Andhra Pradesh

East Godwari-II at Rajahmundry

CC/38/2012

Sri Naraharasetti Ravi Kiran - Complainant(s)

Versus

The Head of Claims, Customer Care Cell, TATA AIG Life Insurance Company Limited. - Opp.Party(s)

P.Rama Raju

29 Jun 2015

ORDER

                                                                                       Date of filing:      17.07.2012

   Date of Disposal: 29.06.2015

 

BEFORE THE DISTRICT CONSUMER FORUM-II, EAST GODAVARI

DISTRICT AT RAJAHMUNDRY

 

        PRESENT: Sri B.Vinay Kumar, B.Sc.B.L.  PRESIDENT

  Smt H.V. Ramana, B.Com., L.L.M., MEMBER.

                                      Sri A Madhusudana Rao, M.Com., B.L., MEMBER

 

CONSUMER COMPLAINT No.38 /2012

                       Monday, the 29^th day of June, 2015

Between:-

 

Naraharasetti Ravi Kiran, S/o.late Chakrapani,

Age 26 years, private electrician, Door No.2-120/2,

Yarnagudem village, Devarapalli Mandal, W.G. Dt.             …        Complainant

 

                             And

 

1)  The Head of Claims, Customer care cell,

     Tata AIG Life Insurance Company Ltd.,

     6^th floor, Peninsula towers, Peninsula corporate park,

     Ganapathrao Kadam Marg, Lower Parel (w),

     Mumbai – 400 013.

 

2)  Authorized Signatory, Tata AIG Life Insurance Co. Ltd.,

     Registered and corporate office, Delphi – B wing,

     Second floor, Orchared avenure, Heeranandani Business

     Park, Powai, Mumbai – 400076.                                        …        Opposite parties         

 

 

                          This case is coming on 19.06.2015 for final hearing before this Forum and upon perusing the complaint, and other material papers on hand, Sri P. Ramaraju, Advocate for the complainant and Sri M. Siva Subba Rao, Advocate for the opposite parties, and having stood over for consideration till this day, this Forum has pronounced the following.

O R D E R

 

(Per Smt. H.V. Ramana, Member)

 

This is a complaint filed by the complainant under section.12 of the Consumer Protection Act, 1986 to direct the opposite parties to pay a sum of Rs.6,46,700/- for 1^st claim for the policy dt.24.11.2009 and Rs.7,12,400/- for the 2^nd policy dt.22.11.2010 total Rs.13,59,100/- with subsequent interest at 12% p.a. from the date of complaint till realization of the amount; award Rs.1,00,000/- as compensation for the deficiency of service; award Rs.50,000/- for the mental agony and award costs of the complaint.

2.         The case of the complainant is that his father insured his life with the opposite party under two insurance policies No.U160507919 dt.24.11.2009 and another policy No.U160513686 dt.22.11.2010 from the branch at Rajahmundry.  His father joined in Life Hospital, Rajahmundry on 17.6.2011 due to high temperature of fever and died on 18.6.2011. The complainant made a claim for receipt of insurance amount.  The opposite parties sent a letter dt.23.3.2012 repudiating the claim of the complainant stating that the complainant’s father false reply to the questions in the application form. His father never suppressed any information sought by the opposite parties. There is a default of negligence on the opposite parties in regard to settlement of the complainant, which amounts to deficiency of service and the complainant is the nominee under the above said two policies. The complainant received an amount of Rs.14,957.49ps under 1^st Policy and Rs.12,954-66ps for 2^nd Policy and he received the same without prejudice to his rights. The complainant got issued a legal notice on 18.4.2012. The opposite parties received the notice on 28.4.2012, but did not give any reply.  On 8.5.2012, the opposite parties sent a letter stating that the 1^st policy was repudiated. The repudiation of the policies by the opposite parties, they against the provision of protection of policyholders interests regulations 2002 and the repudiation of the claim is without any valid reason. Hence, the complaint.   

3.         The opposite parties filed its written version, denied the allegations made by the complainant. It is submitted that the deceased policyholder, Sri Naraharasetti Chakrapani after completely understanding the terms and conditions of their product “Tata AIG Invest Assure Flexi” had voluntarily applied for an insurance policy vide proposal form bearing No.U160507919 dt.19.11.2009. It is submitted that in the said form, complainant i.e. the son of DLI was proposed to be nominee. In the proposal form, the DLI gave all relevant details and information in the prescribed form for an assured sum amounting to Rs.4,95,000/- for which a premium amounting to Rs.7,500/- was proposed to be paid on semi-annual basis for a term of 20 years. It is submitted that in the proposal form of the said aforesaid policy contained question No.5 a, c, f and Q7 & Q8 at Step 10 Health details of the life assured and proposer and the set of questionnaire was given were answered negative by DLI.  It is submitted that in the said proposal form which was duly filled up and signed by the DLI clearly had a provision for a declaration at Step 11 of the proposal form by the DLI wherein it was stated by the DLI that if after the issuance of the policy, it is found that the statement, answers or particulars stated in the proposal form and it’s questionnaire are incorrect or untrue; the insurance company shall incur no liability under the insurance. Thus, the DLI in this case had fully understood the terms and conditions of the policy and further agreed under the agreement therein that if any untrue statement be contained in the application, the policy contract shall be null and void and the moneys which have paid in respect thereof shall stands forfeited to Tata AIA Life Insurance Co. Ltd. Thus, based on the information, declaration and believing the same to be true and also upon receipt of the duly filled form along with the initial premium of Rs.7,500/-, the opposite parties issued the policy bearing No.U160507919 commencement date of 24.11.2009 to the deceased policyholder. Thereafter, policy documents along with schedule were sent to the deceased policyholder, which was duly delivered to the address of the deceased policy holder. Thereafter Sri N. Chakrapani, DLI after completely understanding the terms and condition applied second policy of their product “Tata AIG Invest Assure Flexi Supreme Plan” vide proposal form bearing No.U160513686 dt.22.10.2010. It is submitted that in the said form, complainant i.e. the son of the DLI, was proposed to be nominee. In the proposal form, the DLI gave all relevant details and information in the prescribed form, for an assured sum amounting to Rs.6,00,000/- for which a premium amounting to Rs.20,000/- was proposed to be paid on annual basis for a term of 19 years. In the proposal form of the said aforesaid policy contained question number Q9 a, c and e at Step 4 Health details and the set of questionnaire was given and questions were answered negative by DLI. In the said proposal form which was duly filled up and signed by the DLI clearly had a provision for a declaration at step 10 of the proposal form by the DLI wherein it was stated by the DLI that if after the issuance of the policy, it is found that the statement, answers or particulars stated in the proposal form and it’s questionnaire are incorrect or untrue, the insurance company shall incur no liability under the insurance. Thus, based on the information, declaration and believing the same to be true and also upon receipt of the duly filled form along with the initial premium of Rs.20,000/-, the opposite parties issued the policy bearing No.U160513686 commencement date of 9.12.2010 to the deceased policyholder. Thereafter, policy documents along with schedule were sent to the deceased policyholder, which was duly delivered to the address of the deceased policy holder.   

            That thereafter on 9.8.2011, the opposite party received death claim intimation along with the death claim (claimant’s statement), proof of death (physician’s statement) and death certificate, they were given to understand that the deceased policy holder suddenly died on 18.6.2011 due to fever. That upon receipt of the death claim by the opposite party and as per the terms and conditions conducted the investigation for the said claim. That in the meanwhile during the investigation, the opposite parties vide letter dt.30.11.2011, 7.12.2011 and 14.12.2011 requested the following documents for both the policies in order to proceed further:- (1) Treatment papers of Sri Hasitha Gastroenterology, Dr. Uma Kanth and (2) Complete treatment records of Chronic Liver Disease. It is submitted that during the course of the investigation, it was established that the DLI under treatment for Non Insulin Dependent Diabetes Mellitus, Hypertension and Stroke (Cerebrovascular accident) prior to filing of the application. It is further submitted that during the investigation, it was also found that the DLI was suffering from Hepatitis related Liver Disorder since 3 years, which was prior to the signing of the application. It is pertinent to note that the DLI was admitted to Life Emergency Hospital on 17.6.2011, wherein after the observation, it was stated that the said case id of Hepatitis B, Decompensate Chronic Liver Disease, Hepatic Encephalopathy Grade IV which itself speaks volume. It is important to note in the certificate issued by the Dr. E. Umakanth, it is stated that the DLI was brought to him on 17.6.2011 with the condition of Hepatitis. It is submitted before the Hon’ble Forum that with Non Insulin Dependent Diabetes Mellitus, Hypertension and Stroke (Cerebrovascular accident) cannot be considered has a normal disease, DLI was under an obligation to disclose the said material medical details in the proposal form, which was necessary to answered for the purpose determining the risk under the said policy were intentionally answered in negative by DLI. It is submitted that the said policy was obtained by suppression and mis-representation of facts. Hence, there is no deficiency of service on the part of the opposite parties and the complaint is liable to be dismissed with costs.

4.         Proof affidavits filed by the both sides. Exs.A1 to A13 have been marked on behalf of the complainant and Exs.B1 to B10 have been marked on behalf of the opposite parties. 

5.         In this matter, several adjournments were given to both the parties for arguments, finally, the matter was posted for arguments on condition, but both the parties did not appear before this Forum. Hence, this matter was posted for orders basing on the material available on the record.    

6.         The points that arise for consideration are:

      1) Whether there is any deficiency in service on the part of the opposite

     parties?

             2) Whether the complainant is entitled for the reliefs asked for?

             3) To what relief?

 

7. POINT No.1 & 2:-   Admitted facts of the complaint are that the complainant’s father obtained two insurance policies bearing Nos.U160507919 dt.24.11.2009 and  U160513686 dt.22.11.2010 from the opposite parties. The complainant is the nominee of those two policies. The complainant’s father was joined on 17.6.2011 in Life Emergency Hospital, Rajahmundry due to high temperature and died on 18.6.2011 and the death certificate is herewith filed vide Ex.A9. The opposite parties wrote a letter to the complainant for submission of documents vide Ex.A1 = B6. The opposite party wrote a letter vide Ex.A2, which they submitted that the claim made by the complainant is not a valid claim and also stated that their liability was limited to Rs.14,957.49ps i.e. payment of unit value and the time of intimation plus interest for delayed payment. In the same manner, they wrote another letter and also repudiated the claim for the second policy and also paid an amount of Rs.12,954.66ps as full and final settlement of the said policy vide Ex.A3. The complainant filed duplicate premium receipts vide Exs.A4, A5, A6 & A7 and also filed the statement which was issued by the opposite party to the life assured vide Ex.A8.  The complainant gave a reply for Ex.A1 to the opposite parties vide Ex.A10 in which he stated that his father never had any treatment with Sri Hasitha Gastroenterology Hospital, Rajahmundry and he also got issued a legal notice vide Ex.A11 to the opposite parties and the same was acknowledged by them vide Ex.A12. The Life Emergency Hospital, Rajahmundry gave a certificate with regard to the death of the life assured vide Ex.A13.

            The opposite parties denied the allegations of the complainant and herewith filed the applications made by the life assured with regard to taking the policies from the opposite parties vide Exs.B1 & B3 and also filed schedule of benefits and premiums vide Exs.B2 & B4. The complainant made a representation to the opposite parties along with death certificate, statement of bank account, household card and voter card vide Ex.B5. The opposite parties wrote a letter to the complainant for submission of documents vide Ex.B6 = A1. The opposite parties filed case sheet of Life Emergency Hospital and other medical record vide Ex.B7. They also enquired the Gastroenterologist by name Dr. E. Umakanth and questionnaire is herewith filed vide Ex.B8. The Dr. Umakanth gave a letter vide Ex.B9. The opposite parties sent the amounts as full and final settlement of the claim of the disputed two policies vide Ex.B10.

            The complainant contended that the opposite parties failed to settle the claim and paid Rs.14,957.49ps for one policy and Rs.12,954.66ps for second policy. The complainant has received the above said amounts without prejudice to his rights. The main contention of the complainant is that the opposite parties have to pay the insured sum as per the terms and conditions and they cannot repudiate the claim of the complainant.

The opposite parties contended that the claim made by the complainant was repudiated by them with a reason of misrepresentation of material facts by the deceased life insured at the time of making the proposal and also contended that there is no deficiency on their part. They further contended that non-disclosure of the material medical fact by the life assured is a sufficient ground for repudiation of the said policy. The life assured gone through the proposal form and answered the questionnaire negatively which was given by the opposite parties. The said questions were answered in negatively and the same are reproduced here.

Step 10		Health Details of Life Assured and Proposer	Reply
Q5		Have you ever had any of the following
	(a)	Stroke, epilepsy, fits recurrent headache, paralysis, faints or any other disease or disorder of the brain, spinal cord or nervous?	No
	(c)	Diabetes, thyroid disorders or any other hormone disorder?	No
	(f)	High blood pressure, palpitations, chest pain, raised cholesterol, heart attack or any other disorder of the heart or blood vessels?	No
Q7		In the last 5 years, have you attended any doctor or any other medical facility for investigation or diagnostic test (such as       X-rays, ultrasounds, CT scan, biopsy, ECG blood or urine etc)	No
Q8		Have you had any other illness, injury, operations or abnormality not mentioned under any question above which is recurrent or has symptoms persisting for more than 7 days?	No.

 

The answers stated in the proposal form and questionnaire is incorrect or untrue with any respect and the insurance company shall incur no liability under the insurance. The opposite parties made an enquiry with regard to the health condition of the deceased life insured and filed Exs.B7 & B8 before this Forum. The opposite parties contended that when they investigated the case of the deceased life insured in which they found that the complainant’s father was suffering from hepatitis related disorder since three years, which was prior to the signing of the application.  They also contended that when the deceased life insured was admitted in Life Emergency Hospital on 17.6.2011, they observed that the said case is of Hepatitis B, Decompensate chronic liver disease, Hepatic Encephalopathy Grade IV. They also filed a copy of questionnaire i.e. Ex.B8, in which Dr. Umakanth stated that the deceased life insured was taking treatment since three years and he also stated in Ex.B9 that the condition of DLI was suffering with Hepatitis.

            After perusing the material on record, it is clearly mentioned in Exs.B7, B8 & B9 that the deceased life insured was suffering from Hepatitis Liver disorder since 2009 i.e. prior taking of the disputed two policies. Dr. Umakant who is the treating doctor of the deceased life assured also informed the same to the opposite parties. As per the records, it is noted that the deceased life insured intentionally suppressed the facts and also misrepresented with regard to his health and answered the questions in the questionnaire negatively.

         The opposite parties relied on the following decisions:-

(1)  Supreme Court of India in the case of Satwant Kaur Sandhu Vs. New India Assurance Company Ltd. (2009) 8 SCC 316,

(2) Division Bench of Andhra Pradesh High Court in LIC of India Vs.                              B. Chandravathamma, AIR 1971 AP 41,

(3)   United India Insurance Co. Ltd., Vs. MKJ Corporation (1996) 6 SCC 428,

(4)  Supreme Court in Modern Insulators Ltd., Vs. Oriental Insurance Co. Ltd., (2000) 2 SCC 734,

(5)   LIC of India Vs. Sampat Devi III (2006) CPJ 32,

(6) V. Nalini Vs. LIC of India and Anr I (2008) CPJ 144 State Commission of Tamilnadu,

(7)  PC Chacko and Another Vs. Chairman, Life Insurance Corporation of India and others (2008) 1 SCC 321,

(8)  State of Punjab & Anr. Vs. Smt. Asha rani, III (2003) CPJ 172 (NC),

(9)  National Comission in LIC of India & Anr. Vs. Balbir Kaur I (2009) 212 (NC),

(10) Punjab State Commission in  LIC of India Vs. Smt. Piari Devi & Others, II (2008) CPJ 156 and

(11) Uttarkhand State Commission in LIC of India Vs. Radhika Devi, III (2008) CPJ 226.

After going through the above citations, they are very much applicable to the facts of the present case on hand.  The opposite parties sent two cheques to the complainant for Rs.12,954.66ps and Rs.14,957.49ps towards full and final payment under the two policies i.e. payment of unit value at the time of intimation plus interest for delayed payment.  

Basing on the above discussion, we opined that the deceased life insured suppressed material facts with regard to his health and obtained the policies from the opposite parties. Therefore, there is no locus standi to the complainant to claim the sum assured. As the deceased life insured misrepresentation of material facts with regard to his health and defraud the opposite parties. Basing on the facts and circumstances, we opined that there is no deficiency in service on the part of the opposite parties and the complainant is not entitled for any reliefs as he prayed for.

 

8.  POINT No.3:  In the result, the complaint is dismissed, without costs.

 

      Typed to my dictation, corrected and pronounced by us on this the 29^th day of June, 2015.

 

              Sd/-                                               Sd/-                                         Sd/-

           MEMBER                                   MEMBER                            PRESIDENT

 

 

APPENDIX OF EVIDENCE

                                                                   WITNESSES EXAMINED

 

FOR COMPLAINANT: None                                                                                  FOR OPPOSITE PARTIES: None

 

DOCUMENTS MARKED

 

FOR COMPLAINANT:

 

Ex.A1    Pending memo dt.7.12.2007 from the claim department of Tata AIG Life

  Insurance Company to the complainant.

Ex.A2    Policy rescinding letter dt.8.5.2012 from the Tata AIG Life Insurance Company

  Ltd., to the complainant.

Ex.A3    Policy rescinding letter dt.23.3.2012 from the Tata AIG Life Insurance Company

  Ltd., to the complainant.

Ex.A4    Premium deposit receipt dt.19.11.2009 paid by the complainant’s father in

  favour of opposite party.     

 

Ex.A5    Premium deposit receipt dt.22.11.2010 paid by the complainant’s father in

  favour of the opposite party.

Ex.A6    Premium deposit receipt dt.24.5.2010 paid by the complainant’s father in favour

  of the opposite party.

Ex.A7    Premium deposit receipt dt.31.5.2011 paid by the complainant’s father in favour

  of the opposite party.

Ex.A8    Fund Activity statement dt.28.9.2011 got issued by the Tata AIG Life Insurance

  Company to the complainant’s father.

Ex.A9    Death certificate dt.21.6.2011 in favour of complainant’s father.

Ex.A10  Letter sent by the complainant to the Manager, Claim department, Tata AIG

  Insurance Company Ltd.

Ex.A11  Legal notice dt.18.4.2012 got issued by the complainant through his counsel to

  the opposite party.

Ex.A12  Acknowledgement card dt.26.4.2012 from the opposite party.

Ex.A13  Certificate issued by the Life Emergency Hospital, Rajahmundry.

 

 

FOR OPPOSITE PARTIES:

 

Ex.B1    Application submitted by the deceased N. Chakrapani to the Tata AIG Life

              Insurance Co. Ltd.

Ex.B2    Schedule of benefits and premiums.

Ex.B3    Application submitted by the deceased N. Chakrapani, to  the Tata AIG Life

              Insurance Co. Ltd.

Ex.B4    Schedule of benefits and premiums.

Ex.B5    Death certificate of N. Chakrapani, passbook, ration card, voter card, letter

              addressed by the complainant to Tata AIG Life Insurance Co. Ltd., Hyderabad,

              letter addressed by the complainant to the Tata AIG Life Insurance co. Ltd.,

              Mumbai.

Ex.B6    Letter from Tata AIG Insurance Company, Mumbai to the complainant.

Ex.B7    Case sheet of deceased N. Chakrapani issued by Life Emergency Hospital,

  Rajahmundry.

Ex.B8    Questionnaire for interviewing medical attendant Dr. E. Umakanth.

Ex.B9    Certificate issued by Dr. E. Umakanth, Sri Hasitha Gastroenterology,

  Rajahmundry.

Ex.B10  Letters from Tata AIG Life Insurance Company, Mumbai to the complainant.

            Sd/-                                           Sd/-                                                  Sd/-

      MEMBER                                   MEMBER                                 PRESIDENT