BEFORE THE A.P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION
AT HYDERABAD.
F.A. 1540/2007 against C.C. 106/2006, Dist. Forum, Nellore
Between:
Smt. Malla Venkata Subbamma
W/o. Late M. V. Ramanaiah
Age: 39 years, R/o. Nagulabavi Street
Udayagiri Post, Nellore.
*** Appellant/
Complainant.
And
L. I.C. of India
Rep. by its Senior Divisional Manager
Divisional Office, Dargamitta
Nellore. *** Respondent/
Opposite Party.
Counsel for the Appellant: M/s. K. Visweswara Rao
Counsel for the Resp: M/s. G. Venugopal Rao.
CORAM:
HON’BLE SRI JUSTICE D. APPA RAO, PRESIDENT
&
SMT. M. SHREESHA, MEMBER
WEDNESDAY, THIS THE NINETEENTH DAY OF MAY TWO THOUSAND TEN
Oral Order: (Per Hon’ble Justice D. Appa Rao, President)
***
1) Appellant is unsuccessful complainant.
2) The case of the complainant in brief is that she is the wife of assured late M. A. Ramaiah, who had taken five policies. He died suddenly on 31.1.2005. When she claimed the amount the insurance company settled three claims, and repudiated the two policies one for Rs. 50,000/- commencing from 30.9.2002 and another for Rs. 40,000/- commencing from 11.8.2003. The claims were unjustly repudiated on 31.3.2006. Therefore she claimed the amounts covered under the policies together with accident benefit, bonus, compensation and costs.
3) The insurance company resisted the case. However, it admitted that the complainant is the wife of assured late M.A. Ramaiah a nominee under the policies. It had settled three policies out of five policies and repudiated these two policies on the ground that he had suppressed his ill-health while obtaining the policies. He was suffering from cirrhosis of lever and filarial foot for a long time. It had investigated the matter with Bolleneni Super Special Hospital, Nellore and found that the assured was suffering from the above ailments for the last 15 years. The death having been occurred within a period of three years from the date of commencement of policies and for non-disclosure and mis-representation of facts they being early claims they prayed for dismissal of the complaint with costs.
4) The complainant in proof of her case filed her affidavit evidence and got Exs. A1 to A10 marked while the insurance company filed the affidavit evidence of its Assistant Divisional Manager and got Exs. B1 to B5 marked.
5) The Dist. Forum after considering the evidence placed on record opined that the assured had admittedly suffered from Cirrhosis of lever and filarial foot and suppressing the said fact he obtained the policies. The repudiation was just and therefore dismissed the complaint.
6) Aggrieved by the said decision, the complainant preferred the appeal contending that the Dist. Forum did not appreciate the facts in correct perspective. When he had sustained accidental injury on his left thigh he had fever for the first time on 15.12.2004. He was admitted in Bollineni Super Specialty Hospital, Nellore on 15.12.2004 and was discharged on 22.12.2004. The primary cause of the death was ARF. The policies were taken on 30.9.2002 and 11.8.2003 respectively. If really he was suffering from above said ailments, there was no reason why the other three policies were issued and settled. At any rate, the doctor who prepared the discharge summary was not examined and the certificate issued cannot be taken ex-facie as evidence, and therefore prayed that the amount covered under the policies with benefits, bonus together compensation be awarded.
7) The point that arises for consideration is whether the order of the Dist. Forum is vitiated by mis-appreciation of fact or law?
8) It is an undisputed fact that assured late M. V. Ramaiah had taken five policies for Rs. 50,000/-, Rs. 25,000/-, Rs. 75,000/-, Rs. 40,000/- and Rs. 50,000/- respectively. He had sustained an injury on his left thigh in an accident. He was admitted in Bollineni Super Specialty Hospital, Nellore on 15.12.2004 and was discharged on 22.1.2005. Ten days there after he died on 31.1.2005. The complainant submitted her claim forms. The insurance company settled three of the claims, repudiated the two policies taken under Jeevan Mitra Double Cover Endowment + Profits + accident benefits vide Ex. B2. In other words the complainant being nominee entitled to sum assured + accident benefit + bonus since the death was before maturity. It is not known why the insurance company had settled the other three claims out of five policies and repudiated these two policies. May be a wild guess but we presume that if it allows these claims it had to pay double the sum assured + benefits. It repudiated the claims basing on the discharge summary obtained from Bolleneni Super Specialty Hospital, Nellore marked as Ex. B3. To appreciate the case on hand, we excerpt the treatment given in the said hospital mentioned in the discharge summary.
“Left thigh accidentally injured, treated with antibiotics mean while patient developed ARF with hyperkelemia for which treatment given. Wound healing healthily. Because of past history of Cirrhosis of liver patient developed abdomen dis-tension with ascites for which Gastroenterologist consultation given. For anemia 5 units of packed cells given. Patient developed recurrent seizures for which Neurophysician consultation taken. Right Besilic vein cut and put IV cannula because of exhaustion of all peripheral veins. IV fluids, vitamins, antacids and daily wound dressing given.”
9) The insurance company obviously obtained certificate from their panel doctor Dr. K. Venugopal who gave certificate Exs. B4 & B5 on 5.12.2005 alleging that the primary cause of death was ARF and the secondary cause was ‘Cirrhosis of liver’. At the time of discharge, there was a mention “Left thigh wound healed well” This was given 12 months after the death of the deceased. It is evident from Ex. B3 discharge summary issued by Bollineni Super Specialty Hospital that there was no mention that Cirrhosis of liver’ had anything to do with ARF. It was mentioned “accidental injury to left thigh, followed by pus formation which caused super skeptical burns, swelling and sepsis. Fever since five days not able to walk now.” The death was due to accident to his thigh, later he developed Cirrhosis However, he was discharged after recouping from illness. If really he was suffering from the above said ailment for the last 15 years it could not have been the cause of his death. It is not as if the insurance company was not aware of this. It is not a case where those ailments could be suppressed. It would be evident even if one sees the assured being ‘Cirrhosis of liver’ and filariasis.
10) At the cost of repetition, we may state that the very insurance company had settled the claims for three policies without objecting for payment of the amount. It has been issuing the policies one after another knowing full well his health condition. Assuming without admitting that he did not mention the said ailments, as it has nothing to do with his death. The suppression cannot be said to be material.
The Hon’ble Supreme Court in AIR 1962 SC 814 held that “ the fraudulent suppression of the material facts with regard to the statement must be on material or must suppress the facts which it was material to disclose, the suppression must be fraudulent made by the policy holder prior to the proposal, the policy holder must have known at the time of making the statement that it was false or that it was suppressed facts which it was material to disclose.”
“The Supreme Court in LIC of India Vs. Asha Goel reported in 2001 (2) SCC 160 held that “ the repudiation of contract of a life insurance should be one of extreme caution and such a matter should not be dealt with in a mechanical and routine manner.”
The National Commission in LIC of India Vs. B. Nageswaramma reported in II (2005) CPJ 9 NC held that “doctor’s certificate without affidavit in support is not basis for repudiating the claim. No conclusive evidence produced to suggest the suppression on the part of the deceased. The insurance company was liable to pay the amount.”
11) Coming to the facts of the case, the deceased had accidental injury, took treatment in Bollineni Super Specialty Hospital, Nellore and the doctors certified that he had sustained injury in the accident. 10 days after his discharge he died in the house. There is no evidence let in by the insurance company, by filing the affidavit of the doctor that the death was due to ‘Cirrhosis of liver’ and filariasis. Exs. B4 & B5 are not proved. Even assuming that the same is true, since the so called suppression of ailment is not material, it has nothing to do with the death of the deceased the insurance company pay the amounts covered under policies. . Therefore, we are of the opinion that the complainant is entitled to the amount covered under the policies with benefits + bonus.
12) In the result the appeal is allowed and the order of the Dist. Forum is set-aside. Consequently the insurance company is directed to pay the amount covered under the policies with benefits + bonus together with interest @ 9% p.a., from the date of repudiation till the date of payment together with costs of Rs. 5,000/-. Time for compliance four weeks.
1) _______________________________
PRESIDENT
2) ________________________________
MEMBER
Dt. 19. 5. 2010.
*pnr
“UP LOAD – O.K.”
