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

                                                           C.C. No.69/2022.

                                                                                                                          Date of filing: 09.09.2022.

                                                              Date of disposal: 13.09.2023.

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                    1.    Smt.Sudharani W/o Veershetty,                                                                       

                                                         Age: Major,  Occ: House wife &etc,

                                                            R/o #3-28, Udamanahalli Village

                                                            Post Udamnalli Tq:Humnabad

                                                            Dist:Bidar-585227.                                                                                       

                                                    (By Sri.Sanjaykumar S.Patil., Advocate.)              

V/s

OPPONENT/S                              1.  The Branch Manager,

                                                      SBI Life Insurance Company Limited.          
                                                      H.No.8-9-12-1/6K, 2^nd Floor, Sai tower Near
                                                      Kamath Hotel Udgir Road Bidar-585401,  
                                                      Represented through Service Br.
                                                      SBI Life Insurance Company Ltd, 1^st Floor,

                                                      5-6-530/201,J.B. Towers Pragati Nagar
                                                      Hydrabad Road, Nizambad,

                                                      Telangana-503003.

                                                2.         The Regional Director,

                                                      SBI Life Insurance Company Limited,

                                                      4^th Floor, Door No.6-3-1090/B/4,

                                                      The Grand Raj Bhavan Road,

                                                      Somajiguda, Hyderabad Telangana-500082.

                                                                     (By Smt.Padma Maharaj., Advocate.)

                                                                                 ::  J U D G M E N T  ::

By. Shri.Thriyambakeshwara. Member

The complaint has been filed by complainant under section 35 of the Consumer Protection Act, 2019, against the opponents for the deficiency in service for not settling the Life insurance claim by Ops.  Hence, passed the following judgement.

Brief facts of the complaint.

The brief facts of the complaint in as follows: -

1.         The complainant is the legally wedded wife of one  late Veershetty S/o Manikappa, who was Constable by profession and during his life time he being hale and healthy in the month of June -2020, having impressed by the colorful benefits illustrated by concerned Marketing Officer/Agent of OPs, he insured his life with Ops in policy “SBI Life Smart Plus” (ought to be SBI Life Smart Swadhan Plus)  Policy No.1Z394041906, for an assured sum of Rs.8,90,000/- commencing from 16.06.2020, with the yearly premium of Rs.33,168/- and appointed his legally wedded wife i.e., complainant as nominee to the said policy.  The said DLA fell ill due to Covid -19 pandemic infection and undergone for treatment at Government Hospital BHEL Hyderabad and despite treatment he died on 24.05.2021, in the said hospital. The concerned Birth and Death Registrar of Telengana Government issued Death Certificate of DLA on 08.06.2021. The complainant being nominee of said DLA Veershetty submitted claim on 14.06.2021, to Ops along with requisite documents as directed by Ops, which was repudiated through Ops vide Repudiation letter dt:20.12.2021, on the grounds of alleged pre-existence of disease and the same were not disclosed by DLA prior to proposal date, which is illegal, unlawful and invalid and hence filed this complaint.

Written Version of OP.

2.         Subsequent to service of summons on Ops by this commission, the OP No.1, appeared before this commission on 11.10.2022 by filing his W.V. and OP No.2 filed power on 31.10.2022 and adopted the W.V. filed by
OP No.1.  OP No.1 submitted his written version by categorically denying all most all facts of the complaint along with territorial jurisdiction for maintaining this complaint by further submitting that, the deceased DLA, during his life time had proposed for an insurance policy on his life by submitting a proposal form and by payment of the premium deposit amount.  After underwriting the proposal, the Ops issued a policy “SBI Life Smart Swadhan Plus” Policy No.1Z394041906, for an assured sum of Rs.8,90,000/- which was commenced from 16.06.2020 for a term of 10 years, payable for 5 years annual premium of Rs.33,168/-, and nominated his spouse complainant as Nominee and he died on 24.05.2021 as reported by complainant on 21.06.2021.  It is further averred that, since the death claim arose within a period of 1 year from the date of commencement of the policy, Ops entrusted the claim for investigation in order to make discreet enquires and to submit the report.  The said investigation agency conducted discreet enquires into the death claim and submitted its report to the OPs. As per the investigation, it was found that, the DLA was suffering from Diabetes, Hypertension and lung disease issues from few years and had treatment at different hospitals. As per the Apollo Hospital Hyderabad, Medical Records, DLA was known case of Diabetes, Hypertension and lung disease, which was also not disclosed at the time of proposal by DLA.  Hence, based on the investigation conducted, it is clearly established that, the deceased Life assured had suppressed the material facts by not disclosing his correct health status in the proposal form, which ought to have been disclosed. This act of suppression amounts to breach of the bounden duty of the proposer to furnish correct and complete details in response to the questions in the proposal form as per the term and conditions Ops policy and as per Sec.45 of the Insurance Act 1938.  Apart from that, the contract of insurance void abinitio in terms of Sections 10, 14, 17 & 18 of Indian Contract Act 1872.  Hence, in view of the above legal provision, facts and circumstances of the case in hand and in terms of the Policy insurance contract and declarations contained in the proposal form at question Nos.12(II) and 12(V), which were false answers given by DLA and further declared the same falsely to the respondent company and it had rightly repudiated the claim of the petitioner under the Policy vide Repudiation Letter dated 20.12.2021 held in the name of Late Veershetty on the grounds of false as well as incorrect answers and as per provisions of 13.3 of policy terms and conditions non-discloser of materials facts with malafide intention by the Life assured in the Proposal Form and  accordingly paid up premium is forfeited and same was intimated to complainant and accordingly this OP is not liable for payment of any benefit under the Policy.  The Ops relied on number citations of Apex Court and commissions, however the same were not produced on record in support of their defense.  Hence, prayed for the dismissal of the complaint. 

Evidence of complainant.

3.         The complainant is examined herself as P.W.1 and got marked   documents Ex.P.1 to Ex.P.6 which are as follows,

1. Ex.P.1-Copy of repudiation letter dt:20.12.2021.
2. Ex.P.2-Copy of welcome letter dt:22.06.2020.
3. Ex.P.3-Copy of premium paid receipt dt:16.06.2020 of SBI Life Insurance.
4. Ex.P.4- OP Policy document
5. Ex.P.5- Death Certificate.
6. Ex.P.6- Aadhar Card of complainant.

Evidence of Opponent.

4.         One Dhanya K.P. W/o S.H.Unnikrishanan K.P., is examined as R.W.1 on behalf of OP No.1 company, and got marked 6 documents as per Ex.R.1 to Ex.R.6 which are as below.

1. Ex.R.1-Copy of proposal Form.
2. Ex.R.2-Copy of policy document.
3. Ex.R.3-Copy of Death claim statement.
4. Ex.R.4&4(a)-Copy of OP investigator report.
5. Ex.R.5&5(a)-Copy of discharge summary issued Apollo Hospital.
6. Ex.R.6-Copy of Repudiation letter dt:20.12.2021.

Points/Issues.

5.         On perusal of pleadings, evidence of the both parties and documents, this commission raised the points for discussion as below;

1. Whether the complainant proves that, she is consumer to Ops and further proves the deficiency in service by the Ops in not settling her insurance claim?  
2. Whether the OP.No.1 proves that, complaint is barred by territorial jurisdiction and the DLA suppressed material facts of health prior to proposal made by DLA?
3. Whether the complainant is entitled for any relief sought in her complaint? What orders? 

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

1. In the affirmative.
2. In the negative,
3. In the affirmative and as per the final order.

Points No 1 to 3

7.         In order to decide the complaint issues, this commission discussed points/issues No.1 to 3 altogether for discussion as each points are inter related to each other- as follows.

8.         In order to prove the case of the complaint, the complainant lead her evidence as P.W.1 by way of reiterating the complaint facts and got marked Ex.P.1 to Ex.P.6 documents on her behalf.  In similar manner, OP No.1 also examined himself as per R.W.1 and in order to substantiate his case, he got marked 06 documents i.e., Ex.R.1 to Ex.R.6. On perusal of overall pleadings, evidence of both kinds of the parties, it is not in dispute that, the deceased Veershetty S/o Manikappa Constable had purchased Ex.P.2 to 4 Insurance Policy in question from Ops company and the complainant is the nominee in the said policy as per proposal form Ex.R.1 and policy was in force as on the date of death 24.05.2021 of DLA as per Ex.P.5 death certificate and Ex.R.3 death claim of DLA.  The complainant submitted claim as per Ex.R.3 i.e. death claim Form and other documents.  But, the Ops repudiated the claim of complainant based on Ex.R.4&4(a) i.e., OP investigator’s report and Ex.R.5&5(a) i.e., discharge summary issued by Apollo Hospital.  Accordingly based on the above documents OPs repudiated claim of the complainant as per Ex.P1=Ex.R.6. 

9.         On perusal of the W.V. filed by OP No.1, he raised defences stating that, as per the investigation, it was found that, DLA was suffering from Diabetes, hyper tension and lung disease related issues since many years which is evident from the medical records of Appollo Hospitals Hyderabad as per Ex.R.5&5(a), wherein DLA had treatment and the said material  facts were suppressed by him and hence, non disclosing of health issues in the proposal form at Ex.R.1 by DLA, amounts to breach of the bounden duty of DLA and it was his duty to disclose the same in the proposal form, whereby insurer had been able to decide whether policy deserves to be issued or not to DLA.  The same breach of duty on the part of DLA amounts to violation of the terms and conditions of Sec.45 of Insurance Act 1938 and thereby Ops are not liable for payment of any benefits under the policy as sought by complainant and the premium was forfeited as per Regulation 13.3 (non discloser) of Policy terms and conditions. 

10.       The OP No.1, in order to repudiate the claim of complainant, he relied upon the investigator report submitted by his investigator at Ex.R.4&4(a), who in-turn prepared the said report based on his investigation and medical records said to have been collected by him as per Ex.R.5&5(a).  On perusal of the Ex.R.1 i.e., the proposal Form, which is evident from page No.2 that, one Sndhya Mandadi R/o Hyderabad, i.e., authorized agent of Ops had certified that, she had satisfied as to the personal information received through DLA and same was reported to Ops for issuance of policy.  By considering the permanent residence address of DLA is H.No.3-28 Udamanhalli Tq:Humnabad Dist:Bidar Karnataka and communication address was shown at QT.No.247/E DHEL Township Ramachandra Puram Telengana, and the place of residence of authorized agent of Ops at Tellapur (Hyderabad) as found in 1^st Page of Ex.R.1, So, that, the DLA was not explained by Ops that, how and in what mode the proposal Form was received from DLA by Ops authorized agent, though in the declaration it is shown by declarant place of proposal of DLA at “Medak” Telengana, as found in Page No.54 of policy document as per Ex.R.1.  Apart from OP No.1 evidence, absolutely there is no evidence of said investigator before this commission to verify the very authenticity/veracity of the said investigator report at Ex.R.4&4(a).  Even, on the perusal of Page No.3 of the proposal  Form the signatures of attesting witness i.e., authorised Agent of OPs by name Sandhya Mandadhi as found in 1^st page in Ex.R.1 Electronic application under Customer Declaration  on proposal form, it is shown the place of attesting at Medak and said authorised Agent who witnessed the said document proposal Ex.R.1 is also  not examined by Ops in order to authenticate as to whether she has explained and sought health issue information from DLA as per provisions shown in the repudiation letter  and Para No.5 of W.V. Page No.4.  i.e., question No.12 (II) and question No.12 (V).  Therefore, when such being the things, the investigator report do not create any confidence or credit worthiness report to be relied on by this Commission for accepting, as it is a true version in the absence of his and other attesting witnesses evidence before this commission.  The Ops ought to have explained how and in what manner proposal Form was received from DLA as the authorized agent who had policy from DLA is resident of Tellapur (Hyderabad), where as the DLA was permanent resident of Udamnahalli Dist:Bidar(Karnataka) and Temporary R/o Ramachandrapuram Hyderabad.  Apart from the above the OP No.1 also not examined even the said authorized agent in order to substantiate in accordance with his defense in respect of queries asked by them were falsely answered by DLA as afore discussed.  The investigator report Ex.R.4&4(a) is not trust worthy, as he has not placed his evidence affidavit along with his report and hence this commission is of the opinion that, the said investigator report Ex.R.4&4(a) has got no any evidentiary value in eyes of law, which is based for repudiation of complainant’s claim as per repudiation letter Ex.P.1=Ex.R.6 issued by Ops. The OP No.1 though strongly contended in his W.V. stating that, the DLA had misrepresented about health issues, but in order to substantiate the same about suppressed health issues, the Ops neither examined the treating doctor nor proved in accordance with law the said medical records produced on record.  All the medical records are photo copies of alleged as DLA treatment records, which does not bearing any father name and address on said records and those bear any seal and signature of the authority from whom those were collected.  Therefore, the photo copies produced on record with self attestation of OP No.1 insurance Company seal & sign and got marked under Exhibit R-series  series from Ex.R.4&4(a) to Ex.R.5&5(a) are itself not a proof of documents by producing on record in accordance with law. In this regard this commission gains the judgment of Hon’ble National Commission reported in III-2011 CPJ 418 (NC) by holding that, “Production of document is different from proof of document”.  

11.       Further Non examination of treating doctor is fatal to the case of Ops.  In this regard this commission gains the judgment of Hon’ble NCDRC reported in (2020) CJ 110(NC) rendered in the case of OPs in between SBI Life insurance Co.Ltd Vs Laxmi Ben Nagin Bhai Chavan and ors, the ratio lead down by their lordship,

“Insurance –SBI home loan Master policy-repudiation of death claim on ground of concealment of pre-existing disease –complaint allowed by For a below-both District Forum and state Commission had reached to conclusion after going through all documents that, medical papers have not been properly proved since neither Doctor has been duly examined nor his affidavit has been furnished- National Commission is not expected and required to re-appreciate and re-assess evidences- where on the basis of evidences Fora below have reached to a conclusion which is a possible conclusion, then such conclusion need not be disturbed in revision petition- revision petition dismissed”.   

The OP further instead of raising this type of objections for repudiating the claim of complainant, they ought to had subjected   the DLA for medical examination prior to issuance of policy through their authorized medical practitioner and got it rectified the suitability to issuance of policy to the DLA. In this case instead of taking such precautions while selling the product to the DLA, the OP company kept silent at the initial stage of selling the product, and not done in the instant case as the authorized agent for Ops had the policy from DLA just by getting signature of DLA on Electronic Proposal Form Ex.R.1 Page No. 1^st and 54 & 55, wherein the place of her certification and signing the said proposal by her is at “Medak” Telengana and now after lapse of several months of collecting the premium from the insured, raising subsequent to DLA death on 24.05.2021, thereby Ops trying to escape from the clutches of liability to settle the claim of the complainant, on untenable grounds without there being cogent evidence in support of the repudiation of claim, which cannot be sustained under law. The DLA or the complainant is not supposed to put under the loss of benefits of policy just because of the omissions and commissions of their authorized agent. 

12.       Even in the instant case also the OP No.1 did not prove through any authenticated document in order to substantiate his defence about
mis-representation of suppressed heath issues by DLA prior to his proposal with OPs.  Under the said circumstances this commission is of the considered opinion that, the Ops have utterly failed in their case of repudiating the claim of complainant on the ground that, the Ops authorized agent did not get policy from DLA by explaining the terms and conditions as which is evident from Ex.R.1&2 as afore stated and further they have not examined the concerned treating doctor on DLA prior to date of proposal as per Ex.R.5&5(a) treatment records allegedly of DLA and  as per Ex.R.4&4(a) the investigator who said to have collected those documents under his investigation, was not examined by producing his evidence affidavit and further Ops are also not examined the said authorized agent Smt. Sandhya Mandhadi, who received policy from DLA to speak about the queries posed to said DLA as shown by Ops in their repudiation letter Ex.P.1=Ex.R.6 and to speak under what mode she received said policy from DLA in view of place of residence of DLA and said agent  differs each other as found in Ex.R.1as discussed above. 

13.       Hence, we are of the considered view that, the complainant has proved her case for claim having her permanent residence as shown in complaint cause title which is corroborated with Ex.P.6 her Aadhar Card which is well within the territorial jurisdiction of this Commission in view of Section 34(1)(d) of C.P.Act 2019 and whereas the OP. No 1&2 utterly failed to prove their case as per Ex.R.6 repudiation letter.  Therefore, we answered the point No 1 and 3 in the affirmative in favor of complainant and point No. 2 in negative against to Ops and proceed to pass the following order.

::ORDER::

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

            The OP NO.1&2 are hereby directed to pay complainant/nominee in policy “SBI Life Smart Swadhan Plus” Policy No.1Z394041906, for an assured sum of Rs.8,90,000/-(Rupees eight lakh ninety thousand only) with applicable benefits and bonus if any payable as per policy along with interest 6% p.a. from the date of repudiation as per Ex.R.6 dt:20.12.2021 till realisation along with compensation of Rs.10,000/- for having suffered mentally and inconvenience, and Rs.5,000/- as litigation expense 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   13^th day of September-2023).

Documents produced by the complainant.

1. Ex.P.1-Copy of repudiation letter dt:20.12.2021.
2. Ex.P.2-Copy of welcome letter dt:22.06.2020.
3. Ex.P.3-Copy of premium paid receipt dt:16.06.2020 of SBI Life Insurance.
4. Ex.P.4- OP Policy document
5. Ex.P.5- Death Certificate.
6. Ex.P.6- Aadhar Card of complainant.

Document produced by the Opponent.

1. Ex.R.1-Copy of proposal Form.
2. Ex.R.2-Copy of policy document.
3. Ex.R.3-Copy of Death claim statement.
4. Ex.R.4&4(a)-Copy of OP investigator report.
5. Ex.R.5&5(a)-Copy of discharge summary issued Apollo Hospital.
6. Ex.R.6-Copy of Repudiation letter dt:20.12.2021.

Witness examined.

Complainant.:-

P.W.1- Smt.Sudharani W/o Veershetty,                (complainant).                   

Opponent:- 

R.W.1- Dhanya K.P. W/o S.H.Unnikrishanan K.P.,