This C.C. came before us for final hearing, in the presence of Sri B. Gangadhar, Advocate for Complainant and of Sri G. Harender Reddy, Advocate for opposite parties No.1 & 2; upon perusing the material papers on record; upon hearing the arguments and having stood over for consideration this Forum passed the following:-

O R D E R

(Sri R. Kiran Kumar, FAC President)

This complaint is filed u/sec.12-A of Consumer Protection Act, 1986. 

2.       The averments made in the complaint are that the father of the complainant by name Repakula Krishna has obtained Kotak term plan policy from opposite party No.1 on 30-07-2001 vide policy No.02587786 for a sum of Rs.10,00,000/- by paying an amount of Rs.3,466/- to opposite party No.1 towards 1^st annual premium and the name of the complainant was mentioned as nominee.  The complainant submitted that on 31-08-2012 the father of the complainant went to attend natural call, after attending the same, he came to house and informed that one unknown snake was bite on his right leg big toe, immediately first aid treatment was given and later he was shifted to Government Hospital, Penubally.  On 01-09-2012 the father of the complainant shifted to Government Hospital, Sathupally, at about 4:30 hours he died.  The complainant further submitted that upon the report before the police V.M. Banjara, Police registered a case in Crime No.116/2012 U/s.174 Cr.PC, panchanama was conducted and later upon requisition, the medical officer, Government area hospital, Sathupally conducted autopsy over the dead body of the deceased, issued PME report and opined that cause of death is due to snake bite.  The complainant also submitted that on 11-10-2012 he submitted claim form along with necessary documents to the opposite parties, but the opposite party No.2 sent a repudiation letter stating that they decided to decline the claim of the complainant under the said policy on the ground of non-disclosure and suppression of material information, that the life assured was suffering from tuberculosis prior to the risk of commencement date and defaulted on the treatment regimen.  The complainant also submitted that his father was hale and healthy at the time of taking policy and he is not suffering from any disease much particularly ‘tuberculosis disease’, the agent of the opposite parties obtained total information from the father of the complainant, the father of the complainant was thoroughly checked up through the qualified doctor and the father of the complainant died only due to snake bite on 01-09-2012.  The complainant also submitted that the opposite parties by making false allegations by searching grounds for repudiating the claim to avoid the payment of basic assured sum which amounts to deficiency of service for that the complainant approached the Forum.

3.       On behalf of the complainant, the following documents filed and marked as Exs.A1 to A6.

Ex.A1:- Policy issued by opposite party No.2.

Ex.A2:- Repudiation letter, issued by opposite party No.1.

Ex.A3:- Photocopy of FIR.

Ex.A4:- Photocopy of Final Report

Ex.A5:- Photocopy of PME Report.

Ex.A6:- Photocopy of Inquest Report.

4.       On receipt of notice, the opposite parties No.1 & 2 appeared through their counsel and filed counter.  In their counter, the opposite parties admitted the issuance of policy to the father of the complainant.  The opposite parties submitted that they received a death claim intimation stating that the policy holder expired on 01-09-2012, since the life assured died within one month from the date of issuance of the policy, the claim false under early claim and in order to authenticate the veracity of the proposed claim the opposite parties initiated a claim investigation.   That during the claim investigation stage, astonishing facts were discovered along with pertinent documents substantiating the concealment of material facts by the life assured, in this regard, a RTI application was filed on behalf of opposite parties which was replied by the District T.B. Control Officer, Dr. B. Ramesh Babu, MBBS. DTCD, Khammam as a Public Information Officer in that it was specifically informed abundantly clear that the life assured was suffering from Tuberculosis prior to proposing the said policy and had also defaulted in the treatment regimen.  The opposite party further submitted that in the reply the Public Information Officer, has reported case history from “MOTU, THALLADA”, the said officer also mentioned the details of the T.B.107/2012 of PHC Lanka Sagar, Penubally Mandal, Khammam district and the policy holder obtained the policy by suppressing the material facts regarding his previous disease in the proposal form signed by the policy holder despite there being specific questions pertaining to the medical history of life assured.  The opposite parties also submitted that the life assured intentionally withheld the medical condition being suffered and accorded a negative answer against all the aforesaid questions and has thereby fraudulently obtained the subject policy.  The opposite parties also submitted that the contract of insurance is based on a foundation of utmost good faith that is principle of Uberrimafide, the proposed / life assured has to maintain and observe a complete good faith in entering into an insurance contract with the insurer, the life assured / proposer is under solemn obligation to make a full complete, true and correct disclosure of the material fact which may be relevant for the insurer to take into account while deciding whether the proposal should be accepted, if the life assured / proposed failed to disclose the true and correct material facts to the insurer then the policy obtained by the life assured / proposer stands initiated from the assured or any person claiming under his is not entitled for any benefit under the said policy. The opposite party submitted that in this case it was revealed that the life assured was suffering from T.B. prior to submission of proposal form for their policy and had also defaulted in the treatment regimen which can be clearly depicted from the medical report procured from the District T.B. Control Officer, Dr. B. Ramesh, MBBS, DTCD, Khammam by the opposite party during the process of claim investigation.  The opposite party submitted that the life assured intentionally and purposefully did not disclose the same just to take undue and unlawful gain of it and has admittedly debarred the opposite party company for fair under taking of the proposal and initiated the under taking.   The opposite parties also submitted the complainant filed the present complaint with an ulterior motive and malafide intention to obtain wrongful gain and to cause harassment and prejudice to the opposite parties as such prayed to dismiss the complaint.      

5.       On behalf of the opposite parties, the following documents filed and marked as Exs.B1 to B4.

Ex.B1:- Proposal Form issued by opposite party No.1.

Ex.B2:- Policy document and welcome letter.

Ex.B3:- Photocopy of application to RTI and the reply given by District T.B.   Control Officer, Khammam.

Ex.B4:- Claim Repudiation letter, dt. 30-12-2012.

6.       Written arguments of opposite parties filed.

7.       Heard Oral arguments from both sides.

8.       Upon perusing the material paper on record, now the point that arose for consideration is,

1. Whether complainant is entitled for the claim?
2. To what relief?

Point No.1:-         

In this case the father of the complainant had obtained Kotak term plan policy from the opposite party company and he put the complainant as nominee.  The father of the complainant died on 01-09-2012 due to snake bite.    According to the complainant after the death of his father, the complainant had submitted all the relevant documents to the opposite party company and submitted Claim Form for the settlement of the claim.  According to the complainant, the opposite party No.2 sent a claim repudiation letter stating that they decided to decline the claim of the complainant under the said policy on the ground of non-disclosure and suppression of material information, that the life assured was suffering from Tuberculosis prior to the date of commencement of risk and had defaulted on the treatment regimen.  According to the complainant as the opposite parties by making false allegations and searching grounds to repudiate the claim to avoid the payment of basic sum assured, as such the complainant approached the Forum for redressal. 

From the documents and material available on record, we observed that it is an undisputed fact that the father of the complainant had taken Kotak term policy from the opposite parties.  The father of the complainant died on 01.09.2012.  When the claim was made by the complainant, the opposite party company repudiated the claim on the ground that the father of the complainant on the ground of non-disclosure and suppression of material information at the time of taking policy that the life assured was suffering from Tuberculosis prior to the commencement date of risk and defaulted on the treatment regimen.   To support their case the opposite parties obtained information from the Public Information Officer, who has referred case history from MOTU, Thallada, the said officer who mentioned the details of the T.B. No.107/2012 of P.H.C. Lanka Sagar, Penubally Mandal, Khammam District wherein, in column No.4 in exhibit B3 “Type of case: Others (Sputum Negative) and also we observed in column No.7 Diagnosis and followup details “Diagnosis date 13-03-2012 – result negative and also in column No.10 date and cause of death : 01-09-2012  snake bite”.  From the above record submitted by the opposite parties we observed that the life assured never suppressed the material facts at the time of taking the policy/proposal.  This has become a routine practice for insurance company to repudiate the claim.  Under law, the onus to prove material concealment would lie on the insurer.

The Hon’ble Supreme Court of India in LIC of India Vs Asha Goeal reported in (2001) II SCC 160, observed that the burden of proving that the insured had made false representations suppressed material acts is undoubtedly on the insurance company.  The insurance company has failed to discharge its burden.  The Exhibit B3 lnformation obtained under RTi from District T.B. Control Officer, which was filed by the opposite party company, clearly shows that the life assured died due to snake bite only.  We are of the opinion that there was no evidence to show that the life assured was suffering from Tuberculosis prior to proposing the policy there was no suppression of material fact.  And also from the letter obtained from District T.B. Control Officer it is clear that the life assured / father of the complainant died on 01-09-2012 due to snake bite only.  From the above, we are of the opinion that the insured never suppressed the material facts pertaining to his health.  As the life assured died due to snake bite, the question of suppressing the material fact and obtaining the policy fraudulently by the life assured does not arise and repudiating the claim is nothing but deficiency of service on the part of opposite party company.  As such this point is answered accordingly in favour of the complainant.

Point No.2:-         

          In the result, complaint is allowed in part directing the opposite parties to pay the policy amount of Rs.10,00,000/- with interest @ 9% P.A. from the date of repudiation (i.e. 30-12-2012) till the date of actual payment.

Typed to dictation, corrected and pronounced by us in the open forum, on this the 26^th day of May, 2015.

FAC President               Member

     District Consumer Forum, Khammam.

APPENDIX OF EVIDENCE

WITNESSES EXAMINED:-

For Complainant                                                       For Opposite party   

       None                                                                             None

DOCUMENTS MARKED:-

For Complainant                                                       For Opposite party

FAC President               Member

     District Consumer Forum, Khammam.