O R D E R
(By Sri D.Shankar Rao, Member)
- The brief-facts of the complaint are that the father of the complainant Sri. Singireddy Ram Reddy took Max New York Life Insurance policy No.855099560 with sum insured Rs.13,20,000/- from opposite party No.1 on 23-11-2011. The opposite party No.2 is registered office of Max New York Life Insurance Company Limited at New Delhi. The policy was issued by opposite party No.1 after collecting annual premium instalment Rs.64,606/- from the father of complainant and accepted the proposal application dated 27-10-2011 after fully satisfying with the health conditions. The policy holder Singireddy Ram Reddy died due to heart-attack on 24-03-2012. The matter was reported to opposite parties 1 and 2 and claim material papers are submitted to opposite party No.1 at Nizamabad for payment of sum insured in the policy. Surprisingly the opposite parties have repudiated the claim on 06-06-2012 stating that the information on diseases was not disclosed in proposed form dated 27-10-2011. The contention of opposite parties is totally incorrect. The insured person has not suppressed any material fact known to him at the time of filing proposal. He was also subjected to medical examination by Panel Doctors of opposite parties. Having accepted proposed application on 27-10-2011 and issued policy bond on 23-11-2011, the acts of opposite parties in repudiation the policy claim without any valid reason is illegal and deficiency service and unfair trade practice. Therefore the opposite parties are liable to pay the policy sum insured with 18% interest and Rs.2,00,000/- as compensation along with costs.
2. The opposite parties 1 and 2 have filed their counter. Briefly stated that M/s Max New York Life Insurance Company has changed its name as “M/s Max Life Insurance Company Limited”. Further stated that the claim filed by complainant was rightly repudiated on the ground of intentional concealment of material information. The deceased life assured (DLA) Singireddy Ram Reddy was a known case of “Cancer Buccal Mucosa” since 15-06-2010 prior to filling of proposal Form but he has not disclosed the same in proposed Form. Therefore as per terms and conditions of the policy the claim was repudiated as the policy contract which the opposite parties had with the deceased life assured became void and the complaint is liable to be dismissed.
That in a contract of insurance any fact which would influence the mind of prudent insurer in deciding whether to accept or not to accept the risk is “Material fact”. The Hon’ble Supreme court of India in the case of “Satwant Kaur Sandhu V/s New India Assurance Company Ltd., (2009) 8 SCC 316” has referred the term “Proposal Form” as defined under the Insurance Regulatory and Development Authority 2002 as a ‘Form’ to be filled by the proposer for insurance, for furnishing all material information required by the insurer decide whether to accept or decline, to undertake the risk. If the proposer has knowledge of such fact, he is obliged to disclose it particularly while answering questions in the proposal form.
In proposal Form at page 3 there is a section at part D pertaining to medical information. The deceased life assured were answered negative to a set of questionnaire at question No.3 of proposed form as follows:-
Q3. “Are you or have you ever been diagnosed with any of the following condition, if yes please provide details or attach relevant questionnaire”.
- Cancer, tumor or growth (Malignant or Benign) NO
That based on information provided in the proposed form and after receipt of annual model initial premium amount of Rs.63,624/-, the opposite parties have issued the policy bearing No.855099560 on 23-11-2011 for sum assured Rs.13,20,000/- in favour of deceased life assured Singireddy Ram Reddy under life guaranteed monthly income subject to terms and conditions of policy. The premium @ Rs.63,624/- is to be paid annually.
That on 27-04-2012, the complainant intimated the opposite parties that his father expired on 24-03-2012 and claimed the sum assured in the said policy. Since it was an early claim, the opposite parties have got an investigation conducted as per terms and conditions of the policy for evaluation of the claim through ‘Stellar Insurance Management Services Pvt. Ltd’. From the investigation report dated 21-05-2012 and documents available in hand it came to knowledge of opposite parties that the deceased life assured Singireddy Ram Reddy was a known case of ‘Cancer buccal Mucosa’ since 15-06-2010, prior to signing of the proposal Form. A medical certificate dated 16-05-2012 has also been issued by the Bibi General Hospital and Cancer centre confirming that the deceased life assured Singireddy Ram Reddy was a known case of ‘Cancer buccal Mucosa’ and was admitted in the hospital on 18-08-2010 where he underwent Chemotherapy treatment and was discharged on 30-09-2010. It was clearly observed that the deceased life assured Singireddy Ram Reddy willfully suppressed the material information of his past medical history and was obtained the policy by fraud and mis-representation. Thus the opposite parties have rightly repudiated the claim of complainant. All other allegations made in the complaint have been denied by opposite parties. The complaint being devoid of any merits, be dismissed with costs.
3. During enquiry the complainant has filed his affidavit evidence as PW1 and got marked Ex.A1 to A6 documents and closed his evidence. The opposite party No.2 filed the evidence affidavit of one Anil Sharma Senior Manager (Claim) on 30-07-2013 on be-half of opposite parties 1 and 2 but he has not appeared before the Forum for recording his evidence even though reasonable and sufficient time granted. The opposite parties 1 & 2 have not adduced evidence on their be-half. Hence the evidence on be-half of opposite parties 1 and 2 was closed on 24-06-2014.
4. Heard Arguments.
5. The points for consideration are:-
1) Whether there is any deficiency Service on the part of opposite parties 1 & 2 in repudiation of the policy claim ?
2) To what relief?
6. POINT No.1: There is no dispute that the opposite parties have issued the policy bearing No.855099560 on 23-11-2011 for a sum assured Rs.13,20,000/- in favour of father of the complainant Singireddy Ram Reddy. It is also not in dispute that the life assured Singireddy Ram Reddy expired on 24-03-2012.
The case of complainant is that the opposite parties have issued the insurance policy in favour of his father only after fully satisfying with the health conditions and accepted the proposed application. He was also subjected to medical examination by panel doctors of opposite parties. The policy holder died due to heart-attack on 24-03-2012. The act of opposite parties in repudiation of claim under the policy on 06-06-2012 without any valid reason.
The contention of the opposite parties 1 & 2 is that the deceased life assured (DLA) Singireddy Ram Reddy was a known case of “Cancer Buccal Mucosa” since 15-06-2010 prior to execution of proposal form but he has not disclosed the same in the proposed form. A medical certificate dated 16-05-2012 has also been issued by Bibi General hospital and Cancer Centre confirming that he admitted in the hospital on 18-08-2010 where he underwent Chemotherapy treatment and he was discharged on 30-09-2010. Hence the deceased life assured willfully suppressed the material information of his past Medical history and was obtained the policy by fraud and mis-representation. The opposite parties 1 & 2 have rightly repudiated the claim of complainant.
Therefore the dispute is arised over the suppression of material information of past medical history of deceased life assured (DLA) Singireddy Ram Reddy prior to execution of proposed Form for issuing policy.
The simple plea of complainant is that his father deceased life assured (DLA) Singireddy Ram Reddy has not suppressed any material information known to him and he was also subjected to medical examination by panel Doctors of opposite parties. The policy was issued only after fully satisfying with the health conditions.
In order to prove the case of complainant he filed his own affidavit as PW1 evidence and relied upon Exs.A1 to A6 documents.
It is the plea of opposite parties 1 & 2 that the deceased life assured (DLA) has suppressed the material information of his past medical history prior to execution of proposed Form. The claim was repudiated under fraud and mis-representation. Therefore the burden to be discharged is shifted to opposite parties 1 & 2.
The opposite parties 1 & 2 have filed the evidence affidavit of their Senior Manager one Mr.Anil Sharma on 30-07-2013 into the case, but he has not appeared for recording his evidence. Eventhough reasonable and sufficient time granted the opposite parties have not adduced any evidence on their be-half. Therefore the evidence on be-half of opposite parties is closed on 24-06-2014. Thereafter the case was coming from time to time till 16-10-2014 finally for arguments and heard the arguments of counsel for the complainant on 17-10-2014.
The counsel for the complainant vehemently argued that the opposite parties 1 & 2 have failed to discharge their burden in proving their plea for repudiation of the claim.
We have verified the entire case record and perused the marked documents in Exs.A1 to A6 and un-marked documents placed by opposite parties 1 & 2 along with their counter. Though the opposite parties have taken their plea in their counter and claim repudiation letter in Ex.A4, that the deceased life assured (DLA) Singireddy Ram Reddy has suppressed the material information of his medical past history prior to execution of proposed Form but they have not adduced any evidence even their Senior Manager Mr.Anil Sharma who filed his affidavit but not appeared for recording his evidence. The opposite parties have also failed to examine the investigator who issued the report on 21-05-2012 in respect of investigation stated to be conducted through ‘Stellar Insurance Management Service Pvt. Ltd., The opposite parties have also failed to examine the doctor of Bibi General hospital and Cancer Centre who stated to be issued a medical certificate dated 16-05-2012. Mere placing of medical certificate and investigation report into the case is not-sufficient unless it is proved by produce any tangible evidence that the deceased life assured (DLA) Singireddy Ram Reddy with held information about his past past medical history of hospitalization and treatment in the light of Hon’ble Apex Court judgement between P.Venkat Naidu V/s LIC of India & another reported in CPJ 2011 IV SC-6.
Therefore we are of considered view that the opposite parties 1 & 2 have failed to prove their plea in repudiating the claim of complainant under the policy and there is deficiency service on the part of opposite parties. Accordingly we answered the point No.1.
7. POINT No.2: In view of finding in point No.1, the next issue is that, to what relief the complainant is entitled.
There is no dispute that the opposite parties have issued insurance policy in Ex.A1 for sum insured Rs.13,20,000/- in favour of father of complainant Singireddy Ram Reddy and the complainant is a nominee for the policy. The complainant is also claiming compensation of Rs.2,00,000/- in addition to the policy sum insured with interest @ 18% per annum and cost of the complaint proceedings.
The complainant has not placed any record of evidence how the complainant is entitled for the claim of compensation. Hence we are of considered view that the complainant being a nominee is only entitled for sum insured Rs.13,20,000/- with 9% interest under the policy in Ex.A1 from the date of repudiation i. e. on 06-06-2012 with Rs.1,000/- towards cost of complaint. Accordingly we also answered the point No.2.
In view of afore-said findings in point No.1 & 2, we are of the considered view that the opposite parties 1 and 2 are liable to pay sum insured of Rs.13,20,000/- under the policy in Ex.A1 with 9% interest per annum from the date of repudiation i.e. on 06-06-2012 with Rs.1,000/- towards cost of the complaint.
8. IN THE RESULT, the complaint is allowed in part as under:-
- The opposite parties 1 and 2 are directed to pay sum insured Rs.13,20,000/- under the policy in Ex.A1 with 9% interest per annum from the date of repudiation i.e. 06-06-2012 till realisation to the complainant.
- The opposite parties are also further directed to pay Rs.1,000/- to the complainant towards cost of the complaint.
Typed to dictation, corrected and pronounced by the Member in Open Forum on this the 31st day of October 2014.
