BEFORE THE A.P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION

AT HYDERABAD.

F.A. 975/2008 against C.C.  30/2007, Dist. Forum, Warangal        

Between:

P. Venkayamma, W/o. Late Peddanna

Age: 47 years, Kamalapuram Village

Mangapeta Mandal, Warangal Dist.            ***                         Appellant/

                                                                                                Complainant. 

And

L. I.C. of India

Rep. by its Senior Divisional Manager

Divisional Office, Warangal.                        ***                         Respondent/

                                                                                      Opposite Party.  

Counsel for the Appellant:                          M/s. M. Srinivasa Rao.

Counsel for the Resp:                                  M/s. G. Venugopal Rao.

CORAM:

                             HON’BLE SRI JUSTICE D. APPA RAO, PRESIDENT  

&

                                            SMT. M. SHREESHA, MEMBER

MONDAY, THE TWENTY SECOND DAY OF NOVEMBER 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 Peddanna who had taken insurance policy for Rs. 10 lakhs on 22.2.2004.  Before accepting the proposal he underwent medical check up and only after clearance the opposite party issued the policy.   He was an agriculturist owning 60 acres of land.    He was hale and hearty till 30.11.2004.    When he suddenly fell ill  he was admitted in Life Line Hospital, Warangal and died of cardiac arrest.    He had taken five polices.   Except the above said policy remaining policies were settled.   The repudiation of claim on 30.3.2005 was unjust without any ground whatsoever,  and therefore she prayed that an amount of Rs. 10 lakhs covered under the policy together with interest be granted.

3)                The insurance company resisted the case.   However it admitted issuance of policy on 22.2.2004 with date of commencement on  28.4.2003 for a period of 16 years for a sum of Rs. 10 lakhs with attendant benefits.  On receipt of  information about the death of the deceased  out of five policies four policies were settled, except the case on hand  on the ground that  he had suppressed the material fact.     The hospital record reveals that he was suffering from hypertension and diabetes even prior to taking of the policy.    The policy was taken in order to defraud the corporation.   To the questionnaire supplied to him he categorically stated that he was not having the above said ailments, and  as the information was false claim was repudiated.  It 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 A7 marked while the insurance company filed the affidavit evidence of its Manager and got Exs. B1 to B7 marked. 

5)                The Dist. Forum after considering the evidence placed on record opined that the deceased had suppressed the ailment of hypertension and diabetes etc. revealed from the case record Ex. B2 maintained by Jaya Hospital and therefore opined that the policy was taken to defraud the   insurance company and dismissed the complaint. 

6)                Aggrieved by the said decision, the complainant preferred the appeal contending that the Dist. Forum did not appreciate the facts or law in correct perspective.   The Dist. Forum without any evidence whatsoever had come to a wrong conclusion that he was suffering from hyper tension and diabetes, and suppressed the material fact.    Ex. B2 shows that he was admitted in the hospital for treatment of fever but not hypertension or diabetes, and therefore the repudiation was unjust and prayed that the complaint be allowed.

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  the complainant is the wife of late Peddanna  who had taken five policies out of which a policy was taken for Rs. 10 lakhs  commencing from 28.4.2003  to  28.4.2018 vide Ex. A4.   The claim was denied on the ground that he had suppressed his ailments hypertension and diabetes.    It is an undisputed fact that at the time when the assured submitted the proposal for taking policy he was examined by panel doctor evidenced from Ex. A5 & A6 reports.    They show  that blood sugar; cholesterol is within the normal range.   The condition of lungs and pleura etc. are in normal limits.    Obviously basing on the said reports the insurance company had accepted the proposal and issued the policy Ex. A4.    

9)                The complainant alleges that on 30.11.2004 he suddenly fell ill and was admitted in Life Line hospital vide Ex. A7.    They  made a mention in the coloumn “history and clinical examination’ – complaint of suddenly  became unconscious today.    Patient known case of HTN + DM.”   There was no mention since how long he was suffering from said ailments in order to repudiate the claim.  The insurance company also filed  the case sheet of Jaya hospitals, Hanamkonda to show that he was admitted   on 2.12.2002.   The insurance company had to prove  that at the time when he had taken the policy he was suffering from such ailments.    He was suffering from fever by then and the doctors opined ultimately that he died of cardiac arrest.   The insurance company itself has filed Ex. B5 proposal form.  Against coloumn No. 12 viz., in non-medical cases, please state exact height in cms., and weight in Kgs.   There is a mention that it was “MEDICAL”.   Obviously the insurance company having  not satisfied with his health,  got examined him through panel doctors.   Without any evidence that he had suppressed the said ailments, the insurance company basing on Exs. A7 and B2 & B3 could not have opined that he was suffering from hypertension and diabetes from the date of taking of the policy.   No doctor was examined nor  affidavit was filed in order to show that he was suffering from these ailments at the time when he took the policy.    Simply because it was surfaced in the month of December the presumption that he must have the above ailments from the month of February cannot be drawn.    It is a sheer conjuncture obviously in order to deny the just claim of the complainant.   We may state at this juncture that the insurance company without any compunction whatsoever settled the other four policies they being small amounts ranging from   Rs. 50,000/- to Rs. 1 lakh,  however, when it comes to this policy it being for Rs. 10 lakhs it intends to repudiate by alleging that he had suppressed his ailments.   

The Hon’ble Supreme Court in Mithoolal Nayak v. LIC reported 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.” 

10)              Coming to the facts  the insurance company could not prove that  by the date when the policy was issued  he was suffering from  any of the ailments.    Exs. A5 & A6 positively  would show that he was  free from those ailments, basing on which,   insurance  company had issued the policy.    Now they cannot turn round and  say that he had suppressed these ailments.  Therefore we are of the opinion that the complainant is entitled to the amount covered under the policy.

11)              In the result the appeal is allowed setting aside the order of the Dist. Forum.  Consequently the complaint is allowed directing the insurance company to pay Rs. 10 lakhs  + accrued bonus  and other  attendant benefits as per the policy together with interest @ 9% p.a., from the date of repudiation viz., 15.2.2006 till the date of realization together with costs of Rs. 5,000/-.  Time for compliance four weeks.

1)                _______________________________

PRESIDENT                 

2)      ________________________________

 MEMBER           

                                                                                Dt.  22. 11.  2010.  

*pnr

“UP LOAD – O.K.”