Telangana

Khammam

CC/13/2017

Chimata Ramana,alias Ramanamma,alias Inumula Ramana, W/o. Chimata Pullaiah, Age 50 years, Occu Coolie, H.No.2-36, Singhabupalem, Kothagudem Mandal, Khammam District - Complainant(s)

Versus

The Manager, Exide Life Insurance Company Limited, Kothagudem Town, Bhadradri Kothagudem District an - Opp.Party(s)

Sri.A.Ravindra

24 Apr 2018

ORDER

BEFORE THE DISTRICT CONSUMER FORUM AT KHAMMAM

Dated this, the 24^th day of April,2018

                   CORAM:       1. Sri. P. Madhav Raja, _{B.Sc., M.Li.Sc. LL.M.,}– President

                   2. Sri.Kiran Kumar_{, B.Sc., LL.M.} – Member

                               C.C. No.13/2017

Between                              

Chimata  Ramana @ Ramanamma @ Inumula Ramana,

W/o. Chimata Pullaiah, Age: 50 years,

Occu: Coolie, R/o. H.No.2-36,

Singhabupalem, Kothagudem Mandal,

Khammam District.                                                   …Complainant

                

And

 

1. The Manager,

Exide Life Insurance Company Limited,

Kothagudem Town,

Bhadradri Kothagudem District.

 

2. The Manager,

The Claims Review Committee,

Exide Life Insurance Company Limited,

1^st Floor, Gold Hills, Square, No.690,

Houser Road, Begur Hubli, Bangalore,

Karnataka State – 560 068.                         …Opposite parties

 

 

        This C.C. is coming before us for hearing in the presence of Sri.Aitham Ravindra, Advocate for complainant; and of Sri. Kancharla Vijay Kumar, Advocate for Opposite Party No.1 & 2; upon perusing the material papers on record; upon hearing arguments and having stood over for consideration, this Forum passed the following:-

          

ORDER

(Per Sri P. Madhav Raja, President)

 

          This complaint is filed under section 12(1) of the Consumer Protection Act, 1986. 

 

1.      The set of brief facts in the complaint are that the complainant is the wife and nominee of Chimata Pullaiah. On 10-09-2014 he had obtained the policy bearing No.02976335 by paying premium amount of Rs.12,600/- from the Office of Opposite Party No.1 at Kothagudem, for sum assured amount of Rs.1,00,500/-.  On 01-10-2014 the husband of the complainant Chimata Pullaiah got a snake bite on his right leg ankle during his agricultural operations at the distance of 2 Kilo meters from his residence at about 6.00 A.M. on his cries neighboring land owner Gugulothu Veeraiah approached him and informed the same to his sons on telephone. Immediately after that they shifted the Pullaiah to the Government Area Hospital, Kothagudem wherein the duty Doctors attended, examined him and informed that the Chimata Pullaiah died due to snake bite. The complainant approached the Opposite Party No.1 and submitted the claim form to settle the claim of the said policy.  The Opposite Party No.2 through letter dt:31-12-2014 informed the complainant that they have repudiated the claim on the ground of suppression of material facts that the Chimata Pullaiah died due to Milliary Pulmonary Tuberculosis.  Thereafter the complainant requested the Insurance Ombudsmen through letter              dt:02-03-2015 for settlement of the said claim and the Insurance Ombudsman of A.P., Telangana and Yanam at Hyderabad sought (1) copy of representation made to Grievance Cell, (2) Rejection letter of the company received from its Grievance Cell (3) Policy copy (4)Correspondence exchanged with insurance company, upon which on 06-04-2015 the complainant with covering letter send all the said documents. The complainant further addressed a letter with Claims Review Committee of Opposite Parties at Bangalore to settle the matter but the Opposite Parties have not settled the matter and not paid any amount.  Aggrieving on the acts of Opposite Parties, the complainant approached this Forum seeking the relief for the insured amount of Rs.1,00,500/- and Raiders sum assured of Rs.1,00,000/- and other benefits as per policy from the Opposite Parties and Rs.1,00,000/- towards mental agony and interest  accrued @12% p.a. from the date of death of Chimata Pullaiah. 

 

 2.      In support of her case, the complainant filed Affidavit and documents, which are marked as Exhibits A-1 to A-9.

 

1)      Ex.A-1 is the Photocopy of Exide Life Insurance Cover Note addressed by

Opposite Party No.1, dt:10-09-2014.

2)       Ex.A-2 is the original Medical Certificate of cause of death in Form No.4

dt:01-10-2014.

3)      Ex.A-3 is the original Death Report issued by Medical Superintendent of 

Government Area Hospital, Kothagudem, dt:01-10-2014.

 

4)      Ex.A-4 is the Photocopy of Repudiation letter addressed by the Opposite

Party No.1 to the complainant, dt:31-12-2014.

5)      Ex.A-5 is the original letter from Complainant to Insurance Ombudsmen    

dt:02-03-2015.

6)      Ex.A-6 is the original letter of Insurance Ombudsmen dt:24-03-2015.

7)      Ex.A-7 is the original letter of Insurance Ombudsmen dt:09-04-2015.

8)      Ex.A-8 is the original letter to Insurance Ombudsmen dt:06-04-2015.

9)      Ex.A-9 is the original letter addressed to the Claims Review Committee,

Exide Life Insurance Company Ltd., dt:30-05-2015 along with (2) Postal Receipts.

 

3.       On receipt of notice, the Opposite Party No.1 & 2 appeared through their counsel, filed Counter/Written Version, Affidavits and denied the contentions of the complainant. Further the Opposite Parties stated that the Policy bearing No.02976335 was obtained by the deceased on 10-09-2014 for sum assured amount of Rs.1,00,500/- and rider sum assured of Rs.1,00,000/- and policy term was for (44) years with policy paying term for (16) years. The Opposite Parties had sent policy document with policy terms and conditions and a letter stating provision of cancellation of the policy within (15) days and the life assured retained the policy documents and did not approach the company with any discrepancies regarding policy terms and conditions. As per the Section 24(A) of Consumer Protection Act provides limitation period of (2) years to file any complaint from the date of cause of action, but this present complaint is filed in March,2017, which is after expiry of limitation period and complaint is barred by limitation. The opposite parties further contended that the contract of Insurance is a contract based on uberrimaefidei i.e. Utmost Good Faith, in the present case the deceased life assured suppressed the material facts that he was suffering from Miliary Pulmonary Tuberculosis with COPD and severe Breathlessness and have taken treatment for the same prior to proposal date, which amounts to suppression of material fact. The Opposite Parties have relayed on the following Citations:

1)      Life Insurance Corporation of India  and Others  Vs Smt.Asha Goel and Anr, (2001) ACJ 806.

2)      P.C. Chako and Anr Vs Chairman, Life Insurance Corporation of India and Ors., AIR, 2008 of Supreme Court-424.

3)      TATA AIG Life Insurance Co.Ltd Vs Orissa State Cooperative Bank and Anr (2012) CPJ 310(NC).

         

As the life assured died on 01-10-2014 and it was occurred within (20) days from the commencement of the subject policy, the Opposite Parties have rejected the claim of the said policy vide letter dt: 31-12-2014 and have conducted detailed investigation. On filing RTI sought information from the Medical Superintendent Area Hospital, Kothagudem, Khammam regarding treatment taken by the deceased life assured and received reply on 24-11-2014 that Chimata Pullaiah i.e. life assured was admitted in Government Area Hospital on 28-08-2014 at 1.30 P.M. with I.P.No.11736 and was diagnosed Miliary Tuberculosis with COPD and left with medical advice on 30-08-2014.  That the suppression of material facts becomes clear on a bare perusal of the proposal form and the answers related to the health of the life assured on question No.70,71,75 & 77 have been proven falsified and the said material fact was suppressed by the life assured at the time of procuring the policy. That the question as to existing prior medical condition as specifically asked in proposal form and status thereof directing the nexus with the life assured are material for under writing the risk on the life of the life assured.  Further it is not necessary that there should be some nexus between the cause of death and the deceased suppressed as it will defy the whole purpose of Uberrimaefidei, for which the Opposite Parties have relayed on the judgment passed by the Hon’ble National Commission in Revision Petition No.1061 of 2011, LIC of India and Others Vs Ramamani Patra and Anr.   Hence as per the principles of Section 45 of Insurance Act the contract of insurance is null and void between the parties, and the present complaint is a gross abuse of process of Law. It is submitted that the complainant has acted in bad faith with respect to subject of complaint and approached the Hon’ble Forum with unclean hand and failed to set up the nexus between the damages suffered by the complainant.  The damages claimed are arbitrary without any basis. The complaint being a frivolous and vexatious and the complainant has failed to make out deficiency of service.  Hence the complaint is dismissed with exemplary costs.

 

4. In support of their case, the Opposite Parties No.1 & 2 filed their Affidavits and documents, which are marked as Exhibits B-1 to B-7.

Ex.B-1 is the photocopy of Proposal Form of the deceased dt:10-09-2014.     

Ex.B-2 is the photocopy of letter of Opposite Parties dt:16-09-2014.

Ex.B-3 is the photocopy of Death Intimation cum Claim Form, dt:18-11-2014.

Ex.B-4 is the photocopy of Death Certificate in Form-6 issued by Gram

  Panchayat Secretary, Singabupalem.

Ex.B-5 is the Photocopy of letter of Opposite Parties dt:31-12-2014.

Ex.B-6 is the photocopy of Death Report by Medical Superintendent,

  Government Area Hospital, Kothagudem.

Ex.B-7 is the photo copy of letter of Medical Superintendent, Government   Area

  Hospital, Kothagudem dt:24-12-2014.

 

5.      Both parties filed written arguments and heard oral arguments from both sides.

 

6.      Upon perusing the material papers on record, now the point that arose for consideration is,

1) Whether the complaint is barred by the limitation

2) Whether the complainant is entitled for the claim?

3) To what relief?

 

Point No.1 :- According the material and records it is admitted fact that the diseased Chimata Pullaiah on 10-09-2014 had obtained the insurance policy No.02976335 by paying premium amount of Rs.12,600/ from the Office of Opposite Party No.1 at Kothagudem, for sum assured amount of Rs.1,00,500/-.  On 01-10-2014 the husband of the complainant Chimata Pullaiah died. Being nominee the complainant approached the Opposite Party No.1 and submitted the claim form to settle the claim of the said policy.  The Opposite Party No.2 through letter dt:31-12-2014 informed the complainant that they have repudiated the claim on the ground of suppression of material facts that the Chimata Pullaiah died of Milliary Pulmonary Tuberculosis.  Thereafter the complainant requested through letter dt:02-03-2015 i.e. Ex.A-5 the Insurance Ombudsmen for settlement of the said claim and the Insurance Ombudsman of A.P, Telangana and Yanam at Hyderabad sought (1) copy of representation made to Grievance Cell (2) Rejection letter of the company received from its Grievance Cell (3) Policy copy (4) Correspondence exchanged with insurance company, upon which on 06-04-2015 i.e.Ex.A.8 the complainant with covering letter send all the said documents. The complainant further addressed a letter on 30-05-2015 i.e.Ex.A.9 to Claims Review Committee of Opposite Parties at Bangalore to settle the matter. These all correspondences shows the continue cause of action. As per Sec.3 of Indian consumer Protection Act 1986 The Act is not derogatory to any act but supportive,  therefore the correspondence made to the Ombudsman and  the Opposite party number.2 review committee saves the limitation and continues the cause of action. Therefore the point is answered accordingly.

 

 Points 2 and 3:- The opposite parties have contended that the life assured died on 01-10-2014 and it was occurred within 20 days from the commencement of the subject policy. The Opposite Parties have rejected the claim of the said policy vide letter dt: 31-12-2014 and have conducted detailed investigation. Through RTI filing sought information from the Medical Superintendent Area Hospital, Kothagudem, Khammam regarding treatment taken by the life assured and received reply on 24-11-2014 that Chimata Pullaiah i.e. life assured was admitted in Government Area Hospital on 28-08-2014 at 1.30 P.M. with I.P.No.11736 and was diagnosed for Milary Tuberculosis with COPD and left with medical advice on 30-08-2014 i.e. (Ex.B.7). That the suppression of material facts becomes clear on a bare perusal of the proposal form and the answers related to the health of the life assured on question No.70,71,75 & 77 have been proven falsified and the said material fact was suppressed by the life assured at the time of procuring the policy. That the question as to existing prior medical condition as specifically asked in proposal form and status thereof directing the nexus with the life assured are material for under writing the risk on the life of the life assured but the Ex.A.7 is a photocopy obtained by the investigating agency through RTI petition which does not have any office seal. The Hon’ble National Commission observed in Birla Sun life Insurance co. Ltd V/s Aravind Kumar , I Part-2 ( 2018 ) CPJ.301p.N.C that

           // Suppression of mere existing disease- complaint not barred. It was obligatory for insurer to either produce doctor who allegedly treated him in hospital or to file his affidavit – alternatively, It could have examined an official of hospital to prove authenticity of photocopies which petitioner company filed in support of his case. In absence of such evidence mere production of some un attested  un verified and un authenticated  photocopies  could not have been basis if holding that the deceased  was alcoholic  and diagnosed  with alcohol lever disease and it’s complication- Repudiation  not justified. //

 

 

             The opposite parties mandatory rule is that the insurer will be examined the proposer by the agent or by any of their official and panel doctors before the commencing the policy and in the proposal form they will endorse their consent for acceptance but in the proposed form i.e. Ex.B-1 no authenticity and even the proposed signature column is in blank and only part of the proposal form has filed and was filled in English, nowhere it was mentioned whether the insured is literate and able to read and write English  and  also the opposite parties have not explained that by whom it was filled. The proposal form seems to be not in correct manner and the opposite parties are utterly failed to perform the duties while offering the policy. It is evident through Ex.A.2 and Ex.A.3 that the policy holder was admitted for snake bite in the Area hospital at Kothagudem and died due to snake bite which was an accident and there is no nexus with the said Milary Tuberculosis with COPD. The Hon’ble A.P. SCDRC at Hyderabad in FA 528 of 2011 against CC 69/2009, Dist. Forum, Adilabad  between: 1) LIC of India V/s Smt. K. Aruna @ Kummari Aruna held that there must be proximity and nexus between the suppressed material fact with cause of death.

 

In this case the cause of death is snake bite and suppression of material fact is shown as Milary Tuberculosis with COPD and  the opposite parties have done  acted properly with at most care neglecting the principle of Good Faith and also failed to establish their contentions with correct evidences.  Relaying on the above citations of the Hon’ble commissions we holds that the insured has not made any mistake and there is no nexus to the cause shown by the opposite parties. The snake bite is purely an accident, therefore we opined that the complainant is liable to get the claim amount as claimed by the complainant from the opposite parties and the point is answered accordingly.

 

 

7.      In the result the complaint is allowed directing the Opposite party Nos.1 and 2 to Pay Rs.1,00,500/- towards insurance amount and Rs.1,00,000/- towards Riders sum assured thus totally Rs.2,00,500/- (Rupees Two lakh five hundred only) with interest @ 9% P.A. from the date of the repudiation i.e.         31-12-2014 and further directed to pay Rs.2,000/- (Rupees Two thousand only) to the complainant towards costs within a month from the date of receipt of this order.

 

(Dictated to the Stenographer, transcribed by her, corrected and pronounced by us in the open forum, on this the 24^th day of April, 2018).

                                                                                       

 

 

                                               

         Member                             President

                                              District Consumer Forum, Khammam.

 

 

APPENDIX OF EVIDENCE

WITNESSES EXAMINED:-

 

For Complainant                                                    For Opposite parties  

       None                                                                          None

DOCUMENTS MARKED:-

 

For Complainant                                                    For Opposite parties

   

Ex.A1:-	is the Photocopy of Exide Life Insurance Cover Note addressed by Opposite Party No.1, dt:10-09-2014.	Ex.B1:-	is the photocopy of Proposal Form of the deceased dt:10-09-2014.
Ex.A2:-	is the original Medical Certificate of cause of death in Form No.4,                   dt:01-10-2014.	Ex.B2:-	is the photocopy of letter           of Opposite Parties          dt:16-09-2014
Ex.A3:-	is the original Death Report issued by Medical Superintendent of Government Area Hospital, Kothagudem,                   dt:01-10-2014.	Ex.B3:-	is the photocopy of Death Intimation cum Claim Form, dt:18-11-2014.
Ex.A4:-	is the Photocopy of Repudiation letter addressed by the Opposite Party No.1 to the complainant,             dt:31-12-2014.	Ex.B4:-	is the photocopy of Death Certificate in Form-6 issued by Gram Panchayat Secretary, Singabupalem.
Ex.A5:	is the original letter            from Complainant to Insurance Ombudsmen dt:02-03-2015.	Ex.B5:-	is the Photocopy of letter of Opposite Parties             dt:31-12-2014.
Ex.A6:-	is the original letter of Insurance Ombudsmen dt:24-03-2015.	Ex.B6:-	is the photocopy of               Death Report by Medical Superintendent, Govt. Area Hospital, Kothagudem.
Ex.A7:-	is the original letter of Insurance Ombudsmen dt:09-04-2015.	Ex.B7	is the photo copy of letter of Medical Superintendent, Government   Area   Hospital, Kothagudem dt:24-12-2014
Ex.A8:-	is the original letter to Insurance Ombudsmen dt:06-04-2015.
Ex.A9:-	is the original letter addressed to the Claims Review Committee, Exide Life Insurance Company Ltd., dt:30-05-2015 along with (2) Postal Receipts.

                                               

   

         Member                             President

                                              District Consumer Forum, Khammam.