposite parties created letter dated 16-08-2005 and 21-12-2005 for the purpose of defending the case. He received a letter dated 23-04-2008 along with forms B and B1 from opposite parties which is marked as Ex.A7.
7. The three unsettled policies were lapsed due to nonpayment of premium for the period from 8/2004 to 3/2005 and they were revived on submission of personal statement and on payment of premium due. The three policies were revived on 19-04-2005. The opposite parties corporation contended that the insurance policies were revived on the strength of ordinary revival quotation and personal statement regarding health made by nominee’s husband on 30-03-2005 and 19-04-2005. Ex.B1, the medical examiner’s confidential report dated 30-05-2005 ascertaining answers from L.A. with no policy details and personal statement regarding health for policy No.650474520, Ex.B2, ordinary revival quotation dated 19-04-2005 for policy No.652179312. Ex.B3 ordinary revival quotation and personal statement regarding health for policy No.652176099. Ex.B4, the claim enquiry report, while giving answers to S.No.17 and S.No.19 of Ex.B4 A.K.Jilani Basha, Branch Manager, Atmakur had not recorded the name and address of the Doctors who treated the deceased in past for his last illness and did not obtain particulars of treatment from A.P.S.R.T.C., Hospital, Taranaka, Hyderabad. Further at the end of enquiry report A.K.Jilani Basha recommended for repudiation of claim only after obtaining leave record of the deceased (particulars as in Form – E) from RM Office, Kurnool. But no such leave record was filed before this Forum.
8. According to LIC the revival of lapsed policy is a fresh contract. The insured Late.D.Subba Seshaiah was suffering from Kidney failure and had treatment in APSRTC, Hospital, Taranaka and NIMS, Hyderabad prior to the date of revival of the policies. Dr.Ram who treated the deceased was examined on commission as RW1 and attested copies of discharge record dated 31-01-2005, admission from dated 31-01-2005, discharged record dated 26-04-2005, admission from dated 26-04-2005 are marked as Ex.A8 to Ex.A11 respectively by the Advocate Commissioner.
9. The complainant contended that her husband had not suppressed any material fact and he died due to fever and his death is natural. There is no nexus between the cause of death as alleged by L.I.C. and the decease suffered by her husband. He relied on decision Andhra Pradesh State Consumer Disputes Redressal Commission, Hyderabad IV (2004) CPJ 612. Where in it was held that except filing the case sheets of Hyderabad Nursing home nothing has been established regarding the cause of death and has not acted strictly in accordance with section 45 of Insurance Act, in repudiating the policies. In present case also the opposite parties has not established that the cause of death is on account of suppressed health information. He relied another decision reported in I (2012) CPJ 84 (NC) where it was held that as per settled law, onus to prove that petitioner was suffering from preexisting disease on Insurance Company. In the above case the opposite party has not produced any credible documentary evidence/expert medical opinion in support of its case, and opposite party failed to prove reasons for repudiation of claim.
10. The opposite parties contended that according to section 45 of Insurance Act, 1938, no policy of life insurance shall, after the expiry of two years from the date on which it was effected, be called in question by on insurer on the ground that a statement made in the proposal of insurance or any report of a medical officer or refree or friend of the insured or in any other documents leading to the issue of the policy was inaccurate or false, unless the insurer shows that such statement was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the policy holder and that the policy holder know at the time of making it that the statement was false or that it suppressed facts which it was material to disclose. “Material” shall mean and include all important, essential and relevant information in the context of under writing the risk to be covered by the corporation. In the present case the “Material” to disclose the suppressed facts is deposition of Dr.Ram as RW1 and Ex.A8 to Ex.A11. Dr.Ram deposed that he treated the patient on 01-02-2005 and 02-02-2005. The other doctors who attended the patient are Dr.Swarnalatha, Dr.K.V.Dakshina Murthy, Dr.T.Gangadhar, Dr.Manjusha, Dr.Uttaradas, Dr.L.R.C.Reddy, Dr.Madhav Desai, Dr.Narasimha Rao. Dr.Ram also admitted that he did not record past history in Ex.A10, the patient came to the hospital with complainants of general weakness and loss of appetite and according to Ex.A9 and Ex.A10 the patient was discharged in stable condition. Dr.Ram also admitted that they have no record to show that patient took treatment also else-where. Except Dr.Ram no other doctor was examined or obtained certificate from them. Ex.A8 does not contain the name of the patient and other particulars. Like wise Ex.A11 in which some particulars were not filled. Dr.Ram also deposed that it is the usual practice that some columns of hospital record will not filed by the doctors.
11. The State Commission believed that this “Material” is not legally tenable evidence to support repudiation of claim by Insurance Corporation and was in the opinion that opposite parties corporation could have obtained the certificate from the doctors who had purportedly treated the complainant’s husband. Neither the certificate by the treated doctors nor any legally tenable evidence to support of rejection of complainant’s claim was filed by the insurance company as adduce evidence. Regarding the treatment of complainant’s husband at A.P.S.R.T.C. Hospitals, Taranaka, Hyderabad also the LIC has not produced any supporting documents. Counsel for opposite parties filed citation 1962 – AIR (SC) – 0 – 814, 1919 ACJ 303 (SC), 2010 ACJ 1379, R.P.1585/2011 dated 19-03-2012, R.P.209/2007, dated 12-02-2011, R.P. 2715/2006 dated 29-10-2011, R.P.158/2010 dated 19-07-2011, R.P.2386/2007 dated 02-08-2011, R.P.781/2007 dated 09-02-2011, R.P.2091/2007 dated 31-05-2011. It is true that not giving information of hospitalization undoubtedly is material suppression of fact and it is settled law that contract of insurance between insurer and insurance company is based on the principle of ubberima fieds i.e., a contract entered into “Utmost good faith”. Revival of lapsed policy is also a fresh contract. In the present case “the material” Dr.Ram’s deposition as RW1 and Ex.A8 to Ex.A11 failed to disclose the information of hospitalization of complainant’s husband were not considered by State Commission as legally tenable evidences. Opposite parties not followed section 45 of insurance Act strictly in repudiating the claim. Even after the matter is restored in this Forum opposite parties have not adduce legally tenable evidence.
From what is stated above this Forum holds that the repudiation of claim regarding the policies bearing Nos.650474520 for Rs.1,00,000/-, 652179312 for Rs.50,000/-, 652176099 for Rs.20,000/- is unjust and the complainant is entitled to receive the benefits of the above policies. The opposite parties are also liable for the payment of compensation for causing mental agony to the complainant. As the claim was kept pending and was neither settled nor repudiated.
12. In the result, the complaint is partly allowed directing the opposite parties jointly and severally to pay all the benefits of three policies bearing Nos.650474520, 652179312 and 652176099 with interest at 9% per annum from the date of filing the case. Rs.5,000/- is granted as compensation for mental agony and Rs.1,000/- as cost of the case. Time for compliance is six weeks from the date of receipt of this order.
Dictated to the stenographer, transcribed by her, corrected and pronounced by us in the open bench on this the 8th day of February, 2013.
Sd/- Sd/-
LADY MEMBER PRESIDENT (FAC)
APPENDIX OF EVIDENCE
Witnesses Examined
For the complainant : Nil For the opposite parties : Nill
List of exhibits marked for the complainant:-
Ex.A1 Photo copy of Policy bearing No.652176099
dated 20-04-1999.
Ex.A2 Policy bearing No.650474520 dated 11-11-1997.
Ex.A3 Policy bearing No.652197312 dated 06-12-2001.
Ex.A4 Death Certificate dated 27-05-2005.
Ex.A5 Letter dated 25-07-2005 of opposite party No.1 to
complainant.
Ex.A6 Letter dated 27-07-2005 of opposite party No.1 to
complainant.
Ex.A7 Letter dated 23-04-2008 along with Medical Attendant’s
Certificate.
List of exhibits marked for the opposite parties:-
Ex.B1 Ordinary Revival Quotation Slip dated 19-04-2005
(Policy bearing No.650474520) (11-25) Medical Examiner
Confidential Report dated 30-03-2005 personal statement regarding health dated 30-03-2005.
Ex.B2 Ordinary Revival Quotation Slip dated 19-04-2005
(Policy bearing No.652179312) (14-20).
Ex.B3 Ordinary Revival Quotation Slop dated 19-04-2005
(Policy bearing No.652176099) (14-20) Personal Statement
regarding health dated 19-04-2005.
Ex.B4 Claim Enquiry Report.
Ex.B5 Office copy of Letter dated 16-08-2005 of opposite party No.1
to complainant.
Ex.B6 Office copy of Letter dated 21-12-2005 of opposite party No.1
to complainant.
Ex.B7 Office copy of Letter dated 18-08-2007 of opposite party No.1
to complainant.
Marked by Advocate Commissioner in his Report:-
RW1 Deposition of Dr.Ram.
Ex.A8 Photo copy of Discharge Record dated 03-02-2005.
Ex.A9 Photo copy of Preliminary Admission Form issued NIMS Hospital, Hyderabad.
Ex.A10 Photo copy of Discharge Record dated 05-05-2005 issued by NIMS Hospital, Hyderabad.
Ex.A11 Photo copy of Preliminary Admission Form issued NIMS Hospital, Hyderabad.
Sd/- Sd/-
LADY MEMBER PRESIDENT (FAC)
// Certified free copy communicated under Rule 4 (10) of the
A.P.S.C.D.R.C. Rules, 1987//
Copy to:-
Complainant and Opposite parties :
Copy was made ready on :
Copy was dispatched on :
