This complaint is coming up before us for final hearing on 16-07-14 in the presence of Sri G.Punna Reddy, advocate for complainant and Sri P.Ramanjaneyulu, Advocate for 1st opposite party, Sri M.V.Subba Rao, Advocate for 2nd opposite party, upon perusing the material on record and having stood over till this day for consideration this Forum made the following:-
O R D E R
Per Sri A. Prabhakar Gupta, Member:-
The complainant who is the nominee of policy holder filed this complaint u/s 12 of the Consumer Protection Act seeking directions for grant of Rs.2,40,000/- with interest @12% from the date of death of the policy holder, i.e., from 12-04-13, an amount of Rs.50,000/- towards damages for mental agony and an amount of Rs.5,000/- for grant of costs of the litigation. Since the original policy holder died while insurance policy is in force, now the nominee/L.R. is being filed this complaint.
2. In brief the averments of the complaint are these:
The present complainant is the husband of one Mathangi Maria, filed this complaint for the death claim of policy holder Mathangi Maria. The 1st opposite party is the Insurance Company and 2nd opposite party is the Nationalized Bank who granted house loan and who recommended for the taking present Insurance policy from the 1st opposite party. Coming to the facts of the case the said Mathangi Maria during her life time approached the 2nd opposite party and got a loan for the construction of house building. At the time of getting loan, on the advise of the 2nd opposite party Bank who canvass for taking insurance policy from the 1st opposite party the said Mathangi Maria taken a insurance policy against the payment of premium through 2nd opposite party to 1st opposite party. The master policy bearing No.G0000002 is for the Loan account of said Mathangi Maria bearing No.012430100045107. The policy stands in the name of said Mathangi Maria is bearing No.COL No.19347 and the said policy is in force from 26-02-2013 to 25-02-2024 and the sum assured is 2.40 lakhs. The nature of the payment of premium is one time.
During the force of the said policy the said Mathangi Maria fell ill health on 27-03-13 and admitted in N.R.I. Medical College and General Hospital for the treatment of ill health i.e., for loose motions and vomitings (diarrhea) and finally she expired on 12-04-13 during the course of treatment. The said Mathangi Maria is very hale and healthy till her death. Due to the disease of diarrhea only she died. Further, the said Mathangi Maria during her life time worked as E.C.G. Technician at the N.R.I Medical College and General Hospital. After the death of said Mathangi Maria the present complainant submitted claim form along with all required documents to the 1st opposite party through 2nd opposite party Bank since the deceased was paid the premium through 2nd opposite party bank. In turn the 2nd opposite party bank forwarded the same to the 1st opposite party for processing of claim. Subsequently, the 2nd opposite party repudiated the claim with all false allegations stating that the deceased Mathangi Maria had been suffered from the cancer and was under treatment prior to taking the subject policy. Thus the policy holder suppressed the material fact in connection with her previous decease and so as per the terms and conditions of the policy the 2nd opposite party repudiated the claim. Further, the 2nd opposite party intimated claim repudiation fact by way of letter to this complainant. After receiving repudiation letter, the present complainant approached 2nd opposite party in all the legal ways and all are in vain. The act of the 2nd opposite party in connection with the repudiation of claim is falls under the category of deficiency of services as per the Consumer Protection Act provisions and as the 2nd opposite party bank collected the premium and rcommended for the 1st opposite party insurance policy. So, both opposite parties are committed deficiency of services with regard to the settlement of claim. As there is no other go the complainant filed the present complaint for grant of relief as prayed for.
3. The averments of the version of 1st opposite party in brief
as follows:
In reply to the complaint the 1st opposite party filed his version admitting the fact of receiving premium, issuance of policy and in force of the policy as on date of death of policy holder. The claim of the complainant has been denied by the 2nd opposite party on the ground that the policy holder suppressed her previous decease which was labeled as cancer at the time of making the proposal and getting up policy from the 2nd opposite party. In length the 2nd opposite party explained and mentioned all the material facts of which based the deceased policy holder admitted in hospital, undergone for the treatment of cancer has been explained with documentary proof. The facts all are mentioned in the version may be read as part and parcel of this order. Mainly the 2nd opposite party repudiated the claim which is the subject mater of this case on the ground that the policy holder has been suppressed her previous disease of cancer while taking the policy. Even she was not mentioned in connection with her previous decease of cancer in the proposal form inspite of the columns are made in the said form which are the mandatory columns U/s.45 of Insurance Act. Further, the 2nd opposite party mentioned that if at all the policy holder mentioned her previous disease in the proposal form it is the turning point for them either to issue the policy or to return the paid amount of premium will be decided at that time. Due to suppression of this fact and basing on the maxim “good faith” the 2nd opposite party issued the present subject matter policy. After getting the claim form from the complainant they made inspection through a proper agent of investigating and got all the material documents with regard to the previous decease of the deceased policy holder. On the strength of the investigating documents 1st opposite party rightly repudiated the claim of the present complainant and so there is deficiency of services on their part. For which, the 1st opposite party prayed this Forum to dismiss the present complaint with exemplary costs.
4. The averments of the version of 2nd opposite party in brief
as follows:
In reply to the complaint 2nd opposite party bank filed their version admitting the fact of grant of loan, payment of premium amount to the 1st opposite party for getting insurance policy. The rest of the allegation, i.e., in processing and forwarding the claim there is a negligence on their part is denied. For which, 2nd opposite party mentioned that the policy issued by the 1st opposite party and the claim should be settled by them. In no way the 2nd opposite party is concerned for settlement of claim. Further, they mentioned that the as bank paid the insurance premium amount to the 1st opposite party, they were forwarded the claim form along with all concerned documents to 2nd opposite party in time for the settlement of claim. There is no delay or deficiency of service caused by them in processing the claim form to the 1st opposite party. Since, the 1st opposite party is the answerable party to the present litigation and there is no deficiency of service on their part, they prayed this Forum to dismiss the case against them.
5. Complainant and opposite parties filed their respective affidavits. Ex.A-1 to A-9 marked on behalf of complainant and Ex.B-1 to B-8 marked on behalf of 1st opposite party. No documents were marked on behalf of the 2nd opposite party.
6. Now the points that arose for consideration in this complaint are:
1. Whether there is deficiency of service by the opposite parties in settlement of claim?
2. Whether the complainant suppressed the material fact at the time of giving proposal form and whether the opposite parties established the suppression of material fact?
3. To what relief?
- POINT No.1&2:- The learned counsel for the complainant argued that the present complainant is the husband of deceased Mathangi Maria as well as nominee to the present subject matter policy. Coming to the facts of the case during the life time of the Mathangi Maria she approached 2nd opposite party bank and got a house loan of Rs.2,40,000/-. On the instigation and canvass of 2nd opposite party bank the said Mathangi Maria got insurance policy pertaining to the 2nd opposite party against the payment of premium paid through the 2nd opposite party to the 1st opposite party, and thus she became policy holder. The effectiveness of the policy is from 26-02-13 to 25-02-14. While the policy is in force, the said Mathangi Maria fell ill health for the disease of loose motions and vomitings (diarrhea) and admitted in the hospital and finally expired on 12-04-13 while she was under treatment. Before the death of said Mathangi Maria she never fell ill health and is a healthy person. Since the deceased Mathangi Maria is one of the policy holder of group insurance policy, the present complainant submitted the claim form along with all the required documents for settlement of claim. On one pretext or another the 2nd opposite party repudiated the claim on false ground stating that the deceased policy holder suppressed her material decease which is the main cause for repudiation. The act of the opposite party is not at all tenable and without any evidentiary proof of documents. The present complainant approached this Forum and filed the present complainant against both the opposite parties since both are responsible for the settlement of claim. Hence, he prayed this Forum to pass favourable orders in his favour as prayed for.
8. Counsel for the 1st opposite party argued that the deceased Mathangi Maria already suffered with cancer and under gone surgery for the disease, and she was suppressed the fact at the time of giving proposal form for getting policy. In this contention the learned counsel relied on various documents and argued that on the strength of that documents the present complainant not approached this Forum with clean hands and filed the present complaint based on false allegations. Further, the counsel also argued that the settlement of claim for the present policy to be decided by the 1st opposite party and so there is no role of the 2nd opposite party. With the above arguments and on the strength of the documents the learned counsel prayed this Forum for the dismissal of complaint with exemplary costs.
9. With the above discussions and after careful observation of all the documents filed by the both parties it is an admitted fact that the wife of the present complainant by name Mathangi Maria is one of the member of the group insurance policy pertaining to the 1st opposite party company. The other connected facts, i.e., payment of premium through 2nd opposite party, issuance of policy, enforcement of policy at the time of death of the Police holder all are admitted facts. There is no dispute with regard to these facts. Now the discussing point is whether the deceased Mathangi Maria disclosed her previous disease at the time of giving proposal form for getting insurance policy. On careful observation of Exs.A-4, A-5 and A-6, the contents of the said documents are reflected about the decease of (diarrhea) while she was admitted in the hospital just before her death. In addition to this on observation of the Ex.B-4 which is investigation report prepared by Authorized Investigation Agency by name Mass insurance claim investigation service it contains the previous disease of deceased Mathangi Maria. The said investigation report has been supported by some of the medical prescriptions and out patient card. In addition to that Ex.B-5 which is a certificate of Dr.M.Gopichand, dated 07-12-11 clearly established fact that the deceased Mathangi Maria was diagnosed for the cause of cancer and she was admitted in the City Cancer Hospital for the surgery on 16-11-11 and the surgery was done on 18-11-11. It seems to be the deceased Mathangi Maria suffered with cancer and under gone treatment for the same. On perusal of the proposal form marked as Ex.B-1 submitted by the deceased Mathangi Maria the concerned column No.2 have been not answered properly with regard to her previous disease. The said Ex.B-1 has been executed by the deceased on 26-02-2013. The doctor certificate which was marked under Ex.A-6 issued on 07-02-11 reflects the previous disease of cancer. It seems to be the deceased Mathangi Maria suppressed the material fact of her previous decease. So, concealment of material fact in connection with previous disease will not makes the insurance company for the payment of claim.
10. In this connection we have to know about the meaning of Material fact since the same is not defined in the Act. With the views of Supreme Court Judgment in a case Satwant Kaur Sandhu Vs. New India Assurance Company Ltd., VI (2009) SLT 338 wherein the Supreme Court 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 insurance and has a bearing on the risk involved would be ‘material’.
11. So, with holding of material evidence with regard to previous disease may leads to adverse inference. This view has been taken from a reported authority reported in 2014 (1) CPR 18 (NC) in a case Additional General Vs. Jyani Devi where their lordships held that if material fact has been suppressed or concealed by the complainant it has to be taken as adverse inference. In such a situation there is no deficiency of service on the part of opposite parties in repudiation of the claim. So, this Forum feels that the fact which was suppressed by the deceased person is to be treated as material suppression and so, the present complainant is not at all fit person to receive claim. Since, 2nd opposite party is a bank, made post office work, i.e., collecting of premium, sending of the same to the insurance company and forwarding the claim form are all in done without negligence, complaint against OP2 is dismissed.
In the result, the complaint is dismissed without costs.
Typed to my dictation by Junior Steno, corrected by me and pronounced in the open Forum dated this the 31st day of July, 2014
MEMBER MEMBER PRESIDENT
APPENDIX OF EVIDENCE
DOCUMENTS MARKED
For Complainant:
Ex.Nos. | DATE | DESCRIPTION OF DOCUMENTS |
A1 | 26-02-13 | Copy of certificate of insurance & policy schedule. |
A2 | 26-02-13 | Copy of consent cum authorization form and simple declaration form |
A3 | - | Copy of death certificate |
A4 | 27-02-13 | Copy of OP card issued by NRI General Hospital, Guntur |
A5 | 12-04-13 | Copy of discharge summary issued by NRI General Hospital, Guntur |
A6 | 10-07-13 | Copy of certificate issued by NRI Academy of sciences |
A7 | 03-06-13 | Copy of repudiation letter by OP1 |
A8 | 24-07-13 | Copy of letter issued by OP1 |
A9 | 30-08-13 | Copy of letter issued by OP1 |
For opposite parties:
Ex.Nos. | DATE | DESCRIPTION OF DOCUMENTS |
B1 | - | Copy of Member Form. |
B2 | 26-02-13 | Copy of certificate of insurance & policy schedule. |
B3 | 08-05-13 | Copy of claim intimation form & copy of letter from Andhra Bank, Emani Branch. |
B4 | 27-05-13 | Copy of investigation report of credit policy – death claim. |
B5 | - | Copy of treatment records and copy of medical certificate. |
B6 | 03-06-13 | Copy of claim repudiation letter. |
B7 | 24-07-13 | Copy of letter for re-consideration of claim rejection for insurance attached to A/c.No.012430100045107. |
B8 | - | Copy of proceedings of the insurance ombudsman, Hyderabad |
PRESIDENT
NB: The parties are required to collect the extra sets within a month after receipt of this order either personally or through their advocate as otherwise the extra sets shall be weeded out.
