Andhra Pradesh

Nellore

CC/9/2015

Doniparthi sujathamma Wife of doniparthi Ramaniah - Complainant(s)

Versus

The Authorised Signatory and Manager Birla sunlife Insurance Co.ltd - Opp.Party(s)

N.Mohan Das

29 Jan 2016

ORDER

Date of Filing     :07-02-2015

                                                                                                Date of Disposal:29-01-2016

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM:NELLORE

Friday, this the 29^th day of  January, 2016

 

PRESENT: Sri M. Subbarayudu Naidu, B.Com.,B.L.,LL.M.,President(FAC) & Member                             

                   Sri N.S. Kumara Swamy, B.Sc.,LL.B., Member.

 

C.C.No.9/2015

 

Doniparthi Sujathamma, W/o.Doniparthi Ramanaiah, Hindu, Aged 50 years, D/o.4/8/282, Thummaguntavari Veedhi, Ramachandrapuram, Nawabpet, Near Saibaba Temple, Nellore, S.P.S.R.Nellore District-524 002.                                           ..… Complainant

       

                                                                           Vs.

 

1.	The Authorised Signatory and Manager, Birla Sun Life Insurance Company Limited, 16/1433, Sunshine Plaza, 4th floor, Ramalingapuram, Nellore-524003.
2.	The Managing Director, Birla Sun Life Insurance Company Limited, G Group Tech Park, 5th and 6th floor, Kasar Vadavali, Near  Hypercitymal, Ghobunder Road, Thane (W)-400 061.                                      ..…Opposite parties

                                                             .   

            This complaint coming on 20-01-2016 before us for hearing in the presence of                Sri N. Mohandas, advocate for the complainant and                                                                 Sri  S. Ankaiah, advocate for the opposite parties  and having stood over for consideration till this day and this Forum made the following:

 

ORDER

(ORDER BY  Sri N.S. KUMARASWAMY, MEMBER)

           

This complaint is filed under Section-12 of Consumer  Protection Act, 1986 prays to direct the opposite parties to pay towards the sum assured as per the policy issued to the deceased by opposite parties in policy Nos.006028785 and 006422146 for Rs.5,00,000/- in each policy  with interest at 12%  from the date of death of the deceased i.e., 28-06-2014, costs of Rs.20,000/- in each case.

 

2.         The brief averments of the complaint are that  the deceased namely Doniparthi Ramanaiah insured his life with the 1^st opposite party  under the policy by name  “BSLI Vision Life Income, 2013 on 15-03-2014 by paying Rs.38,426/-  towards 1^st instalment including service charges .  The policy number assigned as 006422146 and  another policy also took by name “BSLI Future Guard Plan Term” on 20-03-2013 by paying Rs.7,592/- towards 1^st instalment including charges bearing policy No.006028785.  In both policies, the complainant who is the wife of  deceased  Doniparthi Ramanaiah nominated his wife  as nominee and the deceased paid instalments upto date till his death dated 28-06-2014.  The complainant further submitted that the 1^st opposite party conducted medical examination through medical team of doctors of Vijaya Hospital, Pogathota, Nellore to the deceased  under  BSLI Vision Life Income 2013 policy but not conducted  to the 2^nd policy by the opposite party for the reasons best known to them.  Soonafter the death of her husband i.e.,  on 28-06-2014, the complainant informed the same to the 1^st opposite party in writing, by surrendering the policy requesting to pay  assured amount as per the policy. On 10-10-2014, the complainant received  a common letter from 2^nd opposite party stating that the claim was repudiated  on the ground, the life assured was suffering from chronic obstructive pulmonary disease  and diolated  cardiomyopathy   much prior to his application for  issuance under the both the policies. The complainant further submitted that  her husband was hale and healthy before taking the policies and the said policies were accepted by the opposite parties with utmost satisfaction about his condition as fit.  The complainant further submitted that the investigations done by the opposite parties were unilateral and not binding on the claimants as the said investigations were not informed  on any day  to attend before the investigation officers.  Further submitted that her husband was  never  admitted in any hospital at the time of issuing policy as he was hale and healthy.  Hence, the repudiation is illegal  and complainant being the legal heir of the deceased prays to pay the claim amount as claimed for in the complaint. Hence, the complaint.

 

            3.         The opposite parties filed written version denying all the  averments made in the complaint except that of  admitting certain facts.  The opposite parties contended that the deceased life assured  took two  policies  bearing policy Nos.006028785 and 006422146 for a sum of  Rs.5,00,000/- each by paying premium of Rs.23,362-48ps. and Rs.39,614/-.  The deceased life assured is a literate person  and he has signed on the proposal forms  after understanding the policy terms and conditions.   It is pertinent to mention that D. Raju in the policy bearing No.006028785  and  M.V.S.Sai in the policy bearing No.006422146 friend of life assured  explained the benefits and features on the subject policies  at the time of inception of the  subject policies.  Hence, the life assured  was well acquinted  with the  benefits payable as per the terms and conditions of the policy.  Subsequently, the nominee, who is the complainant and also wife of the life assured preferred a claim intimation after the death of  her husband who died on  28-06-2014.  The death was occurred  within a period of one year, three months and  eight days from the date of risk commencement and the opposite parties conducted an investigation under the provision of clause 8 (3) Insurance Regulatory and Development Authority.  During the investigation it was disclosed that the life assured was suppressed the material facts of  past medical history before issuance of insurance policy.  The past history was one Chronic   Obstructive Pulmonary Disease and Diolated Cardiomyopathy  which was  having to the deceased  before taking the policy.  A copy of the medical report issued by Bollineni Hospital and the affidavit of the investigator report is produced  for establishing the opposite parties case. Further, the deceased life assured answered the questions in column Nos.11 and 14 pointedout in the proposal form as  negatively. Basing on the same, the investigation has established that the life assured has not disclosed about the past medical history which was material for the opposite parties to underwrite the risk before the issuance of insurance policy.  It may be noted  that, had the deceased disclosed the real fact of suffering the diseases to the opposite parties, the opposite parties would not have issued the insurance policies but the assured suppressed the past history with a fraudulent intent  to get wrongful gain from the opposite parties.  Hence, the claim was repudiated on the ground of suppression of pre-existing diseases at the time of issuing the policy  and hence there is no deficiency in service on the part of opposite parties and the claim may be dismissed with compensatory costs in favour of the opposite parties.

 

4.         The points for determination would be:

1. whether there is any deficiency of service on the paart of the opposite parties

for non-settling the claim of the complainant, if so whether the complainant is entitled for the reliefs as prayed for in the complaint and for costs?

2.  To what relief?

 

            5.         In order to substantiate the complainant averments, the complainant filed evidence on affidavit as P.W.1 and no documents marked on her side.  On the other hand, the opposite parties  filed chief affidavit as R.W.1 and got marked  Ex.B1 to B8.  Written arguments on behalf of complainant side not filed eventhough several opportunities given. Inspite of giving several adjournments, the complainant has not evincing any interest to get on with the case.  Hence, considering the material available on record of the case, the case is proceeded with. Written arguments on behalf of opposite parties filed.  Heard.

 

            6.         POINT No.1:   There is no dispute that opposite parties issued two policies to the deceased Doniparthi Ramanaiah, who died on 28-06-2014 and the complainant is  nominated as nominee under the said policies.  Two policies are one  BSLI Future Guard Plan and BSLIC Vision Life  Income Plan vide Nos.006028785 and 006422146.  The sum assured Rs.5,00,000/- in each policy.  Vide Exs.B1 and B2, which are proposal form and policy document respectively.  The complainant after the death of her husband submitted death claim intimation form Ex.B5 for both the policies  requesting to settle the claim and the claim was repudiated by the  opposite parties, which was marked as Ex.B8  on the ground that the deceased suppressed  pre-existing disease  such as chronic obstructive pulmonary disease  and diolated  cardiomyopathy at the time of obtaining policies.  Now the legal position in well settled  to the effect that  in case of   repudiating  a claim, the insurance company on the ground of suppression of  material fact at the time of issuance of policy, it is the burden of the insurance company to prove the same.  The insurance company  has to first prove that  the deceased was suffering with some  ill-health prior to the policy and  knowingly suppressed the same. The deceased insured answered negatively in the proposal form  for the questionnaire 11(c)(e) and 14 (2)  (ii) (a) (b) , which are mentioned hereunder:

INSURABILITY  DECLARATION for the life to be INSURED:

(c)

(i)	Are you on a  diet or any other medicine of any kind prescribed by doctor?	Answer:  No
(ii)	Are you currently undergoing or intend to undergo any treatment?
(iii)	Have you been advised for any surgical operation, procedure of hospital admission?

 

E.

Have you ever been diagnosed with or treated / consulted for diabetes or sugar in urine, high or low blood pressure, chest pain, heart attack or any other heart disease, stroke, paralysis, kidney, urinary or bladder disorders, reproductive organ or prostate disorders, mental disorder, neurological disease, musculoskeletal disorders, cancer or tumour of  any type, gastro-intestinal, liver disease, tuberculosis, asthma or any their lung disease, blood disorders, anaemia, endocrine or thyroid disorders?

                                                                                                 Answer:  No

14.  MEDICAL HISTORY:

2 (ii)	Have you ever had  a sought advice for the following:	Answer:  No
a)	Chest Pain, High Blood Pressure, Stroke, Heart Attack, Heart murmur or other heart disorder?

 

b)

Asthma, chronic cough, pneumonia, shortness of                      breath, T.B. or other respiratory or lung disorders?

No

 

            7.         The counsel for  the complainant contended that the deceased paid instalments upto date  till his death dated 28-06-2014.    Further  the opposite party conducted medical examination through medical team of doctors of  Vijaya Hospital, Pogathota, Nellore before  policy issued.   For the 2^nd policy the opposite parties did not opt  for medical examination of the deceased for the reasons best known to them.  Further, the deceased was never admitted in any hospital and he was hale and healthy before  taking the policy.  Despite  the assured  was hale and healthy at the time of obtaining policy, the opposite parties repudiated the claim unilaterarily on the ground of suppression of pre-existing diseases  and a repudiation letter dated 10-10-2014 on two policies sent by opposite parties to the complainant, which are not binding on the claimant. Hence, they are liable to pay the insured  amount to the complainant, who is the nominee in the said two policies.  The complainant except her self-serving statement by way of evidence on affidavit, no material  has been placed  to substantiate her contention .

            8.         The  only contention of the opposite parties are that at the time of  making proposal form which indicated the questionnaire, the questionnaire must be answered truthfully but the deceased life  assured had given misrepresentation of material of facts    with regard to his state of health knowingly.  Evidencing the same, the opposite party filed copies of medical reports obtained from Bollineni Super Speciality Hospital, which is marked as Ex.B6.  Ex.B6 contains the deceased admitted in the hospital on 05-02-2013 and discharged on 11-02-2013, who was treated by doctor C.S.S. Raju for the ailments of COPD etc.,   As per the records, the deceased was suffering with COPD since 2010 i.e., much prior to obtaining policy.  Further, opposite parties filed  investigation reports                      dated 02-09-2014 in which report, it was disclosed  that the main disease was  Cardiac and Cardiothoracic Surgery.   Further, the complainant  did not challenge the diseases mentioned in  the hospital records  and did not  cross examined the doctor namely   C.S.S. Raju, who treated the deceased at the time of admission in the Bollineni Hospital.   Hence,  the hospital treatment certificate remained  unrebutted  and uncontroverted and so we have to accept the contents of the hospital records as well as  the treatment given by the doctor namely C.S.S. Raju. Further, one Sri P.S.S. Prakash, who was appointed as investigator by the insurance company gave an affidavit stating in that the deceased was suffering with COPD since 2010. The said facts was also not challenged by the complainant by way of filing rejoinder affidavit.  The opposite parties contended that had insured  declared his pre-existing ailments in the proposal form, the insurer had an opportunity to take a decision either to accept or to reject  the contract of insurance  but intentionally, the deceased suppressed  pre-existing ailments.  The deceased policy holder died  within two years from the date of issuing policy.  From the records, we have to conclude that life assured was suffering from  pre-existing diseases while he was underwent treatment between the dates  05-02-2013 and 11-02-2013.   Thus, there is violation of policy condition by the  husband of the complainant and  as per the terms and conditions of the policy  and in view of the principles laid down by the Hon’ble Supreme Court   in the SATWANT  KAUR SANDHU case, the policy is void and repudiation of the claim of the complainant by the opposite parties is justified.  No trust worthy evidence placed by the complainant in support of her contention to rebut the  evidence of opposite party.  Since the complainant failed to establish the deficiency in service on the part of the opposite parties, the complainant is not entitled any of the reliefs as prayed for and the complaint is  liable to be dismissed.  Accordingly, the point No.1 is answered.

 

          9.           POINT No.2:  In the result, the complaint is dismissed, without costs.

 

Typed to the dictation to the Stenographer, corrected  and pronounced by us in the open  Forum, this the  29^th  day of  January, 2016.

 

                Sd/-                                                                                           Sd/-

 

           MEMBER                                                                               PRESIDENT(F.A.C.)

 

                                                APPENDIX OF EVIDENCE

 

Witnesses Examined for the complainant

 

P.W.1  -

24-06-2015

Smt Doniparthi Sujathamma, W/o.Ramanaiah,  S.P.S.R.Nellore District (chief Affidavit filed).

 

Witnesses Examined for the opposite parties

 

R.W.1  -

10-08-2015

Smt Kshama Priyadarshini adult Indian working as Chief Manager, Legal, Authorised representative of opposite parties (Evidence Affidavit filed).

 

                             EXHIBITS MARKED FOR THE COMPLAINANT

-Nil-

 

 

                         EXHIBITS MARKED FOR THE OPPOSITE PARTIES

 

Ex.B1  -	-	Photocopy of  application No.A 47641951,                                dated 20-03-2013 in policy No.and receipt in favour of   Doniparthi Ramanaiah issued by the opposite parties.
Ex.B2  -	-	Photocopy of  application No.A 49151621,                                dated 03-03-2014 and receipt in favour of   Doniparthi Ramanaiah issued by the opposite parties in policy No.006028785.
Ex.B3  -	20-03-2012	Photocopy of  BSLI Future Guard Plan in favour of Doniparthi Ramanaiah issued by the opposite parties.
Ex.B4  -	03-03-2014	Photocopy of  Vision Life Income Plan in favour of Doniparthi Ramanaiah issued by the opposite parties.
Ex.B5  -	-	Photocopy of Death Claim Intimation Form in policy numbers.006028785 and 006422146, and  Part-3 Declaration and Authorissation. in favour of D.Ramanaiah.
Ex.B6  -	-	Photocopy of Case sheet No.82039 in I.P.No.59377  in favour of  Doniparthy Ramanaiah issued by the Bollineni Superspeciality Hospital, Nellore-524 003.
Ex.B7  -	-	Photocopies of  Affidavit on 09-10-2014 given by PSS Prakash, Stellar Insuance Management Services Private Limited,  Investigation Report-strictly confidential  dated 02-09-2014, Nominee statement translation and Agreement of Doniparthi Sujathamma.
Ex.B8  -	10-10-2014	Photocopy of  letter  from opposite parties to the  complainant.

 

 

                                                                                                              

                                                                                                                     Id/-

                                                                                                         PRESIDENT(F.A.C.)

 

Copies to:

 

1.	Sri N. Mohandas, Advocate, Ongole.
2.	Sri S. Ankaiah,  Advocate, Nellore.

 

Date when free copy was issued: