This case is coming for final hearing on 05.12.2014 in the presence of Sri V.V.Bhaskar Kumar Advocate for the Complainant and of Sri D.Siva Prasad Advocate for Opposite Parties and having stood over till this date, the Forum delivered the following:

: O R D E R :

(As per Smt. K.V.R.Maheswari, Honourable President(FAC) on

behalf of the Bench)

1.       The case of the complainant is that he is the husband of Chadaram Ramulamma who obtained  health care policy from 1^st opposite party bearing Policy No.4111/PLA/58895062/00 which is valid from 05.03.2010 to 04.03.2011 for an amount of Rs.10,00,000/- and the complainant is showed as nominee.  The 2^nd opposite party is looking after P.A claims wing.  While so, on 12.05.2010 the complainant’s wife accidentally fallen from steps and sustained head injury and other injuries by external and visible means and immediately she was taken to area hospital, Anakapalli vide O.P. ticket No.21976 as an out patient.  Later, she was shifted at Shirdi Sai Hospital, Anakapalli for better treatment on 17.05.2010 and 18.05.2010 then, the doctor referred to KGH, Visakhapatnam for better treatment, then the complainant was about to take his wife to KGH on the next day morning, but she died at her house in Tumpala Village on 19.05.2010 due to head injury.  The Complainant stated that he informed the death intimation of her wife to 1^st opposite party as well as local office at Anakapalli on 11.06.2010 and also submitted all the documents and requested the opposite party to settle the claim.  The opposite party registered the crime No.GEN000083709 and sent claim form to the applicant with instructions to fill it and send it to 1^st opposite party, then, the complainant filled the claim form and send it along with documents.  While so, the 2^nd opposite party sent a letter to the complainant on 21.01.2013 requesting for further documents, then, on 30.01.2013 the complainant send all the documents to the 2^nd opposite party but the opposite parties neither settle the claim nor gave any reply to the complainant. 

2.       The complainant also approached the 1^st opposite party and enquired about the claim details regarding death of his wife, then, the 1^st opposite party informed that the claim is in process in the hands of 2^nd opposite party and will be settled within a span of time.  But the opposite parties did not settle the claim amount then, the complainant issued a registered notice on 28.08.2013 to the 2^nd opposite party and after receiving the notice the 2^nd opposite party neither settle the claim nor gave any reply, then again the complainant issued a registered reminder lawyer’s notice on 04.11.2013 and the same was received by the 1^st opposite party who kept silent.  The Complainant stated that because of the acts of the opposite parties, the complainant has no other way, hence he filed a complaint to direct the opposite parties;

a)      to pay the policy amount of Rs.10,00,000/- along with 24% interest from the date of death of his wife

b)      to pay Rs.2,00,000/- towards compensation besides costs of Rs.50,   000/-.

3.       On the other hand, the opposite parties filed their counter and denied the allegations mentioned in the complaint and pleaded that the complainant is not a consumer and there is no deficiency of service on the part of the 1^st opposite party and the Forum has no jurisdiction under Section-2(e) of Consumer Protection Act to entertain the complaint and contract of insurance does not comes under the purview of consumer dispute as envisaged in Section-2(e) of the Act.  Both the opposite parties stated that the complaint filed by the complainant based on the fabricated and created documents thereby violated the principles of utmost good faith as well as the terms and conditions of the policy.  As per the records, the DLA obtained Personal Protect policy for a period of one year and the policy is issued to the policy holder with express terms and conditions attached to the policy itself.  As per the conditions, if the deceased died in a accidental manner subject to complying the terms and conditions of the policy terms and conditions the same assured of Rs.10,00,000/- payable to the nominee and if the policy holder insured sustained disability in accordance with the schedule of the policy, the sum assured payable as per the schedule attached to the policy.  The policy holder obtained the health care policy is incorrect, but the same is personal protect policy and both the opposite parties not well aware about the death of DLA by fallen from steps and died on 19.05.2010, however, the opposite parties received the claim intimation from the complainant on 11.06.2010 i.e., after lapse of more than 30 days, hence that intimation itself is barred by limitation as per the Condition No.7A(i) of policy.  Thus, the complainant committed breach of conditions of policy. 

4.       The opposite parties stated that as per Condition No.7(b)(i)(d)(e)(f) as well as 7(2) of the policy, the complainant is liable to submit proof of accidental death of policy holder by submitting the relevant documents like FIR, PM report, Inquest report etc., as the P.M report alone reveals the actual cause of death of deceased policy holder, but the complainant failed to furnish the relevant and required mandatory documents to the opposite parties including the police records, P.M report etc. As per Condition No.9(1), (3) & (11) of the policy conditions, the contract of insurance is based on the principle of utmost good faith.  The claim of the complainant is based on the fabricated and created documents, thereby the complainant violated the terms and conditions.  Therefore, the complainant not at all admissible.  The death of deceased is only a natural one but not at all accidental one as alleged by the complainant.  The complainant also failed to inform about the accident to the Competent Authorities or to the police authorities or even to the company within time as per the conditions of the policy.  The doctors treated the policy holder with general line of treatment but not at all treated as MLC case.  Thus, the complainant failed to fulfill the terms and conditions of the policy as well as failed to submit relevant documents to the opposite parties either to admit or to repudiate the claim.  Thus, there is no deficiency of service on the part of opposite parties, hence the complaint is to be dismissed. 

5.       At the time of enquiry, the complainant filed his evidence affidavit along with documents which are marked as Exhibits A1 to A12. On the other hand, the opposite parties filed its counter and evidence affidavit along with documents which are marked as Ex.B1.  Both the counsels filed their written arguments and the opposite parties’ counsel represented to consider written arguments as oral arguments.   Heard the counsel of the complainant who reiterated his version.

6.       In view of the respective contentions, the point that would arise for determination is:-

Whether there is any deficiency in service on the part of the opposite parties, if so can the complainant entitle for the reliefs prayed for?

7.       Exhibit A1 is the copy of the policy dated 05.03.2010 bearing policy No. 4111/PLA/58895062/00 for an amount of Rs.10,00,000/- is not disputed by the opposite parties.  Ex.A2 is the O.P. ticket issued by Area hospital, Anakapalle on 12.05.2010.  Ex.A3 is the prescription issued by Sri Shirdi Sai Hospital, Anakapalle on 17.05.2010 wherein, the doctor mentioned that he fallen from steps in his house and caused head injury and the patient is in semi conscious, case is bad referred to NS OP KGH, Visakhapatnam.   Ex.A4 is the death certificate of DLA. Ex.A5 is the letter issued by the complainant to 1^st opposite party on 11.06.2010 by sending policy treatment details and death certificate.  Ex.A6 is the letter issued by the Complainant on 06.08.2012 by enclosing policy copy treatment details.  Ex.A7 is the letter issued by the 2^nd opposite party to the complainant on 21.01.2013 requesting the complainant to submit some of the documents like

1)      NEFT Mandate form duly filled in by the bank and the nominee with a cancel cheque copy for direct fund transfer    

2)      PAN card copy, residence proof of the nominee attested by a Gazette Officer with two photographs of the nominee.

3)      All medical records with OPD and IPD treatment papers with investigation and diagnostic reports stamped/sealed by the respective hospital.

4)      Medical cause of death certificate

5)      Reason for late intimation.

Ex.A8 is the letter issued by the complainant on 30.01.2013 to the 2^nd opposite party by sending all the required documents which are required by opposite parties on 21.01.2013 i.e., Ex.A7.  After that the complainant issued registered Lawyer’s Notice on 28.08.2014 i.e., Ex.A9 and Ex.A10 is the postal receipt of Ex.A9 and again the complainant issued another reminder notice i.e., Ex.A11 and Ex.A12 is the postal acknowledgment of Ex.A11.

8.       The contention of the complainant is that his wife died on 19.05.2010 when fallen from steps because of head injury and the same was informed to opposite parties on 11.06.2010 but even after several correspondences made by the complainant, the opposite parties failed to settle the claim amount and more over took a plea that the complainant has to file the FIR, inquest report, P.M report etc.  The complainant submitted all the necessary documents but the opposite parties failed to settle the claim amount.

9.       The main contention of the opposite parties is that the complainant based on the fabricated and created documents and the policy is issued to the policy holder with express terms and conditions attached to the policy itself as per the condition No.7(1) & (2) the complainant is liable to submit proof of accidental death of policy holder by submitting the relevant documents like FIR, P.M, Inquest report etc. More over, the death of deceased is only a natural one but not accidental one but the complainant claimed the policy amount without supporting the documentary evidence in accordance with the policy terms and conditions.  In Ex.B1 the terms and conditions are clearly explained and the complainant has to follow those terms and conditions but he failed to do so.  Hence the claim is not settled.  But in our view, the opposite parties issued a letter to the complainant on 21.01.2013 i.e., Ex.A7 wherein the opposite parties not mentioned regarding the documents which are mentioned in counter and evidence affidavit those are FIR, PM, Inquest report etc. 

10.     It is to be noted that their required documents PAN card copy, Medical records, death certificate etc., as per Ex.A7 and also mentioned in last paragraph that “We shall proceed with the claim assessment process on receipt of the above require documents”, but there is no mention regarding the FIR, inquest and P.M certificate.  Moreover, the complainant made several correspondences and for those correspondences, the opposite parties also issued a letter regarding request of necessary documents and after that the complainant submit all those documents which are required by the opposite parties but not come forward either to settle the claim amount or to repudiate it.  Then, the complainant again issued two registered notices and even after receipt of the notice, the opposite parties failed to even issue a repudiation letter to the complainant.  The Opposite parties on receipt of necessary documents by the complainant they kept silent and failed to intimate the reasons for non settlement of the claim amount to the complainant.  In Exhibit A7, it is very clear that the opposite parties know about the death of DLA that too, the policy is personal protect policy schedule, hence they have to demand for submission of FIR, PM report and Inquest report, but there is no mention in that letter.  Hence, in our view how the complainant know about the position of his claim while the opposite parties pleaded that as per the terms and conditions these FIR, P.M and Inquest reports are necessary.  But the opposite parties not obtained any signature of the policy holder i.e., DLA in those terms and conditions, hence how can any of the policy holder know about those terms and conditions.  Whatever it may be it is the primary duty of the opposite parties either to settle the issue or to repudiate the claim amount by giving reasons.  But the opposite parties failed to do so.  Moreover, falling from steps is come under accidental death as it is an unexpected incident and Exhibit A2 & A3 are clearly established that the policy holder was semi conscious because of head injury and died after 7 days.  Hence, the opposite parties are liable to pay the policy amount of Rs.10,00,000/- to the complainant within two months. 

11.     Being an illiterate old man, the complainant is under impression that the opposite parties are going to settle his claim amount as he made so many correspondences and also not received any repudiation letter, but even after his pursuance they not come forward to settle the claim amount which causes severe mental agony and financial hardship to the complainant.  Hence, allowing Rs.10,000/- towards compensation is just and proper.

          Accordingly, this point is answered.

12.     In the result, the complaint is allowed directing the opposite parties to pay Rs.10,00,000/- with 9% interest from the date of complaint i.e., 03.12.2013 till the date of realization.  The Opposite parties are further directed to pay Rs.10,000/- towards compensation besides costs of Rs.2,000/-.  Time for compliance two months.

  Dictated to the Shorthand Writer, transcribed by her, corrected and pronounced by us in the open Forum on this the 23^rd day of December, 2014.

     Sd/-                                                                                                  Sd/-

Member                                                                 President (FAC)

                                                                   District Consumer Forum-I 

                                                                             Visakhapatnam

APPENDIX OF EVIDENCE

Exhibits Marked for the Complainant:

Exhibits Marked for the Opposite Parties:

      Sd/-                                                                                                  Sd/-

Member                                                                  President (FAC)

                                                                   District Consumer Forum-I

                                                                             Visakhapatnam

//VSSKL//