BEFORE THE A.P STATE CONSUMER DISPUTES REDRESSAL COMMISSION HYDERABAD.
FA 974 of 2011 against CC 306/2010, Dist. Forum, Guntur
Between:
Buddannagari Venkatesh Reddy
S/o. Narayana Reddy
Flat No. SF-1, 3rd Lane
Padmavathy Residency
Mutyala Nagar
Guntur. *** Appellant/
Complainant
And
Shiram Life Insurance Company Ltd.
Rep. by its Manager
D.No. 3-6-478, 3rd Floor
Anand Estate, Liberty Road
Himayatnagar, Hyderabad-29.
*** Respondent/
Op
Counsel for Appellant : Consumers Guidance Society
Counsel for Respondent : M/s. Associates.
CORAM:
SMT. M. SHREESHA, PRESIDING MEMBER
&
S. BHUJANGA RAO, MEMBER
THURSDAY, THE TWENTY FIRST DAY OF TWO THOUSAND THIRTEEN
ORAL ORDER: (Per Smt. M. Shreesha, Member)
***
1) Aggrieved by the order of the Dist. in CC No. 306/ on the file of Dist. Forum, Guntur, the complainant preferred this appeal.
2) The brief facts as stated in the complaint are that the complainant had obtained a policy in his wife’s name for Rs. 7,50,000/- covering a period of 15 years from 25.9.2007. While so on 27.9.2009 at about 5.30 a.m. his wife died due to Cardio Respiratory Arrest (herein after called ‘CA’). The complainant made a claim which was repudiated by opposite party on the ground that she suffered from Schizophernia since 2004 but the complainant submits that his wife met with an accident and was treated in Peoples Trauma Hospital and thereafter referred to a psychiatrist as she felt depression. She was fit and healthy as on the date of taking of the policy. Though the complainant approached the Op several times there was no response. Hence this complaint seeking for a to the Op to settle the claim together with interest, compensation and costs.
3) The insurance company filed written version stating that the deceased, i.e., complainant’s wife was suffering from Schizophernia since 2004 and was under the care of Psychiatrist Dr. IVL Narasimha Rao of Guntur and these facts were not disclosed at the time of filling of proposal form and even her accident and her treatment at Peoples Trauma Hospital were suppressed. They submit in their written version that they were not of her treatment and also of her accident and treatment at Peoples Trauma Hospital. The proposal form is of immense importance for accepting the life insurance policies, and therefore their repudiation is justified.
4) The Dist. Forum based on evidence adduced i.e., Ex. A1 to A15 and B1 to B9 and the pleadings put forward dismissed the complaint.
5) Aggrieved by the said order the complainant preferred this appeal. The appellant/complainant filed written arguments.
6) The that arises for consideration is whether the order of the Dist. Forum is vitiated by mis-appreciation of fact or law?
7) The facts not in dispute are that the complainant’s wife had taken a policy for Rs. 7 On 27.9.2009 the policyholder died due to C.A. Ex. is a reminder letter 22.1.2010 addressed by Op to the complainant referring to his claim and seeking some documents with respect to medical reports. Ex. A9 & A10 are Ex. A11 is the repudiation letter her psychiatric treatment since 2004, and has not disclosed in the proposal dt. 30.8.2007. The internal claims review has also upheld the repudiation vide Ex. A12 letter dt.
8) It is the respondent/Ops case that their repudiation is justified basing on the investigation report Ex. B4 in which the investigator stated that the assured admitted in Peoples Trauma Hospital, Guntur in the year 2004/2005 as she suffered accidental injuries and she was also a Schizophernia patient with manic depressive psychosis since 2004 and was under treatment. It the Ops case that the very suppression of this disease and treatment in the proposal form itself is against the terms and conditions of the policy and the principles of Uberrima fides and therefore submitted that their repudiation is justified.
9) The appellant/ complainant in Ex. B7 which is the letter written by him to Internal Claims Review Committee stated that she was referred to a psychiatrist as she felt depression on account of injuries suffered by her in an accident but she was definitely not Schizophernia patient. We observe from the record that the policy in effect from 25.9.2007. Whereas it is the case of the that she was suffering from Schizophernia and was under treatment since 2004. The complainant admits that his wife who is the was suffering from depression since she suffered injuries in an accident but she had recovered completely by the time of filling of proposal and there was no wilful and wanton suppression.
10) It is important to note that Section 45 of the insurance Act reads as
“45. Policy not to be called in question on ground of mis-statement after two years—No policy of life insurance effected before the commencement of this Act shall after the expiry of two years from the date of commencement of this Act and no policy of life insurance effected after the coming into force of this Act shall after the expiry of two years from the date on which it was effected, be called in question by an insurer on the ground that a statement made in the proposal for insurance or in any report of a medical officer, or referee, or friend of the insured, or in any other document leading to the issue of the policy, was inaccurate or false, unless the insurer shows that such statement was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the policy-holder and that the policy-holder knew at the time of making it that the statement was false or that it suppressed facts which it was material to disclose: Provided that nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to do so, and no policy shall be deemed to be called in question merely because the terms of the policy are adjusted on subsequent proof that the age of the life insured was incorrectly stated in the proposal.”
The Hon’ble Supreme Court P.C. Chacko Vs. Chairman, LIC of India reported in III (2008) CPJ 78 (SC) held:
Section 45 postulates repudiation of such policy within a period of two years. By reason of the aforementioned provision, a period of limitation of two years had, thus, been specified and on the expiry thereof the policy was not capable of being called in question, inter alia on the ground that certain facts have been suppressed which were material to disclose or that it was fraudulently been made by the policy holder or that the policy holder knew at the time of making it that the statement was false. Statute, therefore, insurance policy. It takes into account the social security aspect of the matter.
11) Section 45 of the Insurance Act stipulates that the insurance company should establish that if there was any wilful and fraudulent suppression issuance of the policy. The suppressed facts should be material to disclose, and more over insurer should establish by some documentary evidence that it a material suppression. In the instance case the Op did not file the medical record showing that she is Schizophernia patient and the complainant could establish by filing the record that the policy holder died due to CA on 27.9.2009. It does not have any nexus to the alleged Schizophernia the year 2004. It is the complainant’s case that she suffered temporary depression only on account injuries suffered in an accident and she recovered completely. In the absence of any affidavit of the doctor who has treated the patient or any hospital treatment record to show that the patient took treatment for Schizophernia, and it had any nexus with the cardiac arrest, we are of the considered that the repudiation by the Op is unjustified.
12) In the result the appeal is allowed and the order of the Dist. Forum is set-aside and consequently the complaint is allowed directing the Op to pay Rs. 7,50,000/- covered under the policy with interest @ 9% p.a., from the date of repudiation till the date of payment together with costs of Rs. 3,000/-.
1) _______________________________
PRESIDING MEMBER
2) ________________________________
MEMBER
21/03/2013
*pnr
UP LOAD – O.K
