This case is coming for final hearing on 17-3-2015 in the presence of Sri Adari Appa Rao, Advocate for Complainant and Sri Sanapala Karuna, Advocate for Opposite parties and having stood over till this date, the Forum delivered the following.                                                                                                                                                                                                                                                                                                                                                                                           

: O R D E R :

(As per the Honourable Member Sri V.V.L.Narasimha Rao on behalf of the Bench)

1. The present Complaint is filed under Sec.12 of C.P.Act on 20.02.2013 against the Opposite Parties 1 & 2 and the Complainant requested the Forum to direct the Opposite Parties 1 & 2 (1) to pay the insurance claim amount of Rs.1,80,000/- along with interest @ 24% p.a. from the date of claim till realization (2) to pay compensation of Rs.20,000/- for causing mental agony and personal inconvenience (3) to award costs for legal expenditure.

2. The brief facts are as follows:- The Complainant submits that her husband obtained life insurance policy from the Opposite Parties 1 & 2 bearing No.C191158188 on 15.03.2010. Sum assured for the said policy is Rs.1,80,000/-. The complainant is the nominee in the said policy. The complainant husband died on 1.7.2010 at the residence. Thereafter when the complainant is searching for housetax passbook, she noticed the policy and then on 7.10.2011 she addressed a letter to the Opposite Parties to settle the insurance claim. After receiving the said request letter one person came to the village and he stated that he came for investigation with regarding to the insurance claim submitted by the complainant. The Investigator suggested the complainant to submit the original document to the 2^nd Opposite Party. The complainant submitted the original policy bond, original death certificate to the 2^nd Opposite Party and obtained acknowledgement. Thereafter on 11.04.2012 Complainant received the repudiation letter i.e. Claim rejecting letter from the 1^st Opposite Party that the life insured i.e. her husband is expired prior to the signing in the application form. Hence the complainant was constrained to file the present complaint before this Forum seeking reliefs.

3. Notices were served to the Opposite Parties. On behalf of Opposite Parties Sri P.B.Ganapathi, Assistant Manager-Legal filed counter and stated as follows. The complainant has not approached the Forum with clean hands and that too the complaint is filed on baseless allegations and also there is no cause of action for filing the present complaint. The DLI (Complainant’s husband) at the time of making the said proposal has misrepresented his age, which amounts to suppression of the facts at the time of filing and signing the proposal form. The statement given by the wife of the DLA (Complainant) clearly stated that she is drawing widow pension from March 2010 i.e. prior to filing of the application form. The Opposite Parties received the application of the DLA i.e. the Complainant’s husband for Tata AIG Health Protector Plan vide Policy Proposal Form No.C280804835 dt. 13.03.2010. In the Proposal form, Complainant gave all details and information in the format for model premium of Rs.2974/- which was proposed to be paid by insured annually. During the investigation of the Investigator which was established that in the statement given by the wife of the DLA it is clearly stated that she has been drawing widow pension by March, 2010 i.e. prior to the filing of the application form. To prove the said allegation, the Opposite Parties has filed the investigation report and statement of the wife of the DLA. The complainant has filed the present complaint with a malafide intention to extract the wrongful names from the Opposite Party, as the policy was obtained by suppressing the facts on the name of her husband after death of the complainant’s husband. As there is no deficiency of service on part of the Opposite Party, the complaint is liable to be dismissed under Sec.26 with exemplary costs. Along with the counter averments, the Opposite Parties has relied upon the case law AIR 1971 AP 41, LIC of India Vs. B.Chandravathamma which related to the issue of the repudiation of the claim by the insurance company, wherein there is mis-representation of the facts and has fraudulent and deliberate intention for not giving the proper facts, the complaint is dismissed.

4. On perusing the pleadings of the both sides the Forum has framed the following issues for consideration: a) Whether there is any deficiency on part of the Opposite Parties b) To what relief.

5. The Complainant has filed her Evidence Affidavit and on her behalf Exs.A1 to A6 were marked. The Opposite Party filed Evidence Affidavit along with 6 documents. As the said documents were Photostat copies, no documents were marked on behalf of the Opposite Parties. The Complainant and the Opposite Parties submitted written arguments as well as the oral arguments.

6. Point No.1:  The present complaint is filed by the Complainant against the Opposite Parties for the claim of the insurance claim for Rs.1,80,000/- wherein the Policy was obtained by her husband vide Policy No. C191158188. The said policy was obtained by her husband on 15.03.2010 and her husband died on 1.7.2010. The Opposite Parties version is that the Policy was obtained by suppressing the actual facts that the Complainant has died on 28.02.2010 and for claiming the wrongful claims from the Opposite Party and to deceive the Opposite Party.

7. Observing the entire pleadings of the both sides and strong contention of the Opposite Party that the complaint is liable to be dismissed, we are of conclusive opinion that the unmarked documents i.e. 6 documents filed by the Opposite Parties has to be observed applying principles of natural justice to meet the both ends of justice.

8. Exhibit A1 is the Policy Information page, wherein the said document was mentioned as the Policy No. C191158188. The said Policy was obtained on 15.03.2010 and the Policy date is 15.03.2010. The Policy holder name is mentioned as RAMASURI VEGI and with regarding to the nominee column as C-APPLICATION. The assured amount for the said policy is mentioned in the Ex.A1 as Rs.1,80,000/-. The details for claim of policy amount is as follows: a) For accident death benefit-Rs.1,00,000/- b) Total, Permanent disability benefit -Rs.80,000/- c) Term Life Benefit-Rs.1,80,000/-                                                                                    The amount of Rs.2,696/- is paid towards the premium for annual payment for the Policy. Ex.A2 is the death certificate of the Complainant’s husband wherein it was mentioned as Complainant’s husband died on 1.7.2010 and the certificate was issued to the Complainant on 3.7.2010. Ex.A3 is the letter dt. 7.10.2011 submitted to the Opposite Parties for clearance of the Rs.1,80,000/- insurance amount. Ex.A4 is the copy of the Ex.A2 Death Certificate and on the Ex.A4 the Opposite Party has endorsed that the Policy bond copy and the Claim form along with Death Certificate was received. Ex.A5 is the repudiation letter dt. 11.4.2012 given by the 1^st Opposite Party stating that basing upon the investigation of the Investigator the complainant’s husband had expired prior to the signing the application form and the claim is rejected. Ex.A6 is the application form for obtaining the Insurance policy, which shows that Insured date of birth is 1.7.1964.

9. The 6 unmarked documents filed by the Opposite Parties are:- The application form for taking the policy on 13.03.2010 signed by the complainant’s husband, mentioning his date of birth as 2.8.1963 and other details mentioned showing the insurance claim, the confrontation of the authorized official/intermediatory of the Opposite Party’s company i.e. Agent Sri P.Govind, Ration Card copy of the Complainant (Front and back side), filed as Doc.No.1. The Policy information page, initial premium deposit for the policy and C.S.O. cover sheet were filed as Doc.No.2. The premium payment notice for paying annual premium for 15.03.2011 dt.14.02.2011 and lapse notice dt.15.04.2011 for paying the insurance premium, filed as Doc.No.3. The claimants statement, death certificate of complainant signed by Sri Narasinga Rao, Panchayat Raj secretary dt. 3.7.2010, filed as Doc.No.4. The 9 pages Investigation Report, Letter dt. 27.10.2011 served by the Complainant to clear the claim, death certificate copy of the complainant’s husband, filed as Doc.No.5. The repudiation letter dt. 11.4.2012 along with risk verification details, filed as Doc.No.6. In this matter there are two proposal form dt.10.03.2010 i.e. Ex.A6 and Proposal Form dt.13.03.2010 for the Policy C191158188. But the Opposite Parties’ are strongly relying upon the proposal form dt.13.03.2010 only.

10. Though the Opposite Party has stated in para 10(III) that upon the investigation and the Investigator has furnished the statement of the complainant that she is drawing widow pension by March, 2010 is filed along with the 6 documents. On perusing all the 6 documents filed by the Opposite Parties and the Exs.A1 to A6, there is no statement filed by the Complainant that she is getting widow pension from March, 2010. Hence the Opposite Party cannot rely upon the said version.

11. In the application form furnished by the Opposite Parties enclosed with the Doc.No.1, it reveals that the Complainant husband has signed on the application form on 13.03.2010 at Visakhapatnam for obtaining the insurance policy from the Opposite Parties. The Agent who contacted the complainant’s husband at the time of taking the policy is Sri P.Govind and his Agent No.4166902. The Confirmation letter enclosed with the Doc.No.1 i.e. Confrontation given by Sri P.Govind stating that “I have received a copy of this Sales illustration and understand that any non-guaranteed benefits assumed in the Sales illustration are subject to change and are not guaranteed. As seen from the Ex.A1 with regarding to the nominee condition for the Policy No.C191158188, in the nominee column it was mentioned as C-APPLICATION. In the application form filed by the Opposite Party along with Doc.No.1 as per guidance of the Ex.A1 Column, it reveals that the Complainant V.Venkatalaxmi is the nominee. In the Ex.A5 repudiation letter of the 1^st Opposite Party in Para 3 it was stated as the claim of the complainant is rejected as the Life Insured (Complainant’s husband) prior to the signing in the application form. Observing the application form and the confrontation letter given by the agent Sri P.Govind, dt. 13.03.2010 and the terms and conditions mentioned in the declaration as the Sales illustration are subject to change and not guaranteed. Before giving the policy No.C191158188 if there is any suspection or any doubt it is the duty of the authorized signatory or the Opposite Parties to enquire about the same and then Opposite Parties has to give the policy. Here observing the facts in this case confronting the authorized official/agent Sri Govind’s statement the policy was given to the complainant’s husband.

12. As per case law 2014 (III) CPR 178 (NC) Manager, Bajaj Allianz Co.Ltd. Vs. M/s.Rajkumar, it was held that “usually the authorized member of the Insurance Company examined the insured assists the fitness and after complete satisfaction, then only the policy will be issued. Therefore, the opposite party is wrong in repudiating the claim of complainant”. Hence observing the principle of the case law and the confrontation of the authorized counsel Sri Govind i.e. Agent’s Statement when the policy was given to the Complainant’s husband on 15.03.2010 by taking Rs.2,696/- the Opposite Parties cannot taken back step for repudiating the claim stating that the insured has expired prior to signing on the application form.

13. Even observing the investigation report filed by the Opposite Party vide Doc.No.5, though the Investigator has stated that the Complainant’s husband died on 28.02.2010, in Page No.2 of the report, the investigator came to a conclusion that the Complainant is the wife of the insured Sri Bhaskar Rao, aged 23 years is related to the insured as son, Haritha, aged 17 years related to the insured as daughter. Observing Page No.3 of the report the Investigator stated that the information was gathered from the relatives of the insured including Complaint’s son V.Bhaskar Rao, Cell: 9133805863, Haritha, daughter of the insured. In page No.4 of the report in information column Investigator’s stated that the neighbour’s informed the investigator that due to frequent alcoholic, he suffered with chronic cough and breathlessness and he died due to that in the year 2010. Except the year 2010 there is no date and month is mentioned. In the same report, the Opposite Party Investigator stated that without enquired about the ANM at Gajuwaka Sub Centre, PHC, he received information that on 28.02.2010 the insured has died. Upon the enquiry of the ANM Hospital employees Ms.Hyma, it reveals that insured died on 28.02.2010. In Page No.6 of the report, the Investigator stated that he has contacted the Secretary, Mr.Laxminarayana, Cell : 9959676802 for verifying the death certificate. He confronted that the insured died on 1.7.210, but for further clarification, the Secretary Mr.Laxminarayana is avoiding to meet the investigator.

14. When the Opposite Parties are relying upon the investigation report and stating that Ms.Hyma of ANM Centre stated that insured died on 28.02.2010 and also the death certificate i.e. Ex.A2 was given by Sri Laxminarayana and the said Laxminarayana is not responding for further verification, the Opposite Parties could have filed the petition under Sec.13(4)(i) of C.P.Act for calling the witness or examine the witness on the oath. The Opposite Parties has not utilized the said provision and not called the said persons to prove that the insured i.e Complainant’s husband died on 28.02.2010.

15. Even observing the Ex.A2, Death Certificate and the version of Investigator in Page No.6 of report when the Opposite Parties has not rebutted the version of the Sri Laxminarayana, Secretary who gave death certificate they could not rely upon the stand that the complainant’s husband died on 28.02.2010. Hence observing the Ex.A2, Death Certificate, we conclude that the complainant’s husband on 1.7.2010 only and the complainant is entitled for the claim of the policy basing upon the terms and conditions of the policy. Thereby, there is deficiency of service on the part of Opposite Parties 1 & 2.

16. Point No.2: Ex.A3 is the letter submitted by the Complainant on 7.10.2011 to settle the Insurance claim. Letter dt.27.10.2011 enclosed with Doc.No.5 of Opposite Parties and the conclusion of the Investigator mentioned in information column in Page No.4 of the report reveals that the husband of the complainant died as he is a chain smoker and frequent alcoholic and while suffering with chronic cough and breathlessness he died. Even the complainant also admitted in the complaint that the complainant’s husband died at the residence only. As seen from Ex.A1 schedule of benefits and premiums, it reveals the sum assured for the Policy No. C191158188 is Rs.1,80,000/-. So observing the details for paying the benefit for the policy and the version of the complainant that her husband died in his residence with severe cough and breathelessness, the complainant is entitled only for the claim of Rs.1,80,000/- only from the Opposite Parties towards “Term Life Benefit”. The Opposite Parties 1 & 2 are directed to pay Rs.1,80,000/- to the Complainant @ 12% p.a. from 7.10.2011 till realization. As interest is awarded to the Complainant, the complainant is not entitled for any compensation. The Opposite Parties are liable to pay Rs.5,000/- towards costs for the litigation. Accordingly point No.2 is answered.

17. In the result the complaint is allowed in part. The Opposite Parties 1 & 2 are jointly and severally liable to pay Rs.1,80,000/- to the Complainant along with interest @ 12% p.a. from 7.10.2011 till realization. The Opposite Parties are also liable to pay Rs.5,000/- towards costs for legal expenditure. Time for compliance is 30 days from the date of receipt of this order.

    Dictated to the Stenographer, transcribed by him, corrected by me and pronounced  by us in the open Forum on this the 31^st  day of March, 2015.

                                

     

            Sd/-                                                                               Sd/-

    President (FAC)                                                        Member                                                                                                        District Consumer Forum – I,

                                                                                  Visakhapatnam

     

    APPENDIX OF EVIDENCE

     

     

    Exhibits Marked for the Complainant:

Exhibits for the Opposite Parties:

-NIL-

      Sd/-                                                              Sd/-

President (FAC)                                                        Member                                                                                                  District Consumer Forum – I,

                                                                              Visakhapatnam