This C.C. is coming on before us for final hearing in the presence of Sri.P. Rama Kishan Rao, Advocate for complainant and of Sri.M.M.G. Ranga Rao, Advocate for opposite parties 1 & 2; upon perusing the material papers on record and upon hearing the arguments, this Forum passed the following order;

O R D E R

(Per Sri R.Kiran Kumar, Member)

          This Complaint is filed u/s.12-A of Consumer Protection Act, 1986. 

2.      The averments made in the complaint are that the mother of the complainant obtained life insurance policy bearing No.44033509501 for worth of Rs.3,50,000/- vide UTN No.111L068V01, commencing from 09-01-2012 and the complainant is the nominee in the said policy.  The complainant further submitted that his mother unfortunately died on 31-12-2012 due to Massive Heart Attack, he being as nominee under the policy, he submitted claim form along with all relevant documents to the opposite parties for payment of death claim.  The complainant further submitted that he received a letter No.OPS/12/CL/D/99826 vide claim ID.No.44406 alleging therein that the mother of the complainant answered the question No.13 (iv) and 13 (xv) in the proposal Form as ‘No’ and as per the records available with the opposite parties the mother of the complainant was under treatment for coronary artery disease prior to the date of commencement of policy and also alleged that as per the material facts available with the opposite party, late Seethamma was much older than the age declared by her at the time of signing the proposal form, she has misrepresented her age and had the correct age has been disclosed in the proposal Form she would have been found eligible for the insurance the claim of the complainant repudiated that the material facts were not disclosed at the time of signing of the contract of insurance.  The complainant further submitted that the agent of the opposite party approached the mother of the complainant, with mesmerizing words made believe her about the policy and the mother of the complainant attracted to the same and obtained the policy, in fact the agent of the opposite parties filled the proposal Form after ascertaining the information with documents from the mother of the complainant by collecting all required proofs and submitted to the same to opposite party No.2, who in turn accepted the same and issued the policy. 

3.      The complainant further submitted that as the opposite party failed to settle the claim and repudiated the claim in flimsy grounds, the complainant got issued legal notice to the opposite party on 13-09-2013 and the same was acknowledged by opposite party on 23-09-2013, thereafter  the opposite party no.2 issued a reply on 30-09-2013 by alleging that their company made investigation in the claim and they found that the mother of the complainant was suffering from and was taken treatment for coronary artery disease prior to the date of commencement of policy and she did not disclose in the proposal Form.  The complainant submitted that the reply notice clearly shows that the opposite parties has been making evading attitude by dispute in the claim on flimsy grounds and they failed to enclose the documents to show that the complainant misrepresented the facts at the time of giving proposal Form,  therefore these acts of opposite parties in repudiating the claim of the complainant amounts to deficiency of service as such the complainant filed the present complaint. 

4.      On behalf of the complainant, the following documents were filed and marked as Exs.A.1 to A.6. 

Ex.A.1:- Office copy of legal notice, dt. 13-09-2013 with acknowledgement.

Ex.A.2:- Reply notice got issued by opposite party dt. 30-09-2013.

Ex.A.3:- Photocopy of Aadhar Card of Yammani Seethamma.

Ex.A.4:- Repudiation letter issued by OP. dt. 19-03-2013.

Ex.A-5:- Policy Extract Copy issued by Help Desk.

5.      On receipt of notice, opposite parties appeared through their counsel and filed counter.  In their counter, opposite parties submitted that the deceased life assured, Smt. Yammani Seethamma committed a breach of the principle utmost good faith by suppressing the material fact that she was under treatment for coronary artery disease prior to the date of commencement of risk and by under stating her actual age.  The opposite parties also submitted that at the time of signing the proposal Form on 30-12-2011, she replied in negative to the question Nos. 13(iv) During the last 10 years have you undergone or advised to undergo hospitalization, an operation or any investigation or tests or medical treatment?  and 13 (xv), Are you suffering from or did you suffer or undergo investigation in the past from or have been advised to undergo investigation or treatment for [d] heart disease?.  The opposite party submitted that from the records the deceased life assured was suffering from coronary artery disease prior to the commencement of policy and she deliberately suppressed the material fact and obtained the policy fraudulently.  The opposite party also submitted that the deceased life assured mentioned the date of birth as 1-1-1962 i.e. her age as 49 years  in the proposal form but it was found that she much older than age declared by her and procured insurance policy fraudulently.  The opposite parties also submitted that had she disclosed her correct age in the proposal form, she would have been found ineligible for insurance and the complaint is not maintainable and prayed to dismiss the complaint.

6.      The opposite parties also submitted that as per the prescription slip dated. 16-09-2011 given by Dr. Prabhakar Rao, the Deceased Life Assured was having a B.P. reading of 170/100 and she was prescribed medicine for BP and was advised for further investigations.  The opposite parties also submitted that the Bill cum receipt of Usha Cardiac Centre Ltd., Vijayawada, dt. 02-11-2011, the deceased life assured was admitted there on 27-10-2011 and was discharged on 02-11-2011 for a treatment of Coronary Artery disease, in the Coronary Angiograph Report dt. 01-11-2011 done at Usha Cardiac Centre Ltd., it is noted that “Pre Cath Diagnosis: CAD, Ischaemic CMP, Selerotic AV, Mild AR, Reduced LV Function EF: 30%, the above reports clearly establish the pre existing illness of the deceased life assured.  The opposite parties also submitted that the proposal form was signed on 30-12-2011, the date of commencement of risk on the life Smt. Y. Seethamma under the policy was 09-01-2012 and from the reports it is clear that the diseased life assured was suffering from Coronary artery disease prior to the commencement of the policy.  The opposite parties also submitted that as per the voter’s ID submitted by the DLA along with the proposal form, her date of birth was mentioned as 01-01-1962, which means that she was 49 years old at the time of proposal and in the Electoral Roll of 2013 of Khammam Assembly Constituency it is mentioned that she was 62 years in 2013, which means she was 60 years on the date of proposal, in Civil supplies card issued in 2005 it is stated that Smt. Y. Seethamma was 60 years, which means she was 66 years at the time of proposal, from the above documents it clearly reveals that the DLA understated her age and procured the insurance cover fraudulently.  Age is a vital and material factor to decide the prima-facie eligibility of the proposer into insurance cover.  The risk increased with age if the correct had been mentioned, the proposal would not have been accepted only after her extra medical report the opposite parties further submitted that the DLA thus committed a breach of doctrine of utmost good faith, any statement of age would render the contract of insurance is void and the opposite parties have sufficient evidence on record to prove that the DLA grossly understated her age to get the insurance cover fraudulently.

7.      The opposite parties to support their contention, they relied on the judgments of the Hon’ble National Commission, in case of LIC of India Vs. Hira Devi (RP No.4048 of 2009), Panni Devi Vs. LIC (III) (2003) CPJ 15 (NC), the judgment of the Hon’ble Supreme court in Satwant Kumar Sandhu Vs. New India Assurance Co. Ltd., Civil Appeal No.2776 of 2002, Chackochan Vs. LIC of India in Civil Appeal No.5322 of 2007.

8.      The opposite parties further submitted that the claim occurred within 11 months 22 days from the date of commencement of policy, this shows that  the DLA was under treatment coronary artery disease which she had not disclosed the same in the proposal Form.  The opposite parties further submitted that the claim was repudiated and the policy investment amount of Rs.50,804/-  was paid to the complainant as per the terms and conditions of the policy document.  There is no contractual obligation on the part of opposite parties to pay any amount of whatsoever nature to the complainant and the complaint is not eligible for any benefit from the opposite parties towards claim amount, hence the complaint is not maintainable and prayed to dismiss the complaint.

9.      On behalf of the opposite parties the following documents were filed and marked as Exs.B.1 to B.9.

Ex.B.1:- Proposal Form.

Ex.B.2:- Policy Document.

Ex.B.3:- Claims Investigation Report.

Ex.B.4:- Photocopy of Doctor Prescription along with medical reports.

Ex.B.5:- Photocopy of Bill cum Receipt issued by Usha Cardiac Centre, Vijayawada. dt. 02-11-2011.

Ex.B.6:- Photocopy of Coronary Angiography Report, dt. 01-11-2011.

Ex.B.7:- Photocopy of Electoral Identity Card.

Ex.B.8:- Photocopy of Photo Electoral Roll 2013.

Ex.B.9:- Photocopy of Civil Supplies Card.

10.    Opposite parties filed their written arguments. 

11.    Upon perusing the material papers on record and upon hearing the arguments, now the point that arose for consideration is,

Whether the assured had suppressed the material facts pertaining to her health at the time of submitting proposal form, consequently the complainant is entitled for the claim amount under the policy?

Point:-

12.    In this case the mother of the complainant during her lifetime obtained insurance policy for a sum assured of Rs.3,50,000/- on 9-1-2012 vide bearing No.44033509501 from opposite party No.2 and shown the name of complainant as nominee.  That on 31-12-2012 the mother of the complainant died due to massive heart attack.  After death of his mother, the complainant intimated the same to opposite parties and submitted all the relevant documents requesting to settle the death claim of his mother.  But the opposite parties made investigation on the death of the insured.  On investigation the opposite party came to know that the deceased/ life assured had intentionally suppressed the material facts about her health that the deceased life assured was admitted in Usha Cardiac Centre, Vijaywada on 27-10-2011 and was discharged on 02-11-2011 for a treatment of Coronary Artery disease, in the Coronary Angiograph Report dt. 01-11-2011 done at Usha Cardiac Centre Ltd., it is noted that “Pre Cath Diagnosis: CAD, Ischaemic CMP, Selerotic AV, Mild AR, Reduced LV Function EF: 30%, the above reports clearly establish the pre existing illness of the deceased life assured  and she did not disclose the same in her personal statement, which is directly effect the issuance of policy on her life, as such the opposite parties repudiated the claim of the complainant, for that the complainant approached the Forum. 

13.    It is an undisputed fact that the mother of the complainant died on 31-12-2012, while she had taken policy on 09-01-2012.  After taking the policy within 1 year from the date of policy, the mother of the complainant died.  By virtue of insurance act, since the death was within two years, the opposite party insurance corporation made investigation.  During the course of investigation the opposite party corporation came to know that the mother of the complainant / the deceased life assured was admitted in Usha Cardiac Centre, Vijayawada on 27-10-2011 and was discharged on 02-11-2011 for a treatment of Coronary Artery disease, from the above reports it is clearly established that the deceased has taken treatment of coronary artery disease in Usha cardiac centre, Vijayawada and to support their case the opposite party corporation filed Exs.B.5 & B.6 patient record issued by the said hospital, the record shows that the deceased has taken treatment in the said hospital.  From the above there is no reason to doubt about the medical record furnished by the opposite party corporation. 

          And also we observed that the opposite party company repudiated the claim of the complainant as it was found that DLA had misrepresented the facts while replying to the specific questions in the proposal Form bearing No.44AB899527 and the same has been intimated to the complainant vide letter dated 19^th March, 2013.  The opposite parties also intimated that investment value under the policy amount of Rs.50,804/- has been transferred to the IDBI bank account of the complainant bearing No.03741040000068208 on 19^th March, 2013 as per the terms & conditions of the policy.   

14.    The complainant failed to produce any evidence to disprove the case of opposite parties.  In fact when the assured had taken treatment in Usha Cardiac Centre, Vijayawada on 27-10-2011 and was discharged on 02-11-2011 for a treatment of Coronary Artery disease,  it cannot be said that she was hale and healthy at the time of submitting proposal form.  The facts remains that the insured had suppressed the material facts regarding her health.  Since the suppression is material, the repudiation of claim according to us was justified.  In these circumstances we cannot attribute any deficiency of service on the part of opposite parties as such this point is answered against the complainant.

          In the result, the complaint is dismissed.  There is no order as to costs.    

          Typed to dictation, corrected and pronounced by us in the open forum, on this the 29^th day of January, 2015.

       Member                  FAC President             

District Consumer Forum, Khammam

APPENDIX OF EVIDENCE

WITNESSES EXAMINED:-

For Complainant:-                                                 For Opposite party:-   

       -None-                                                                       -None-

DOCUMENTS MARKED:-

For Complainant:-                                                           For Opposite party:-   

                Member                  FAC President             

District Consumer Forum, Khammam