A. P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION : AT HYDERABAD
FA 71/2013 against CC 108/2011 on the file of the District Consumer Forum, Ananthapur
Between :
01. The Manager,
Shriram Life Insurance Company Limited
OPP. Judge Bungalow, Aravind Nagar
Ananthapur.
02. The Regional Manager,
Shriram Life Insurance Company Limited
DBR Cardic, Opp Krishna Reddy Hospital,
Reddy and Reddy Colony
Tirupati, Chittoor District
03. The Assistant Manager,
Shriram Life Insurance Company Ltd
Regd and admn office
3-6-478, Anand Estate, III floor
Liberty road, Himayathnagar,
Hyderabad – 29 rep by its
Assistant General Manager .. Appellants/OP. 1,2 & 3
And
Smt. D. Varalakshmi,
W/o late D. Ramakrishna
D. No. 4-152, Vidyaranya nagar
Papampet, Ananthapur .. Respondent/complainant
Counsel for the Appellants : M/s. K.R.R. Associates
Counsel for the Respondent : M/s. K. Narsi Reddy
Coram ;
Sri R. Lakshminarasimha Rao… Hon’ble Incharge President
Sri T. Ashok Kumar .. Hon’ble Member
And
Sri S. Bhujanga Rao.. Hon’ble Member
Friday, the Sixth day of December
Two Thousand Thirteen
Oral Order : ( As per Sri T. Ashok Kumar , Hon’ble Member )
****
1. This is an appeal preferred by the opposite parties 1 to 3 as against the orders dated 03.09.2012 in CC 108/2011 on the file of the District Consumer Forum, Ananthapur. For convenience sake, the parties as arrayed in the complaint are referred to as under :
2. The brief facts of the complaint are that the complainant is the wife of one D. Ramakrishna. During life time, he has taken an Insurance policy, namely, Sree Plus from the opposite party o. 1 vide polciy No. 080800131856, which commenced from 11.08.2008 and its term was for 15 years. The sum assured under the said policy was Rs.7,50,000/- and the premium paid by him was Rs.1,00,000/- for one year. While the things thus stood, on 13.02.2009 the said policy holder died and after his death, the complainant, who is no other than his wife made a claim for the sum assured to the opposite parties. Later on 20.01.2010, OP.3 had sent a letter to the complainant that since she failed to produce the medical record of her late husband for the treatment said to have been taken at St. John’s Medical College Hospital, Bangalore to the opposite parties. OP.3 decided to close the claim and treat the matter as closed and that however on receipt of the above required documents, the claim under the above policy will be re-opened and processed accordingly. Subsequently, the complainant got issued a legal notice dt. 12.04.2010. The opposite party no. 3 issued a reply notice dt. 18.05.2010 stating that the in a preliminary enquiry they came to know that the deceased during his life time had taken treatment in St. Johns Medical College Hospital, Bangalore and that the complainant addressed a letter to the Ops to send the copy of the preliminary enquiry report but it was not furnished and that one of the agents of Ops, namely, Narayan Reddy, came to her house and took her signatures on blank papers and that the opposite papers without any valid reasons evading the process of the claim and that it amounts to deficiency in service and thus prayed to allow the complaint and direct the Ops 1 to 3 to pay Rs.7,50,000/- assured amount under the subject policy together with interest @ 18% p.a., Rs.50,000/- compensation for deficiency of service and Rs.1,00,000/- towards mental agony.
3. The opposite party No. 3 resisted the complaint by filing a counter and the same has been adopted by Ops 1 and 2. The gist of the counter is that deceased D. Ramakrishna obtained subject policy for Rs.7,50,000/-by paying premium of Rs.1,00,000/- per year showing his wife as nominee and that the policy commenced on 11.08.2008 and its term was 15 years and that it was issued on good faith basing on the information furnished by the deceased policy holder in the proposal form. On receipt of death information that he died on 13.02.2009 due to fever, the opposite parties on 02.04.2009 forwarded claim forms to the nominee through their private investigator, namely, G. Rama Murthy and requested her to submit claim forms duly filled enclosing relevant documents and simultaneously the said investigator has conducted preliminary enquiry into the death of the life assured and found that the life assured was a severe alcoholic and smoker and had been under the treatment since 2005 at Perar Hospital, Badanapalli and St. John Medical College Hospital, Bangalore. But the complainant did not submit the required Medical Record though asked to send the same vide letter dt. 19.12.2009. In such circumstances, Ops were constrained to close the claim vide letter dt. 20.01.2010 informing the complainant that the claim will be reopened and processed upon receipt of the required information sought for. For the legal notice dated 12.04.2010, suitable reply dt.18.05.2010 was given and that the Ops did not take any decision either admitting or rejecting the death benefits under the subject policy and that there is no deficiency in service and thus prayed to dismiss the complaint.
4. Both side filed affidavit evidence reiterating their respective contentions aforesaid Ex. A1 to A11 and Ex. B1 to B14 were marked on their behalf respectively.
5. Having heard both sides and considering the material on record, the District Forum vide impugned orders allowed the complaint in part directing the Ops 1 to 3 jointly and severally to pay Rs.7,50,000/- with 12% P.a. to the complainant from the date of death till the date of payment and also Rs.5,000/- compensation for deficiency in service and Rs.2,000/- costs giving one month time for compliance
6. Aggrieved by the said order, the opposite parties preferred this appeal and mainly contended that the Ops have accepted the risk on the life of assured basing on the information furnished by him and hat the deceased life assured did not reveal that he was chronic alcoholic and smoker and that the contract of Insurance is void and that even though the complainant was requested to furnish medical record regarding the treatment said to have undergone by the deceased at Perar Hospital, Badanapalli and St. John Medical College and Hospital at Bangalore. She did not submit the same and therefore the Ops were constrained to close the claim and that the private investigator G. Rama Murthy submitted a report with regard to the said habits of the deceased. It is also contended by the Ops that the claim was closed and it is neither repudiated nor allowed and that the complainant was informed to revive the claim enclosing necessary documents asked for by the Ops and thus the complaint was prematured and that there is no deficiency in service on the part of the Ops and thus prayed to allow the appeal, set aside the impugned order and consequently to dismiss the complaint.
7. Heard both side counsel with reference to their respective contentions in detail and written arguments were filed by the complainant and the opposite parties.
8. Now the point for consideration is whether the order of the District Forum is vitiated either in law or on facts ?
9. POINT :
There is no dispute that the complainant is the wife and nominee of the deceased policy holder, namely, D. Rama Krishna and that during his life time the said deceased had taken ‘sree plus’ insurance policy bearing No.080800131856 from the opposite parties company by paying requisite premium of Rs.1,00,000/- which commenced from 11.08.2008 and its term was 15 years and that the assured amount playable was Rs.7,50,000/-. Similarly, there is no serious contest or dispute that the life assured died on 13.02.2009 and the case of the complainant is that he died due to fever and thatafter the death of her husband she submitted the claim forms A, B, C in June, 2009 itself but falsely contending that the deceased was a chain smoker and having alcoholic habit and that took treatment in St. John Medical College Hospital, Bangalore etc. since 2005.
10. The opposite parties in a dubious manner did not allow the claim and asked her to produce medical evidence or certificates from the said hospital which are not in existence and that the said acts of Ops amount to deficiency in service and that the District Forum considering all the aspects meticulously allowed the complaint in part and there are no grounds to interfere with the said order.
11. On the other hand, the opposite parties contended that on good faith basing on the information furnished by the deceased policy holder in proposal form that he is not a smoker and alcoholic the subject policy was issued in his name but the preliminary enquiry report of the investigator namely G. Rama Murthy marked as Ex. B-15 as additional evidence in this appeal establish that the deceased suppressed the said habits and obtained the subject policy and that undergone treatment at St. John Medical College Hospital, Bangalore, so also, Perar Hospital, Badanapalli and that he died on account of severe ailments which has nexus with the said habits and as such the complainant was asked to submit medical record of her husband but she did not do so and as such the claim was closed further informing the complainant that in the event of her submitting the required information and medical record the claim will be processed and that since there is no repudiation of the claim the complaint is premature and that there is no deficiency in service on their part and that the District Forum erroneously passed the impugned order and as such it is liable to be set aside.
12. Admittedly the said preliminary enquiry report of the alleged investigator not filed before the District Forum and it was ordered to be received as additional evidence vide orders in IA 2854/2013 dated 03.12.13. Possibility of the opposite parties getting such a report so as to suite their circumstances cannot be ruled out to avoid the claim. The burden is on the opposite parties to prove that the deceased policy holder was a chain smoker and chronic alcoholic. But there is no dependable evidence or material from their side in the said context on record. If really the opposite parties believed that in connection with such bad habits the deceased fell ill and undergone treatment in the hospitals referred to by them, nothing prevented them to approach the said hospitals and ask them to give copies of the medical record. So also, to file an application either in the Forum or in this Commission to call for such a record but they did not do so for the reasons best known to them. On the other hand, they are insisting the complainant to submit the same, which according to her is not in existence. Mere contention of the Ops and report of the investigator that the deceased was chronic alcoholic and a chain smoker is not sufficient to believe the Ops in the said context and the source of information to investigator is not believable. When there is no dependable evidence as to the alleged habits of the deceased question of his suppressing the same at the time of filing of the proposal form could not be appreciated. Hence the decision reported in IV (2013) CPJ 370 (NC) in between LIC of India Vs. Shahida Khatoon is not helpful for the Ops in this case. So also IV (2010) CPJ 38 between Suraj MalRam Nivas Vs. United India Insurance Co. Ltd. In such circumstances, non-settlement of claim of the complainant basing on subject policy amount to deficiency in service and virtually it amounts in a way repudiation. The District Forum discussed the issue in a correct manner and allowed the complaint in part and the appeal is devoid of merit and liable to be dismissed.
13. In the result, the appeal is dismissed confirming the order of the District Forum. Time for compliance is one month from the date of receipt of the order. No order as to costs of the appeal.
INCHARGE PRESIDENT
MEMBER
MEMBER
DATED : 06.12.2013.
