The Asst. General Manager, Shriram Life Insurance Co.Ltd., Hyderabad & another - Opp.Party(s)
Siddamsetti Venkateswarlu, Advocate, Khammam.
04 May 2010
ORDER
BEFORE THE DISTRICT CONSUMER FORUM AT KHAMMAM Varadaiah Nagar, Opp CSI Church consumer case(CC) No. CC/09/48
Smt. Gade Rajani, W/o. Late Srinivas, R/o. Saradhinagar, Khammam.
...........Appellant(s)
Vs.
The Asst. General Manager, Shriram Life Insurance Co.Ltd., Hyderabad & another Shriram Life Insurance Khammam.
...........Respondent(s)
BEFORE:
Complainant(s)/Appellant(s):
OppositeParty/Respondent(s):
OppositeParty/Respondent(s):
OppositeParty/Respondent(s):
ORDER
BEFORE THE DISTRICT CONSUMERS FORUM AT KHAMMAM Dated this, the 4th day of May, 2010 CORAM: 1. Sri Vijay Kumar, B.Com., LL.B., President 2. Smt. V. Vijaya Rekha, B.Sc. B.L., Member 3. Sri.R.Kiran Kumar, B.Sc., LL.B., Member C.C.No.48 of 2009 Between: Smt. Gade Rajani, w/o late Srinivas, age:35years, r/o H.No.1-5-70, Saradhinagar, Khammam. Complainant And 1.The Asst. General Manager, Shriram Life Insurance Co. Ltd., Regd. Office 3-6-478, 3rd floor, Anand Estate, Liberty Road, Himayath Nagar, Hyderabad. 2. Shriram Life Insurance, R/o H.No:2-3-99, II floor, Gandhi Chowk Khammam. Opposite parties. This C.C. is coming on before this Forum for final hearing in the presence of Sri.S. Venkateswara Rao, Advocate for complainant and of Sri.G.Hareender Reddy, Advocate for opposite parties; upon perusing the material papers on record; upon hearing the arguments, and having stood over for consideration, till this day, this Forum passed the following:- ORDER (Per Sri.Vijay Kumar, President) 1. This complaint is filed u/s.12-A of Consumer Protection Act, 1986. The averments made in the complaint are that the complainant is the wife of Gade Srinivas, who obtained Shri Plus Unit Linked Insurance Policy, bearing No. 1006200125572 for a sum of Rs.1,00,000/-, the date of insurance is from 28-12-2006. The deceased has paid three premium installments of Rs.10,000/- for each year and subsequently died on 30-06-2008. On the date of death the policy was in force. After his death his wife who is the nominee submitted claim forms along with Policy Bond to the opposite party for settlement of the policy amount. But to the surprise of the complainant the claim has been repudiated on the ground that the deceased/insured was suffering with health problems i.e. chronic disease like liver cirrohosis and hypertension. On that the complainant got issued a legal notice on 12-01-2009. For the legal notice, the opposite parties issued reply notice on 28-01-2009. Hence this complaint. 2. On receipt of the notice, opposite party appeared through an advocate and filed counter and admitted that the deceased has obtained a policy and contended that the deceased was in the habit of chewing gutkha and suffered with liver cirrohosis problem, since the year 2006 and also filed documents investigation reports, hospital records of Mahaveer and NIMS etc. and lab reports, which reveled that the policy holder undergone treatment for the liver cirrohosis prior to the issuance of the policy. The investigator is also appointed by the opposite party and as per the investigation the deceased suffered with liver problem diabetic. The opposite parties refused to pay the claim on the pretext that the deceased suffered with liver cirrohosis and prayed to dismiss the complaint. 3. On behalf of the complainant an affidavit is filed reiterating the contents of the complaint and also filed and marked the following documents. Ex.A.1.:- Office copy of legal notice, dated 12-01-2009 Ex.A2:- Consignment tracker, issued by DTDC Courier and Cargo Ltd. Ex.A3.:- Courier Receipt, dated 12-01-2009. Ex.A4.- Reply notice dated 28-01-2009 Ex.A5.:- Letter dated 20-09-2008 addressed by the opposite party No.1 to the complainant. Ex.A6:- Original Premium receipt No. 0146092, dated 20-02-2008. Ex.A7.:- Deposit Acknowledgement receipt No. 15130004,dated 20-02-2008, for Rs.10,000/- Ex.A8.:- Broucher of Shri Plus Unit Linked Insurance Plan. 4. Apart from the complaint, the complainant also filed her chief affidavit. 5. On behalf of the opposite parties, the following documents filed and marked. Ex.B1.:- Proposal for Unit Linked Insurance Ex.B2.:- Xerox copy Policy Schedule Ex.B3.:- Xerox copy First Premium receipt No.0092253, dated 28-12-2006 Ex.B4:- Letter dated 06-09-2008 Ex.B5:- Letter dated 06-09-2008 Ex.B6.:- Investigation report dated 12-09-2008 Ex.B7:- Copy of medical case sheets records of Mahaveer Hospital and NIMS, Hyderabad . Ex.B8.:- Office copy of repudiation letter dated 20-09-2008 Ex.B9.:- Original Postal receipt, dated 20-09-2008. Ex.B10.:- Original Acknowledgement Ex.B11.:- Legal Notice dated 12-01-2009 Ex.B12.:- Reply Notice dated 28-01-2009 Ex.B13.:- Postal receipts dated 31-01-2009 EX.B14.:- Acknowledgement 6. On behalf of the complainant, written arguments filed. Heard both sides. Perused the oral and documentary evidence. Upon which the points that arose for consideration is, 1) Whether the complainant is entitled to the amount covered under the policy? 2) To what relief? POINT NO.1: 7. So far as the taking of the policy by the husband of the complainant is concerned, it is not in dispute. It is also not in dispute that the husband of the complainant died on 30-06-2008. The only dispute raised by the opposite party is that at the time of taking policy the deceased/policy holder was suffering with chronic disease like liver cirrohosis and hypertension. In support of their contention the learned counsel for opposite party vehemently argued and submitted that the deceased died on 30-06-2008 and he has taken policy on 28-12-2006 and he died within a period of two years from the date of taking policy. As it was early claim, the opposite party No.1 has appointed an investigator by name G. Ram Murthy, who investigated the death of the deceased/insured. As per the investigation he has verified medical records of Mahaveer Hospital, Hyderabad and collected medical record and submitted along with report. As per the medical record Ex.B7, dated 28-09-2007, the deceased appeared to have suffering from liver cirrohosis and diabetic. Apart from this a number of medical record, dated 01-08-2007, 02-08-2007, 31-08-2007, 28-09-2007, 30-07-2007, 01-08-2007, 04-08-2007 and 17-03-2008 pertaining to the treatment taken by the deceased/insured at Mahaveer Hospital, Hyderabad, are also filed. These are the medical record issued by Dr. Rupender Prasad, Gastroentrologist of Mahaveer Hospital, Hyderabd. As per the medical record the deceased/insured was suffering with liver cyrohosis subsequent to the date of taking of policy. After taking the policy, the deceased/insured had paid three installments of the premium. These medical record, substantially established that the insured suffered with liver cirohosis only in the year 2007. It cannot be presumed as preexisting disease. The insured himself is not aware that he was suffering liver cirohosis as on the date of submitting the proposal form for taking the policy. The opposite party has not filed any record to show that the disease by which the insured was suffering, was preexisting. Even as per the investigator report, the deceased/policyholder suffered with liver cirrohosis only in the year, 2007, but not prior to 2007. Absolutely no record is filed to substantiate the contention that the complainant suffered with the said disease prior to taking of the policy. Therefore, it cannot be presumed that this was pre-existing disease in contravention of 14(1) of the proposal form. When the complainant himself was not aware for the existing disease, the question of revealing in the proposal form does not arise. The learned counsel for opposite party further argued that the policyholder was in the habit of chewing gutka, this allegation has not been substantiated by him. Whether the policyholder suffered with the problem of liver cirrosis even prior to taking of the policy cannot be presumed or predicted, unless the same is substantiated by examining an expert doctor. In the absence of any expert opinion, it cannot be presumed that the problem of liver cirrosis was existing with policy holder even prior to the taking of the policy. The entire medical record referred to by the opposite party pertains to the period subsequent to the taking policy by the deceased. There is no nexus between taking treatment for liver cirrosis with pre-existing disease. The opposite party is not justified in repudiating the claim of the complainant on the ground that the deceased suffered with liver cirrosis prior to the taking of the policy. This cannot be presumed as pre-existing disease. Therefore, we are of the opinion that the repudiation of the claim by the complainant is not justified. The complainant is fully entitled to the amount covered under the policy. The complaint is fit to be allowed. Point No.2: 8. In the result, the complaint is allowed, directing the opposite parties to pay a sum of Rs.1,00,000/- (Rupees one lakh only) covered under the policy bearing No. 1006200125572, together with interest at 9% P.A. from the date of filing of complaint till the date of realization and further directed to pay an amount of Rs.1,000/- (Rupees one thousand only) towards costs of the litigation. Dictated to the steno, transcribed by her, corrected and pronounced by us in the open forum on this the 4th day of May, 2010. PRESIDENT MEMBER MEMBER DISTRICT CONSUMERS FORUM, KHAMMAM APPENDIX OF EVIDENCE Witnesses examined for complainant: -None- Witnesses examined for opposite party: -None- Exhibits marked for complainant: Ex.A.1.:- Office copy of legal notice, dated 12-01-2009 Ex.A2:- Consignment tracker, issued by DTDC Courier and Cargo Ltd. Ex.A3.:- Courier Receipt, dated 12-01-2009. Ex.A4.- Reply notice dated 28-01-2009 Ex.A5.:- Letter dated 20-09-2008 addressed by the opposite party No.1 to the complainant. Ex.A6:- Original Premium receipt No. 0146092, dated 20-02-2008. Ex.A7.:- Deposit Acknowledgement receipt No. 15130004,dated 20-02-2008, for Rs.10,000/- Ex.A8.:- Broucher of Shri Plus Unit Linked Insurance Plan. Exhibits marked for opposite party: Ex.B1.:- Proposal for Unit Linked Insurance Ex.B2.:- Xerox copy Policy Schedule Ex.B3.:- Xerox copy First Premium receipt No.0092253, dated 28-12-2006 Ex.B4:- Letter dated 06-09-2008 Ex.B5:- Letter dated 06-09-2008 Ex.B6.:- Investigation report dated 12-09-2008 Ex.B7:- Copy of medical case sheets records of Mahaveer Hospital and NIMS, Hyderabad . Ex.B8.:- Office copy of repudiation letter dated 20-09-2008 Ex.B9.:- Original Postal receipt, dated 20-09-2008. Ex.B10.:- Original Acknowledgement Ex.B11.:- Legal Notice dated 12-01-2009 Ex.B12.:- Reply Notice dated 28-01-2009 Ex.B13.:- Postal receipts dated 31-01-2009 EX.B14.:- Acknowledgement PRESIDENT MEMBER MEMBER DISTRICT CONSUMERS FORUM, KHAMMAM
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