Complaints filed on: 30-11-2022
Disposed on:30-06-2023
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, TUMAKURU
DATED THIS THE 30th DAY OF JUNE 2023
PRESENT
SMT.G.T.VIJAYALAKSHMI, B.Com., LLM., PRESIDENT
SRI.KUMARA.N, B.Sc. (Agri), LL.B., MBA., MEMBER
SMT.NIVEDITA RAVISH, B.A., L.L.B, LADY MEMBER
CC.No.180/2022
SRI. T. NAGARAJA NAYAKA
S/O LATE THIPPESWAMY
A/a 34 years, R/o K.T.Halli Village,
Nidagal Hobli, Pavagada Taluk,
Tumakuru District.
……….Complainant/s
(By Sri. Radhakrishna, Adv.,)
V/s
The Deputy Manager,
Bharathi AXA Life Insurance
Company Ltd., Unit No.1904,
19th Floor, Parinee, Creeseen 20,
G Block, Bandra, Kurla Complex,
BKC Road, Behind MCA Ground,
Bandra East Mumbai-400 051,
Maharashtra, IRDA of India Reg.
No.130 CIN, U66010MH2005 PLC 157108.
……….Opposite Party
(By Sri. Mohan .S, Adv.,)
:ORDER:
BY SMT.G.T.VIJAYALAKSHMI, PRESIDENT
This complaint has been filed by the complainant against the OPs U/s 35 of the Consumer Protection Act 2019 with a prayer to direct the OPs to pay the insurance policy amount to complainant as he is the nominee to the policy bearing No.502-2797293 obtained by his deceased Father along with Rs.2,00,000/- towards compensation for mental agony and harassment.
2. The brief facts of the complaint are as under:-
The deceased Father of the complainant was working as Civil Contractor around Tumakuru District and he was hale and healthy and during his lifetime, he was obtained insurance policy with OP No.2 on 23.10.2019 for basic premium amount of Rs.54,634.38 in Bharati AXA Life Super Endowment Plan, bearing policy No.502-2797293 and the complainant is the nominee to the said policy which commences from 26.10.2019 and maturity date on 29.10.2039. The complainant further submitted that his Father had paid the insurance premium amount and the OP No.2 issued receipt, documents, bond and other certificates in favour of his deceased Father. It is further submitted that his Father Thippeswamy was suffering from chest pain and also MyoCardial infraction and he was took treatment at SSM Multi Speciality Hospital Pvt., Ltd., Hassan and as per the advice of the concerned Doctor, he was taken necessary treatment, but unfortunately, his Father died on 18.02.2020 and the duty doctor Vinayaka .N., M.B.B.S. MD., declared the death of his Father as “heart attach”.
The complainant further submitted that since he is the nominee to the said policy and as per said Bharati AXA endowment plan and as per section 30 of Insurance Act 1938, the complainant being the nominee is only entitled to all the death benefits/policy amount from the OP and it is the legal duty of the OP to pay the death benefits under the policy to the complainant. Hence, the complainant No.2 approached the OP No.2 and produced the policy certificate, death certificate, copy of Aadhar Card and other necessary documents before the OPs and the OPs has received the same, but intentionally not paid the policy amount and refused to pay the same, hence the complainant issued legal notice on 06.05.2021 and on 20.09.2022, but on receipt of the same, the OPs did not pay the policy amount. Hence, the complaint.
3. After receipt of notice, the OP No.2 written a letter with a request to delete their name as the insurance Ombudsman is not interested party in the case. Considering the facts of the case, and reasons stated/mentioned in the letter and as per order of the Hon’ble High Court of Rajasthan (S.B.Civil Writs No.13053/2018), the OP No.2 i.e. Insurance Ombudsmen is deleted from the array of the OP No.2.
3(a) The OP No.1 appeared through their counsel and filed the version contending that the policy holder only after reading the terms of the policy sings the proposal form and therefore the policy holder is bound by the terms and conditions of the policy. The complaint filed by the complainant is false, frivolous, and vexatious and also abuse of process of law and not raise any consumer dispute. The complainant has not approached this Commission with clean hands. The Father of complainant obtained policy bearing Number 502-2797293 which was issued on 29.10.2019 and on 12.08.2020, the OP No.1 received an death claim intimation from the complainant stating that the Life insured died on 18.02.2020 due to heart attack and upon receipt of claim, the OP appointed an investigator to investigate the genuineness of the claim of the complainant and during the investigation, the Asha worker and Gram Panchayath informed the investigator that complainant’s Father diagnosed with heart illness around 6 months earlier to death and advised by the Apollo hospital for surgery and life assured was a diabetic and hypertension and gained weight in last one year around 110 kg and also life assured regularly consuming alcohol and was a smoker and further it is contended that the treating doctor of life assured Dr.Chakkara Reddy informed and provided certificate stating that life assured consulted him in 2015 and was diagnosed with Type 2 diabetes Mellitus and further in the report of Ultrasonography dated:16.03.2019 found “Subcutaneous Cellulitis” in the lower part of leg of life assured. Hence, the life assured did not mention the above mentioned medical conditions in the proposal form at the time of issuance of policy. The life assured has failed to comply with the terms and conditions of the Insurance Police and has concealed the material information in order to gain undue advantage from the OP.
The OP further contended that after receipt of claim, during investigation it is found that life assured was diagnosed with myocardial infarction/LI had risk of DM since 5 years and HTN since 3 years and suggestive of cellulites right lower limb and the same was not intimated to the OP No.1 at the time of signing the proposal form, hence the deceased life assured has misrepresented the facts at the time of issuance of the policy. The life assured also not answered correctly to the questions asked in the proposal form and thereby suppressed the material facts. Hence, as per the terms and conditions of the policy, they have repudiated the claim of the complainant, therefore there is no any deficiency of service on their part. On these among other grounds, it is prayed to dismiss the complaint.
4. The complainant has filed his affidavit evidence and produced some copies of documents, which are marked at Ex.P1 to P16. Sri. Snehal Sawant, Senior Manager has filed his affidavit evidence on behalf of OP.
5. Both complainant and OP No.1 filed their written arguments. We have heard the arguments of counsel for complainant, but OP No.1 submitted that there is no oral argument on their side.
6. On perusal of pleadings and documents produced by the complainant and OP No.1, the points that would arise for our consideration are:
- Whether there is any deficiency in service on the part of OP?
- Whether complainant is entitled for reliefs sought for?
7. Our findings to the aforesaid points are as under:
Point No.1: Partly in the affirmative
Point No.2: As per the final order.
:REASONS:
8. The admitted facts between the parties are;
- During the lifetime of complainant’s Father Thippeswamy S/o Narasimhappa was insured life insurance policy with the OP No.2 on 23.10.2019 for basic premium amount of Rs.54,634.38 in Bharati AXA Life Super Endowment Plan vide policy bearing No.502-2797293.
- The said policy was issued on 26.10.2019 and maturity date is 29.10.2039.
- The complainant’s Father Thippeswamy was suffering from Chest pain and also Myocardial infraction and he was took treatment at SSM Multi Speciality Hospital Private Limited, Hassan, but unfortunately, the complainant’s Father died on 18.02.2020. The duty doctor Vinayaka .N. declared the death as “Heart attack”.
- The complainant being the nominee is entitled for the death benefits from the OP. Hence, the complainant approached the OP No.2 by producing the necessary documents before the OP. The OP received the same, but refused to settle the claim.
9. The main allegation of the complainant is that in spite of receiving all necessary documents, the OP repudiated the claim of the complainant.
10. On the contrary, the OP contended that the Father of complainant obtained policy bearing Number 502-2797293 which was issued on 29.10.2019 and on 12.08.2020 the OP received a death claim intimation from the complainant stating that the Life insured died on 18.02.2020 due to heart attack and upon receipt of claim, the OP appointed an investigator to investigate the genuineness of the claim of the complainant. The OP further contended that after receipt of claim, during investigation it is found that life assured was diagnosed with myocardial infraction/LI had risk of DM since 5 years and HTN since 3 years and suggestive of cellulites right lower limb and the same was not intimated to the OP at the time of signing the proposal form, hence the deceased life assured has misrepresented the facts at the time of issuance of the policy.
11. To prove the case, the complainant produced the exhibits i.e. Ex.P1 is the death certificate of the complainant’s Father, Ex.P2 is the hospital treatment certificate issued by the SSM Hospital, Hassan. In this exhibit, the date of admission of the complainant is mentioned as 18.02.2020 and date of discharge as 18.02.2020 and further mentioned as “diagnosis arrived at Myocardial Infarction” and nature of illness reported as “unconscious and Gasping”. In Ex.P3 i.e. last attending Doctor Certificate, the primary cause of death mentioned as “MYOCARDIAL INFRACTION” and also mentioned time of illness is one hour. In Ex.P5, the death of the complainant’s Father declared and in this document clearly mentioned pulse and B.P. not recorded. Ex.P13 dated:30.09.2020, as per this exhibit, the OP repudiated the claim of the complainant. The reason reads as under:-
“As per documents received at claim stage, it has been established that life insured was a known case of Diabetes Mellitus since 5 years and hypertension since 3 years. This history is prior to his proposal and that all the aforesaid replies, were falsely given in the proposal form”.
As per the above exhibit, the OP repudiated the claim of the complainant on the ground of “Diabetes Mellitus and hypertension”. But the existence of Diabetes Mellitus and hypertension is not sufficient to repudiate the claim and the death of the insured should actually occur due to Diabetes Mellitus and hypertension.
From the above exhibits, it is clear that the OP not produced any evidence to show that the complainant suffered and died due to hypertension and diabetes. Mere statement/production of doctor certificate is not enough. The OP not examined any doctors or even treating/consulting doctor in this regard. Moreover, the OP failed to establish that from the diabetes mellitus and hypertension only, the death occurred and also failed to establish that the direct cause for death is hypertension and diabetes mellitus. Nowadays, the hypertension and diabetes considered as life style diseases and it can be easily controlled with the conservative medication.
12. Considering the facts and circumstances of the case and in the light of observation made by the Hon’ble Apex Court and Hon’ble National Commission in catena of judgments, we found there is a deficiency of service on the part of OP and thereby caused mental agony to the complainant. Hence, the complainant is entitled to sum assured amount under the policy with interest @ 9% PA from the date of repudiation to till realization. For the act of OP, the complainant is compelled to approach this Commission. Therefore, the complainant is entitled for Rs.10,000/- as compensation for mental agony and Rs.10,000/- as litigation expenses. Accordingly, we pass the following:-
:O R D E R:
The complaint is allowed in part.
The OP is directed to pay Rs.6,02,119/- (sum assured under the policy) along with interest @ 9% PA from the date of repudiation i.e. 30.09.2020 to till realization.
The OP is further directed to pay Rs.10,000/- as compensation and Rs.10,000/- as litigation expenses.
The above order shall be complied by the OP within 45 days from the date of receipt/knowledge of the order.
Communicate the order to the parties at free of costs.
