This C.C. is coming on before us for final hearing in the presence of Sri.P.B. Sri Ramulu, G. Kutumba Rao, Advocates for complainant and of Sri.G. Sita Rama Rao, Advocate for opposite parties 1&2; upon perusing the material papers on record and upon hearing and having stood over for consideration, this Forum passed the following order;

O R D E R

(Per Sri R.Kiran Kumar, Member)

          This Complaint is filed u/s.12-A of Consumer Protection Act, 1986. 

2.      The averments made in the complaint are that the husband of the complainant, by name Bonala Lakshminarayana joined Unit linked insurance policy “Bajaj Allianz Capital Unit Gain”, offered opposite party No.1 for Rs.2,00,000/- in the year 2007 by paying Rs.25,000/- to the opposite party towards first premium.  The complainant submitted that the opposite parties issued policy bearing No.38844134 for a term of 15 years commencing from 30-02-2007 and the complainant is the nominee in the said policy.  The complainant further submitted that her husband paid second premium of Rs.25,000/- in the year 2008, unfortunately he died on 21-12-2008 due to cardio respiratory arrest, at Global Hospital, Hyderabad.  The complainant further submitted that she being as nominee under the policy, on 07-03-2009  she submitted claim form along with relevant documents to the opposite parties, in the month of June 2009 the opposite party No.2 gave a letter dt. 16-04-2009 stating that the repudiated the claim, while reviving the policy on 28-11-2008 the husband of the complainant did not disclosed that he undergone operation of renal transplantation on 21-09-2008 and that he has history of diabetes mellitus for 10 years, and advised the complainant to file review petition, as per their advise the complainant filed review petition to the claims review committee and the review committee also confirmed the cause of repudiation.  The complainant further submitted that her husband was operated for renal transplantation in Global Hospital in the month of July, 2008, he was discharged on 13-10-2008 in good health condition, after informing all the above facts the husband of the complainant paid second premium, the husband of the complainant died due to septicemia, septic shock which caused cardiac arrest and not due to the failure of the operation of renal transplantation,  the repudiation of the claim of the opposite parties are tenable and are invented for repudiating the claim which amounts to deficiency of service on the part of opposite parties.  The complainant further submitted that irrespective of honoring the claim or repudiation of claim, the opposite parties are bound to pay the value of the units accrued under the policy, but the opposite parties are silent with regard to the value of units, as the complainant has no other go, the complainant filed this complaint.

3.      On behalf of the complainant, the following documents were filed and marked as Exs.A.1 to A.5. 

Ex.A-1:- Letter written by Opposite party No.2 confirming the issuing of policy to the husband of the complainant dt. 16-02-2007.

Ex.A-2:- First premium receipt issued by Opposite party no.1, dt. 13-02-2007.

Ex.A-3:- Letter addressed by Opposite party no.2 repudiating the claim dt. 16-04-2009.

Ex.A-4:- Letter addressed by the complainant to review committee dt. 30-06-2009.

Ex.A-5:- Reply given by Opposite party no.2 dt. 22-09-2009.

4.      On receipt of notice, opposite parties appeared through their counsel and filed counter.  In their counter, opposite parties admitted that the husband of the complainant B. Lakshminarayana joined in United linked policy for a coverage of Rs.2,00,000/- in the year 2007 by paying Rs.25,000/- accordingly the opposite parties issued policy bearing No.38844134 for a term of 15 years commencing fro 13-02-2007 to 13-02-2022.  The opposite parties also submitted that the complainant filed claim Form to the opposite parties and the same was rejected through a letter dt. 16-04-2009 informing that on receiving the death intimation of the life assured, the company made various investigations and confirmed that the deceased life assured was hospitalized in September 2008 as a case of and stage renal disease on continuous ambulatory peritoneal dialysis with past history of diabetes mellitus on medication for 10 years and also had undergone for renal transplant on 21-09-2008, these facts known to the deceased life assured, but he did not disclose in declaration of good health submitted for reviving the policy dt. 28-11-2008.  The opposite parties further submitted in view of the suppression of health condition and fraud played by the deceased life assured at the time of reviving the policy.  The opposite parties also submitted that after receipt of the letter dt.16-04-2009 the complainant again submitted a letter on 13-06-2009 stating that her husband was not suffered with diabetes and that they disclosed all the facts to the agent Vallat Srinivas handed over relevant documents, but in fact no documents have been submitted to the opposite parties insurance company.  The opposite parties further submitted that if the said facts were informed to the company the company would stop the policy and enquire into the matter immediately thereafter only it would revive the policy and the complainant without approaching the insurance ombudsman approached the Forum by suppressing the material facts, as such this complaint is not maintainable and prayed to dismiss the complaint. 

5.      On behalf of the opposite parties the following documents were filed and marked as Exs.B.1 to B.5.

Ex.B.1:- Statement of Account as on 13-03-2009.

Ex.B.2:- Discharge Summary of B. Lakshminarayana.

Ex.B.3:- Death Certificate issued by GHMC, Hyderabad.

Ex.B.4:- Death Report issued by Global Hospitals, Hyderabad.

Ex.B.5:- Investigation Report submitted by Satyam Investigations to Opposite party company, dt. 31-03-2009.

6.      Opposite parties filed their written arguments. 

7.      Upon perusing the material papers on record and upon hearing the arguments, now the point that arose for consideration is,

i)       Whether the assured had suppressed the material facts pertaining to his health at the time of revival of policy, consequently the complainant is entitled for the claim amount under the policy?

ii)       Whether the complainant is entitled for Fund Value amount under the policy?

Point No:-1

          In this case the husband of the complainant during his lifetime obtained insurance policy bearing No.38844134 from opposite party No.1 and shown the name of complainant as nominee.  On 28/11/2008 the husband of the complainant approached the opposite party No.2 branch office, Khammam and revived the policy by paying the premium amount and the policy was revived on the same day.  That on 21-12-2008 the husband of the complainant died at Global Hospital, Hyderabad.   After death of her husband, the complainant intimated the same to opposite parties and submitted all the relevant documents requesting to settle the death claim of her husband.  But the opposite parties made investigation on the death of the insured.  On investigation the opposite party came to know that the deceased/ life assured had intentionally suppressed the material facts about his health that the deceased life assured was hospitalized in September 2008 as a case of end stage renal disease on continuous ambulatory peritoneal dialysis with past history of diabetes mellitus on medication for 10 years and also had undergone for renal transplant on 21-09-2008, and he did not disclose the same in his personal statement, which is directly effect the issuance of policy on his life, as such the opposite parties repudiated the claim of the complainant, for that the complainant approached the Forum. 

          It is an undisputed fact that the husband of the complainant died on 21-12-2008, while he had taken policy on 13-2-2007 and the same was revived on 28-11-2008.  After revival of the policy within a month from the date of revival,  the husband of the complainant died.  By virtue of insurance act, since the death was within one month from the date of revival, the opposite party insurance corporation made investigation.  During the course of investigation the opposite party corporation came to know that the husband of the complainant the deceased life assured was hospitalized in September 2008 as a case of end stage renal disease on continuous ambulatory peritoneal dialysis with past history of diabetes mellitus on medication for 10 years and also had undergone for renal transplant on 21-09-2008 and to support their case the opposite party corporation filed Exs.B.2 patient record issued by the said hospital, the record shows that the deceased was taken treatment in the said hospital. 

          From the above there is no reason to doubt about the medical record furnished by the opposite party corporation.  The complainant failed to produce any evidence to disprove the case of opposite parties.  In fact when the assured had taken treatment in Global Hospital, Hyderabad, it cannot be said that he was hale and healthy at the time of revival of the policy.  The facts remains that the insured had suppressed the material facts regarding his health.  He took treatment before the date of revival of insurance policy, evidenced from Ex.B.2.  From the above it is clear that the deceased life assured obtained the policy by giving wrong answers on material issue, by misrepresenting about the previous ailment as such the opposite party has not committed any deficiency of service in repudiating the claim.  As such this point is answered against the complainant. 

Point No:-2                  

We also observed that, as far as the entitlement of other death benefits regarding the payment of fund value is concerned, the deceased / insured paid first premium amount of Rs.25,000/- on 13-02-2007 and paid second premium amount of Rs.25,000/- in the year 2008, thus in all he paid an amount of Rs.50,000/- to the opposite parties towards yearly premium, thereafter, he died due to ill health, but the opposite parties failed to pay the fund value amounts, is not just and proper.  Withholding of huge amounts of common people is not justifiable and is also against the principles of natural justice.  And also as per section 6 (a) terms & conditions of the policy the opposite parties could not avoid their liability in payment  and the company shall be liable to pay fund value, if any, to the complainant, the fund value as at the date of receipt of intimation of death at the company’s office, as the deceased / policy holder died after the policy anniversary.  Therefore, this point is answered accordingly in favour of the complainant by holding that the opposite parties are liable to pay fund value, if any, to the complainant.

          In the result the complaint is allowed in part directing the opposite parties to pay regular fund value, if any, under Bajaj Allianz Capital Unit Gain plan to the complainant as at the date of receipt of intimation of death at the company’s office, together with interest @9% P.A. within one month from the date of receipt of this order.  The opposite parties also directed to pay Rs.1,000/- towards costs.

          Typed to dictation, corrected and pronounced by us in the open forum, on this the   30th     day of January, 2015.

       Member                  FAC President             

District Consumer Forum, Khammam

APPENDIX OF EVIDENCE

WITNESSES EXAMINED:-

For Complainant:-                                                 For Opposite party:-   

       -None-                                                                       -None-

DOCUMENTS MARKED:-

For Complainant:-                                                           For Opposite party:-   

   Member                  FAC President             

District Consumer Forum, Khammam