::BEFORE THE DISTRICT CONSUMER DISPUTES  REDRESSAL COMMISSION AT BIDAR::

                                                                      C.C. No.46/2022.

                                                                                                                                     Date of filing: 10.05.2022.

                                                              Date of disposal: 16.05.2023.

P R E S E N Ts:-    

                                (1) Shri. Mabu Saheb H.Chabbi,                                                                                                               B.Com.,LL.B.,(Spl.),

                                                                              President.,  

                                (2) Kum. Kavita,

                                                               M.A.,LL.B.,(Spl.),  

                                                                         Member.

                                     (3) Shri.Thriyambakeshwara,

                                                                                   B.A.,LL.B.,(Spl.), 

                                                                                           Member.

COMPLAINANT/S                    Sharanbassappa S/o Shivvakumar,

                                                      Age:Major, Occ: Private Service,
                                                      R/o Yarnalli Tq and Dist:Bidar.                                                                                                   

                                                    (By Sri.K.K.Patil, Advocate.)                           

                 V/s

OPPONENT/S        1. Shriram Life Insurance Company Ltd., Plot  
                                  NO.31 and 32 5^th and 6^th floor Ramky 
                                  Selenium beside Andhara Bank Training
                                  Centre, Financial District Gacchi Bowli 
                                  Hyderabad-32.

                                  2. The Divisional Manger,
                                 Shriram Life Insurance Company Division 
                                 Office Chennai, Mookambika complex
                                 4^th floor, No.4^th Lady Desikachary Road
                                 Mypapore pin.600004. T.N.

                                 3. The Branch Manager,
                                 Shriram Life Insurance Company Ltd.,
                                 Branch Office Gulbarga (Kalburgi) S-9/2,                                  

                                 2^nd floor Asian Business Centre Beside
                                 Asian Mall S.P. Office Road, Pin-585102.                                                             

                                                                                (OP.No.1 By.Smt.Padma M., Advocate, 
                                                                                 and OP No.2&3 Ex-parte.)

::  J U D G M E N T  ::

By. Mabu Saheb H.Chabbi,,. President.

The complainant has filed the complaint under section 35 of the Consumer Protection Act, 2019, against the opponents for the deficiency of service caused by not settling the claim amount of the insurance policy of the deceased Smt.Jagadevi the mother of the complainant.  Hence, upon conclusion of the trial, the following judgement is passed.

Brief facts of the complaint.

The brief facts of the complaint in nut-shell are as follows: -

1.         The mother of the complainant Smt.Jagadevi W/o Shivakumar Karamunge had purchased insurance Policy No.NP011911150562 from OPs by showing the complainant as nominee and the OP had agreed to pay assured amount to the complainant, in the event of death of the policy holder.  Premiums were regularly paid by the insured.  On 24.07.2020 the mother of the complainant, Smt.Jagadevi died due to cardiac Arrest.  At that time the said insurance policy was in force and the complainant submitted a claim form along with all the necessary documents to the OPs for settling the insurance claim.  But, the OPs rejected the claim of the complainant by showing the reason that, the case of deceased was a known case of Amyothraphic lateral sclerosis.  The deceased died due to cardiac Arrest, but not due to any ALS as stated by OP No.1 in its repudiation letter dated 11.02.2021.  Hence, the complainant was constrained to file the present complaint against OPs for claim of assured insurance policy amount of Rs.3,62,000/- with cost and compensation from the OPs. 

The Gist of Written version of OP No.1.

2.         The OP No.1, upon receipt of notice, appeared before this commission through its counsel and submitted its written version.  The OP No.2 and 3 have not appeared and failed to file their W.V. in spite of service of notice to them.  Hence, OP No.2 and 3 are placed ex-parte.  The gist of the w.v. of OP No.1 is as below.

3.         Fact that the deceased had insured her life with OP No.1 company is not disputed.  But, while submitting proposal Form, the deceased provided false and misleading information to the OP and therefore OP repudiated the claim.  At the time of proposal, the life assured had replied in the proposal Form at question No.14.K and 14.K.1 in the negative.  The complainant had intimated the death of his mother to the OP and the OP entrusted for investigation, to a private investigation agency by name “Phoenix Investigation” to check the veracity of proposal and claim.  The said agency collected crucial medical documents and submitted its report to the OP.  As per investigation report the mother of the complainant was suffering from Amytraphy Lateral Sclerosis (ALS) and she was on regular medicine and had taken medical treatment from Bhalke Vydehi Hospital, Bidar and she was admitted in the said hospital on 23.07.2020 with a complications of quadriplegia + Dysarthria + Aspiration Pneumonia + Severely emaciated and Hypotension at the time of admission and also for known case of ALS (Amytraphy Lateral Sclerosis).  As per claim Form-B issued by Dr.Siddalingeshwar Mathpati the deceased life assured suffering with said A.L.S. and the same was diagnosed one year prior to the policy signing date.  The deceased suppressed the said illness in proposal form and obtained policy by providing misleading information to the OP.  In the proposal form to the question No.14K-have you ever suffered from any of the alignments mentioned below.  The answer was No.  For question No.14.K.1 Ailments relating to heart, stomach, lungs, Liver, Kidney, Digestive/ Reproductive/ Brain/ Nervous system/ the answer was-No.  As per the Policy Terms and Conditions, wherein Section 45 of the Insurance Act,1938 which states that, “45 (1) No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years from the date of the policy i.e., from the date of insurance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever in later.  (2) A policy of life insurance may be called in question at any time within three years from the date of issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy., whichever is later, on the ground of fraud: Provided that the insurer shall have to communicate in writing to the assured or the legal representatives or nominees or assignees of the insured the grounds and materials on which such decision is base”.  In view of the above said false information furnished by the deceased insured, the claim of the complainant was repudiated by the OPs and the OP No.1 prayed to dismiss the complaint. 

Evidence of complainant.

4.         The complainant got examined himself as P.W.1 by filing his evidence affidavit on 27.09.2022 and on 13.10.2022 and got marked 9 documents as Ex.P.1 to Ex.P.9 those are as below.

1. Ex.P.1-Copy of Rejection of claim letter issued by OP to the complainant dt:11.01.2021.
2. Ex.P.2-Copy of forwarding letter and policy schedule letter to the deceased name dt:27.11.2019.
3. Ex.P.3-Copy of death summary report issued by Bhalke Vydehi Hospital pertaining to deceased Jagadevi W/o Shivakumar.
4. Ex.P.4-Copy of death certificate pertaining to Jagadevi Karamunge.
5. Ex.P.5-Copy of Aadhar Card pertaining to Smt.Jagadevi Karamunge.
6. Ex.P.6-Copy of Aadhar Card pertaining to complainant.
7. Ex.P.7-Copy of proposal Form dt:18.11.2019.
8. Ex.P.8-Copy of Non-Ulip policy schedule issued by OP to the deceased Smt.Jagadevi Karamunge.
9. Ex.P.9-Copy of proposal acceptance letter issued by OP.

Evidence of OPs.

5.         One Sri.E.Sridhar S/o Late E.J.Lingam, General Manager of OP company got examined on behalf of OP company as R.W.1by filing his evidence affidavit on 21.01.2023 and got marked 13 documents as Ex.R.1 to Ex.R.13 on behalf of Ops, those are as below.

1. Ex.R.1=Ex.P.7–Copy of proposal Form dt:18.11.2019.
2. Ex.R.2=Ex.P.5- Copy of Aadhar Card pertaining to deceased Smt.Jagadevi Karamunge.
3. Ex.R.3-Copy of First Premium receipt.
4. Ex.R.4=Ex.P.8-Copy of Non-Ulip policy schedule.
5. Ex.R.5=Ex.P.2- Copy of forwarding letter and policy schedule.
6. Ex.R.6-Copy of death intimation letter by complainant to OP dt:11.09.2020.
7. Ex.R.7-Copy of death claim intimation Form dt:11.09.2020.
8. Ex.R.8=Ex.P.4-Copy of death certificate pertaining to Jagadevi Karamunge.
9. Ex.R.9- Copy of investigation report by Phoenix Investigation.

10. Ex.R.10=Ex.P.3-Copy of death summary report pertaining to deceased Jagadevi Karamunge.
11. Ex.R.11-Copy of medical attendants certificate.
12. Ex.R.12-Copy of letter issued by OP to the complainant dt:03.12.2020.
13. Ex.R.13=Ex.P.1-Copy of rejection of claim letter issued by OP to the complainant dt:11.01.2021

Points/Issues.

6.         The Argument advanced by the both parties heard, based on the pleadings and documents produced by both parties the points that arose for consideration before this Commission are as below. 

1. Whether the complainant proves that, he is consumer to OPs and further proves the deficiency of service from the OPs?  

2. Whether the OP No.1 proves that the rejection of claim of the complainant is in accordance with law?

3. Whether the complainant proves that, he is entitle for claim of the insurance and compensation from the OPs?

4. What orders? 

7.         Our answers to the points raised above are as follows: -

1. In the affirmative.
2. In the negative.
3. In the affirmative.
4. As per the final order.

Points No.1 to 3.

8.         In order to decide the said issues, since the points/issues No.1 to 3 are inter related all the 3 points are discussed together as follows. 

9.         The complainant and OP No.1 have filed their respective evidence affidavit as P.W.1 and R.W.1 by reiterating the facts of their respective pleadings and got marked the documents to establish their respective cases.  The policy issued by the OPs in the name of deceased Smt.Jagadevi W/o Shivkumar Karamunge as per Ex.P.8=Ex.R.4 by the OP No.1 company, is not disputed.  The facts that, the complainant is nominee to the deceased Smt.Jagadevi Karamunge and further, the death of deceased Smt.Jagadevi Karamunge occurred on 24.07.2020 as per Ex.P.4=Ex.R.8 are also not in dispute.  In view of these admitted facts, we can ascertained that, the complainant is consumer to the OPs and OPs are service providers to the complainant in this case.  Hence, complainant proved that, he is consumer to the OPs.

10.       The case of the complainant is that, the mother of the complainant Smt.Jagadevi Karamunge died due to Cardio-respiratory-arrest.  In support of his contention he has produced Ex.P.3 the death summary report, in which  the cause of death has been shown as Cardio-respiratory-arrest, and further the complainant submits that the deceased had no other problem in her health but, the main contention of the OP No.1 in its W.V. is that, the complainants mother Smt.Jagadevi W/o Shivakumar Karamunge has not furnished proper and correct information regarding the questions raised in the proposal Form regarding her health condition prior to the signing of proposal Form.  For that reason only the OP company has repudiated the claim of the complainant through letter dated 11.01.2021 to the complainant as per Ex.P.1.  In support of this repudiation letter the OP No.1 has conducted independent investigation from an independent private agency called phoenix investigation.  The said investigation agency has submitted its report as per Ex.R.9, and based on that report the OP has repudiated the claim of the complainant as per Ex.P.1 letter issued to the complainant.  The investigation agency of OP No.1 is said to have collected some medical reports pertaining to Smt.Jagadevi Karamunge and as per such medical report the said Smt.Jagadevi Karamunge was having an ailment of Amytraphy Lateral Sclerosis (ALS) since one year and was taking treatment for it from Hospital.  The OP has also produce Ex.R.11 the medical attendants certificate, which is said to be issued by Dr.Siddalingeshwar V.Mathpati, in the said document the said doctor has stated that, Smt.Jagadevi Karamunge was diagnosed with ALS since one year, Ex.R.10 is another document which is said to be issued by Dr.Siddalingeshwar V. Mathpati, regarding the death summary of Smt.Jagadevi.  In that, report also he has stated that, “the patient was admitted on 23.07.2020 at 8.00 p.m, and noted in the column of “course in the hospital” at Ex.R.11 that, “the patient was admitted, K/C/O. ALS Amytraphy Lateral Sclerosis quadriplegia + Dysarthria + Aspiration Pneumonia + Severely emaciated and Hypotension at the time of admission.  O/E BP-Systolic 70, SPO2-70% with o2 by face mask 3ltr.  Supportive treatment started in intensive care unit but patient progressively deteriorated despite all supportive measures.  Patient attender refused to for intubation and ventilator support Patient had Cardio Respiratory Arrest At 05.00am, CPR was done but could not be revived.  Declared Expired at 6.15am, on 24.07.2020”.  The OP No.1 has relied much upon these documents as per Ex.R.9 to Ex.R.11 but the OP has not made any efforts to examine either the private investigation agency to prove the document at Ex.R.9 examined the said Dr.Siddhlingeswhar V.Mathpati to prove the contents of Ex.R.10 and Ex.R.11.  Mere production of investigation report or medical attendant certificate as per Ex.R.9 and Ex.R.11 and death summary report at Ex.R.10  may not sufficient to prove that, the said Smt.Jagadevi Karamunge had such ailment as stated in the above said document prior to the signing of policy proposal as per Ex.R.1.  Moreover, the OP No.1 has not produced any document or evidence to show that, the deceased was suffering from the ailment of ALS as on the date of proposal Form or prior to the date of proposal Form for insurance. 

11.       The OP No.1 has repudiated the claim of the complainant as per Ex.P.1 by stating that, the deceased has not disclosed the correct information regarding the question No.14.K and question No.14.K.1 in Ex.R.1 proposal Form, based on the negative answer given by her the OP comes to a conclusion that, she has provided false information in the questions stated in Ex.R.1.  Apart from that, the OP No.1 has not made any efforts to prove that, the said Smt.Jagadevi had such ALS disease prior to the date of signing the proposal Form, mere production of the medical attendants certificate may not be sufficient to hold that the deceased was suffering from such ailment, without getting any concrete evidence, from the concerned doctor who has attended the patient.  Even the OP has not examined the surveyor who is said to have conducted the survey regarding the veracity of proposal Form and claim Form submitted by deceased and complainant.  In support of the said case we gain the judgment of NCDRC New Delhi reported in (2022) CJ 894 (NC) between LIC of India Vs Bhajon, the Key points of the said case is that, “Insurance –Life insurance policy- death due to heart attack –claim repudiated on ground of pre-existing heart ailment-claim allowed by Fora below- there are concurrent findings on facts by District Forum and State Commission in favor respondent / complainant- National Commission in exercise of its revisional jurisdiction is not required to re-assess and re-appreciate evidence on record-petitioner has challenged impugned order on very same grounds which were raised before District Forum as well as State Commission- where two inter petition of evidence are possible concurrent findings based on evidence have to be accepted and such findings cannot be substituted in revisional jurisdiction –revision petition dismissed. 

            In an another judgment of NCDRC New Delhi reported  in (2017) CJ 630 (NC) between LIC of India Vs Sarojani and Anr.,  The ratio laid down by the lordship is that, “ Repudiation of death claim on ground of suppression of 3 existing ailment must be based on firm evidence”. 

            The facts of the case on hand resembles with the facts of the above cited two cases, wherein the OP No.1 has not produced any medical evidence to show the pre-existing ailment of Smt.Jagadevi prior to the date of proposal Form submitted by her.  In view of the above said observation made by this commission that, the repudiation of the claim of complaint by the OP No.1 is not in accordance with law and the provisions of the Sec.45 of Insurance Act are not applicable to the case on hand as the OP No.1 fails to prove the pre-existing ailment of Smt.Jagadevi Karamunge as on the date of proposal Form.  Moreover, the OP No.1 has not produce any such document or evidence to show that, the deceased had knowledge of alleged ALS as on the date of proposal Form.

12.       In view of the detailed discussion as afore stated by this commission,  we are of the considered opinion that, the complainant has proved his case against OPs  and the point No.1 and 3 answered in the affirmative are in favor of the complainant and Point No.2 is answered in the negative as against OPs and hence, we proceed to pass the following order.

::ORDER::

        The complaint filed u/s 35 of CP Act 2019, by the complainant against OPs is hereby allowed in part along with cost and compensation.

       The Ops No. 1 to 3 are hereby directed to pay to the complainant the assured amount of for Rs.3,62,000/- (Rupees three lakhs sixty two thousand only) as per Non-Ulip policy schedule No.NP011911150562, (Ex.P.8), with interest at the rate of 9% p.a. from the date of Ex.P.1 (rejection of claim) i.e., dated 11.01.2021 till the date of realisation. 

The OPs are hereby directed to pay compensation amount of Rs.10,000/- and litigation charges as Rs.5,000/- to the complainant.  The above orders shall be complied by Ops within 45 days from the date of this order.                         

            Intimate the parties accordingly.                         

 (Typed to our dictation then corrected, signed by us and then pronounced in the open Commission on this 16^th day of May-2023).

Documents produced by the complainant.

1. Ex.P.1-Copy of Rejection of claim letter issued by OP to the complainant dt:11.01.2021.
2. Ex.P.2-Copy of forwarding letter and policy schedule letter to the deceased name dt:27.11.2019.
3. Ex.P.3-Copy of death summary report issued by Bhalke Vydehi Hospital pertaining to deceased Jagadevi W/o Shivakumar.
4. Ex.P.4-Copy of death certificate pertaining to Jagadevi Karamunge.
5. Ex.P.5-Copy of Aadhar Card pertaining to Smt.Jagadevi Karamunge.
6. Ex.P.6-Copy of Aadhar Card pertaining to complainant.
7. Ex.P.7-Copy of proposal Form dt:18.11.2019.
8. Ex.P.8-Copy of Non-Ulip policy schedule issued by OP to the deceased Smt.Jagadevi Karamunge.
9. Ex.P.9-Copy of proposal acceptance letter issued by OP.

Document produced by the Opponent.

1. Ex.R.1 –Copy of proposal Form dt:18.11.2019 (Ex.P.7).
2. Ex.R.2- Copy of Aadhar Card pertaining to deceased Smt.Jagadevi Karamunge (Ex.P.5).
3. Ex.R.3-Copy of First Premium receipt.
4. Ex.R.4-Copy of Non-Ulip policy schedule (Ex.P.8).
5. Ex.R.5- Copy of forwarding letter and policy schedule (Ex.P.2).
6. Ex.R.6-Copy of death intimation letter by compliant to OP dt:11.09.2020.
7. Ex.R.7-Copy of death claim intimation Form dt:11.09.2020.
8. Ex.R.8-Copy of death certificate pertaining to Jagadevi Karamunge(Ex.P.4).
9. Ex.R.9- Copy of investigation report by Phoenix Investigation.

14. Ex.R.10-Copy of death summary report pertaining to deceased Jagadevi Karamunge (Ex.P.3).
15. Ex.R.11-Copy of medical attendants certificate.
16. Ex.R.12-Copy of letter issued by OP to the complainant dt:03.12.2020.
17. Ex.R.13- Copy of rejection of claim letter issued by OP to the complainant dt:11.01.2021 (Ex.P.1).

Witness examined.

Complainant.

P.W.1- Sharanbassappa S/o Shivvakumar,                                 (complainant)

Opponent.

R.W.-1 Sri.E.Sridhar S/o Late E.J.Lingam, General Manager of OP company.