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

                                                           C.C. No.81/2022.

                                                                                                                           Date of filing: 17.11.2022.

                                                              Date of disposal: 28.02.2024.

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.                       

COMPLAINANT/S                    1.    Baswaraj S/o Irappa,

                                                            Age:60 years,Occ:Agriculture,

                                                            R/o KalBemalgi, Tq:Zaheerabad and
                                                       Dist:Medack, Nowresideing at
                                                       H.No.17-4-239 Ratna Pooja Yedlapure
                                                       Gumpa Ring Road, Bidar.   

                                                     2.    Prabhavathi W/o Baswaraj,

                                                      Age:55 years,Occ:House work,

                                                            R/o KaBemalgi, Tq:Zaheerabad and
                                                       Dist:Medack, Nowresideing at
                                                       H.No.17-4-239/1(6) Ratna Pooja Yedlapure
                                                       Gumpa Ring Road, Bidar.                              

                                                  (By.Sri.K.Kashinath and
                                                   Sri.Rajkumar K. Advocate.)                           

V/s

OPPONENT/S                           1. The Divisional Manager,
                                                     Sri Ram Life Insurance Company Limited  
                                                     Ramkey Selenium, 5^th Floor, Plot No.31-32  
                                                     Beside Andhra Bank Training Centre
                                                     Financial District Hyderabad -500032.

                                                     (By Sri.Suresh Auradkar And
                                                      Smt.Padma Advocate).
                                                                                           

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

By Shri. Mabu Saheb H.Chabbi, President.           

The complaint is filed by the complainants under section 35 of the Consumer Protection Act 2019, against the opponent for the deficiency of service caused by not settling the claim of the complainant based on the policy.  Hence, passed the following judgement.

Brief facts of the complaint.

The brief facts of the complaint are as follows: -

2.         The complainant’s son Sri Santoshkumar had purchased insurance policy No.NN012002117551 from OP for an assured amount of Rs.5,00,000/- with the term of 10 years commencing from 20.02.2020 with the yearly basic premium of Rs.2270/-.  The complainant No.2 being the mother of Sri.Santoshkumar was shown as nominee to the policy and the complainant No.1 is the father of said Santoshkumar.  Due to ill health the insured Santoshkumar suffered from high fever and had undergone treatment with the specialist doctor.  Despite that, the said insured died on 07.07.2020 in his house.  Complainant’s are the legal heirs of the said  Santoshkumar, they submitted the claim form to the Ops with all relevant documents to settle the claim of complainant’s for an assured amount of Rs.5,00,000/-.  But, the OP has rejected the claim of the complainant by issuing a letter dt:28.05.2021 on false grounds.  The insured has not concealed anything in the proposal form but, the OP contended that, the insured was suffering from hyper tension with mild bilateral pleural Effusion and concentric LVH  before commencement of policy, as against the repudiation of the claim of the complainant’s the complaint got filed against OP for claim of insurance. 

Written Version of OP.  

3.         The notice issued by this commission to the OP is served upon it and the OP appeared through its counsel before this commission and filed its W.V. and the gist of the W.V. is as below. 

            The OP has admitted the fact of purchase of insurance policy No. NN012002117551 by the insured Santoshkumar, for an assured amount of Rs.5,00,000/- payable by the OP in the event of death of the insured if terms and conditions are complied.  As per the investigation conducted by the OP it is found that, at the time of proposal form the insured has given false information regarding his health condition, the investigation team has collected crucial medical documents and it came to know that, the insured was suffering from highper tension since 03 years and further came to know that, he was suffering from kidney related ailment and took treatment at various hospitals such as Aditya Hospital, Vikarabad, the Deccan Hospital, Somajiguda Hyderabad and Osmaniya General Hospital Hyderabad and was on dialysis for every 02 days and died due to said complications.  The policy of the insured may be called in question at any time within 03 years from the date of issuance of policy, if the insured found to be provided false information in the proposal form.  In view of this fact the complaint is not maintainable.  The policy was purchased by the insured in a deceitful manner by suppressing the previous ailment and hence the claim of the complainant’s was rightly repudiated.  The OP has filed his additional W.V. on 02.08.2023 submitting that, the OP has refunded the premium of Rs.2,270/- on humanitarian grounds as ex-gratia by directly transferring into the account of nominee through NEFT Ref. No.87221891075363 dt:28.03.2022 to the account No.34002250025813.  the complainant has accepted the said ex-gratia payment without any protest.  Hence, prayed to dismiss the complaint.           

Evidence of complainant.

4.         The complainant No.2 Prabhavati W/o Basvaraj is examined on 17.04.2023 and on 09.11.2023 answers to interrogatories as P.W.1 and got marked documents Ex.P.1 to Ex.P.07 which are as follows,

1. Ex.P.1-Copy of Policy schedule.
2. Ex.P.2-Copy of repudiation letter dt:28.05.2021.
3. Ex.P.3-Copy of death certificate of Santoshkumar.
4. Ex.P.4- Copy of Aadhar Card of complainant No.1.
5. Ex.P.5-Copy of Aadhar Card of complainant No.2.
6. Ex.p.6-Copy of lease agreement 15.06.2020.
7. Ex.P.7-Copy of Aadhar Card of Ravindrakumar S/o Shamrao Yakatpure.

Evidence of Opponent.

5.         One, Sri.E.Sridhar S/o E.J.Lingam, General Manager of OP company, has been examined as R.W.1 ad got marked 11 documents as per Ex.R.1 to Ex.R.11 on behalf of OP Company.

1.  Ex.R.1-Copy of proposal Form.(2 pages)

2. Ex.R.2-Copy of policy schedule with terms and conditions.(25 pages)
3. Ex.R.3-Copy of death claim intimation form dt:18.09.2020.
4. Ex.R.4 –Copy of death certificate of Santoshkumar.
5. Ex.R.5-Copy of investigation report dt:30.04.2021.(5pages)
6. Ex.R.6-Copy of discharge summary  of The Deccan Hospital dt:01.07.2020.(2pages)
7. Ex.P.7-Copy of outpatient ticket of Osmaniya General Hospital dt:07.07.2020.(26pages)
8. Ex.R.8-Copy of description and lab investigation report issued by Aditya Multi Speciality Hospital.(3 pages)
9. Ex.R.9-Copy of Echocardiography report issued by Bhalke Vydehi hospital dt:23.10.2019.(2 pages)
10. Ex.R.10-Copy of Ultrasound Abdomen issued by Sree Scan Centre dt:25.06.2020.(3 pages)
11. Ex.R.11-Copy of repudiation letter issued by OP dt:28.05.2021.(3 pages).

Points/Issues.

6.         Learned counsel for the parties have argued the case on merits.  Learned counsel for OP filed his written argument.  On perusal of pleadings, and documents of the complainant, this commission raised the points for consideration as below;

1. Whether the complainant’s prove that, they are consumers to the OP and further prove the deficiency of service caused by the OP in not settling the claim of insurance to the complainant’s?  
2. Whether the complainant’s are entitled for any relief as sought in their complaint?

3. What orders? 

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

1. In the affirmative.
2. In the affirmative.
3. As per the final order.

Points No 1 and 2.

8.         In order to decide the complaint issues, this commission discussed points/issues No.1 and 2 together as each points are inter related to each other- as follows.

9.         In order to prove the case of the complainant the complainant No.2 has lead their evidence as P.W.1 by way of reiterating the facts of the complaint and got marked Ex.P.1 to Ex.P.07 documents on their behalf.  Sri.E.Sridhar S/o E.J.Lingam, General Manager of OP company has been examined as R.W.1 by filing his evidence affidavit and reiterated the contents of its W.V. in its evidence affidavit and got marked 11 documents to prove the defence case.

10.       The case of the complainant is that, The complainant’s son Sri Santoshkumar had purchased insurance policy No.NN012002117551 from OP for an assured amount of Rs.5,00,000/- with the term of 10 years commencing from 20.02.2020 with the yearly basic premium of Rs.2270/-.  The complainant No.2 being the mother of Sri.Santoshkumar shown as nominee to the policy and the complainant No.1 is the father of said Santoshkumar.  Due to ill health the insured Santoshkumar suffered from high fever and undergone treatment with the specialist doctor.  Despite that, the said insured died on 07.07.2020 in his house.  Complainant’s are the legal heirs of the said  Santoshkumar, they submitted the claim form to the Ops with all relevant documents to settle the claim of complainant’s for an assured amount of Rs.5,00,000/-.  But, the OP has rejected the claim of the complainant by issuing a letter dt:28.05.2021 on false grounds.  The insured has not concealed anything in the proposal form but, the OP contended that, the insured was suffering from hyper tension with mild bilateral pleural Effusion and concentric LVH before commencement of policy.

11.       There is no dispute regarding the purchase of policy by the insured from the OP Company and hence, Ex.P.1 =Ex.R.2 policy schedule and its contents have been considered to be proved by the complainant.  In view of this fact the complainant’s have proved that, they are consumers to the OP and the OP is considered to be the service provider to the complainant’s.  Further there is no dispute regarding the death of the insured Santoshkumar as on the date 07.07.2020 and hence, the document Ex.P.3 =Ex.R.4 the death certificate of insured Santoshkumar need not have any detail discussion in this case.  The complainant’s have produced Ex.P.6 lease agreement to show their residence proof at Bidar, the OP is not disputing the said Ex.P.6 document. 

12.       The OP has produced Ex.R.3 copy of death claim intimation form and Ex.R.5 the investigation report said to be issued by Lavanya and Company that, the insured was suffering from HTN since 03 years and Kidney disease since 01 year and died because of Kidney failure.  Both documents were said to be issued on 18.09.2020 and 13.04.2021, both documents were subsequent to the date of proposal form.  The OP has produced Ex.R.6 the discharge summary dt:01.07.2020 said to be issued by Deccan Hospital, Ex.R.7 copy of outpatient ticket dt:07.07.2020 said to be issued by Osmania General Hospital, Ex.R.8 Copy of description and lab investigation report said to be issued by Aditya Multi Speciality Hospital Tandur, Ex.R.10 Copy of Ultrasound Abdomen report said to be issued by Sree Scan Centre dt:25.06.2020, were the documents which have been said to be issued by different hospitals pertaining to insured Santoshkumar.  The OP contended that, as per the above said documents of different hospitals he was suffering from Kidney failure and was also suffering from HTN.  But, on going through the date of issuance of above said document Ex.R.3, Ex.R.5, Ex.R.6, Ex.R.7, Ex.R.8 and Ex.R.10 pertains to the date of 18.09.2020, 30.04.2021, 01.07.2020, 07.07.2020, 23.06.2020 and 25.06.2020.  On going through the dates of these documents the insured was not having any such alleged ailment as on the date of proposal Ex.R.1 dt:18.02.2020.  Mere production of the documents of different hospitals regarding the case sheets and the laboratory reports said to be issued by the Hospital Authorities cannot be considered that, the insured was suffering from the alleged ailment as stated in the W.V. of OP.   

13.       The information furnished through Ex.R.1 proposal form with regard to the health condition of the insured appears to be correct and proper as on the date of 18.02.2020.  The OP has failed to prove that, the insured was suffering from the Kidney failure and was suffering from such ailment as on the date of proposal and prior to the date of proposal.  The OP has produced Ex.R.9 the Lab and Diagnostics report issued Bhalki Vydehi Hospital dt:23.10.2019 regarding Echocardiography report, as per this report produced by the  OP the health condition of the insured was normal and intact prior to proposal of policy.  The OP Company has not examined any of the doctors or medical officers of the different hospitals as shown in Ex.R.6, Ex.R.7, Ex.R.8, Ex.R.10 before this commission by producing the respective evidence affidavit of the concerned medical officers.  They above said documents which has been produced by the OP cannot be considered as conclusive proof in the given set of circumstances.  The complainant has produced one judgment of Hon’ble National Commission in support of his case reported in III (2009)CPJ 91 (NC), between Rashida Khatoon Vs LIC of India the Hon’ble lordship laid down the proposition that, “Consumer Protection Act, 1986-Section2(1)(g)-Life Insurance-Suppression of material facts-Claim repudiated-Contention, insured suffering from Hypertension, L.S.Hemiplesia, Diabetes, Inter Cerebral Haemorrhage, not disclosed-Complaint allowed by Forum-Order set aside in appeal relying upon report of Sr.consultant doctor-Hence revision-Affidavit of concerned doctor not filed-Report of Sr.Consultant remains unsubstantiated, unproved-State Commission erred in relying upon unproved document-Order of Forum restored.  The facts of the case and the proposition laid down by the lordship in the above said case are applicable to the case on hand.  Hence, the OP has caused the deficiency of service against the complainant’s by not settling the claim of the complainant’s based on insurance.   

14.       The complainant No.2 has been called to answer for interrogatories by the OP and the answers given by the complainant No.2 on 09.11.2023 are not helpful to the OP case.  The answers given by the complainant regarding the previous sufferance and ailment of insured, treatment taken by the insured at various hospitals and cause of death of insured by various complications was denied by the complainant No.2 in her answers to interrogatories. 

15.       The OP in his additional W.V. stated that, he has refunded an amount of Rs.2,270/- to the complainant through NEFT to the account of the complainant. The complainant has not whispered anything about the above said alleged refunded amount by the OP either in the pleading or in the evidence of P.W.1.  However, the burden is upon the OP No.2 to prove the said fact of refund of Rs.2,270/- to the complainant No.2 but, the OP has not produced any document to show that, he has refunded the above said amount to the complainant on 28.03.2022.  Hence, the contention of the OP cannot be considered without proof of document.

16.       The document Ex.R.6 copy of discharge summary, Ex.R.7 copy of outpatient ticket, Ex.R.8 copy of case sheet said to be issued by Aditya Hospital, Ex.R.10 copy of ultrasound Abdomen report were produced by OP with its seal of office, but not the certified copies issued by concerned hospital been produced by the OP and hence the source of document cannot be accepted by this commission as evidence. The OP has repudiated the clam of the complainant as per Ex.P.2, stating that, the insured was suffering from hypertension which was prior to risk commencement dt:20.02.2020.  But, the OP contended in his W.V. and evidence that the insured was suffering from Kidney failure.  The OP cannot raise such new plea in his pleading without assigning the said reasons in the repudiation letter.  Hence, the new ground and the reasons stated in pleading and evidence cannot be accepted. In support of this assigned reason we gain the Judgment of Hon’ble Supreme Court reported in 2019(4) CPR 654 (SC).  The Hon’ble Supreme Court laid down the preposition that, “Insurance company cannot travel beyond grounds mentioned in letter of repudiating.- If insurer has not taken delay in intimation as a specific ground in letter of repudiation, they cannot do so at stage of heaving of consumer complaint”.   

17.       In view of the above said discussion made by this commission, the reasons for repudiation of the claim of the complainant’s as per Ex.P.2 cannot be considered as proper and legal.  The genuine claim of the complainant’s has to be settled by the OP as per the Policy Ex.P.1 for an assured amount of Rs.5,00,000/- to the complainant’s.  the complainant have proved the deficiency of service caused by the OP to the complainant’s in non settling the claim of insurance and hence answered the point No 1 and 2 in the affirmative in favour of complainant’s and proceed to pass the following order.

::ORDER::

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

            The OP is hereby directed to pay an amount of Rs.5,00,000/- (Rupees five-lakh only) based on Ex.P.1= Ex.R.2 insurance policy bearing No.NN012002117551 along with the interest at the rate of 9% p.a. from the date of repudiation letter Ex.P.2=Ex.R.11 dt:28.05.2021 till the realisation of entire amount along with compensation of Rs.10,000/- for sufferance and inconvenience caused to the complainant and Rs.5,000/- as litigation expense within 45 days from the date of this order to the complainant.

            Intimate the parties accordingly.                         

 (Typed to our dictation then corrected, signed by us and then pronounced in the open Commission on this 28^th day of February-2024).

Documents produced by the complainant.

1. Ex.P.1-Copy of Policy schedule.
2. Ex.P.2-Copy of repudiation letter dt:28.05.2021.
3. Ex.P.3-Copy of death certificate of Santoshkumar.
4. Ex.P.4- Copy of Aadhar Card of complainant No.1.
5. Ex.P.5-Copy of Aadhar Card of complainant No.2.
6. Ex.p.6-Copy of lease agreement 15.06.2020.
7. Ex.P.7-Copy of Aadhar Card of Ravindrakumar S/o Shamrao Yakatpure.

Document produced by the Opponent.

1. Ex.R.1-Copy of proposal Form.(2 pages)
2. Ex.R.2-Copy of policy schedule with terms and conditions.(25 pages)
3. Ex.R.3-Copy of death claim intimation form dt:18.09.2020.
4. Ex.R.4 –Copy of death certificate of Santoshkumar.
5. Ex.R.5-Copy of investigation report dt:30.04.2021.(5pages)
6. Ex.R.6-Copy of discharge summary  of The Deccan Hospital dt:01.07.2020.(2pages)
7. Ex.P.7-Copy of outpatient ticket of Osmaniya General Hospital dt:07.07.2020.(26pages)
8. Ex.R.8-Copy of description and lab investigation report issued by Aditya Multi Speciality Hospital.(3 pages)
9. Ex.R.9-Copy of Echocardiography report issued by Bhalke Vydehi hospital dt:23.10.2019.(2 pages)
10. Ex.R.10-Copy of Ultrasound Abdomen issued by Sree Scan Centre dt:25.06.2020.(3 pages)
11. Ex.R.11-Copy of repudiation letter issued by OP dt:28.05.2021.
    (3 pages).

Witness examined.

Complainant.:-

P.W.1- Prabhavathi W/o Baswaraj,                              (complainant No.2).   

Opponent:- 

R.W.1- Sri.E.Sridhar S/o E.J.Lingam, General Manager of OP company.