DISTRICT CONSUMER DISPUTES REDRESSAL FORUM  PALAKKAD

Dated this the  21^st  day of March  2016

Present   : Smt.Shiny.P.R. President

               : Smt.Suma.K.P.  Member                                  Date of filing: 18/12/2014

               : Sri.V.P.Ananatha Narayanan, Member

                                                      (C.C.No.202/2014)       

Valsalakumari,

W/o.Late Krishnadas,

7/284/2, Krishna,

Harisankar Road, Tharekkad,

Palakkad, Kerala                                                   -        Complainant

(By AdvA.K.Sundareaswaran) 

Vs

1.The Manager,

    M/s.ICICI Prudential  Insurance Co.Ltd.

    ICICI Prulife Towers, 1089 Appasahib-

    Marathe Marg, Prabhadevi, Mumbai – 400 025

(By Adv.M.R.Manikandan)

2.The Manager,

    M/s.ICICI Prudential Insurance Co.Ltd.

    Soorya Buildings, Palakkad Kerala                         -        opposite parties

O R D E R

By Smt.Shiny.P.R.  President.

Brief facts of complaint.

 Complainant’s husband Krishnadas joined one life insurance policy bearing number 15187164 under Prudential Life Stage Wealth II (Unique identification No.105 L118 Vo. 1) through the agent of 2^nd  opposite party. The sum assured was Rs.3,50,000/-and annual premium was Rs.50,000/-  for a continuous  period of five years and the complainant’s husband had paid the 1^st           and 2^nd  installments  of  Rs.50,000/-each in the year 2012. Subsequently the husband of complainant died on 22/09/2012 and the complainant and other legal heirs of the deceased made an application before the 1^st  opposite party on 29/10/2012 alongwith original policy certificate, death certificate and other papers. On 29/12/2012 the opposite parties made a reply to the complainant repudiating the claim on the ground of ‘suppression of material information’. Thereafter the complainant made another application before the 1^st  opposite party on 28/2/2013 as required under Rule 13(3) of redressal of parties grievance Rules 1998, and on reply dated 18/3/2013 the opposite parties repeated and asserted their earlier stance and directed the complainant  to approach insurance ombudsman if the complainant is not satisfied with the reply. Then complainant approached Insurance Ombudsman and filed a complaint on 24/5/2013. Insurance Ombudsman received the complaint and passed an award on 27/10/2014 without hearing and not considering any of the documents filed by the complainant.

The policy holder has not suppressed any material fact or information as alleged by the opposite parties. Complainant submitted that withholding the policy amount entitled to the complainant by imposing unnecessary and illegal conditions unilaterally by the opposite parties are against the policy conditions and such acts amount to unhealthy trade practices. Hence complainant prays for an order directing the opposite parties to pay

a)policy amount of Rs.3,50,000/- alongwith 12% interest from the date of application made by the complainant.

b)a sum of Rs.50,000/- as compensation and

c)entire cost of the proceedings to the complainant.

Complaint was admitted and issued notice to opposite parties. After receiving the notice, 1^st opposite party   appeared before the Forum.   2^nd opposite party was absent and hence name called and set exparte.

1^st opposite party filed version contending the following:

Complainant has not come with clean hands. The complainant’s husband has concealed and suppressed material and relevant facts of the case. Complainant and her husband were guilty of concealment of true facts and has committed the breach of basic condition of insurance i.e. the principle of Uberrima Fide. The policy is a legal contract between the policy holder and the insurer company, based on the principle of good faith and is subject to the terms and conditions of the policy. Under the provisions of Section 45 of the Insurance Act, 1938 a Life Insurance Policy can be called in question on the ground of concealment of material facts within two years of commencement of the policy. The Life Assured died almost within 18 months from the date of commencement of the policy and the medical documents obtained by the company shows that the life assured was hospitalized on March 12, 2008 and was diagnosed of bipolar disorder and advised medication for the same. It was further noted that the life assured was suffering from systematic hypertension and diabetes mellitus type II since 2008.  Therefore the 1^st opposite party company has rightly repudiated the claim raised by the complainant on the ground of suppression of material facts. However, as a special case and gesture of goodwill GRC had decided to make an ex-gratia payment of Rs.94,709/- to the complainant. The same was intimated to the complainant vide letter dated March 18,2013. Hence there is no deficiency in service on the part of 1st  opposite party. Complaint being frivolous and vexatious is liable to be dismissed.

 Both parties filed their respective chief affidavits. Ext.A1 to A5 are marked from the side of the complainant. Exts.B1 to B6 are marked from the side of the 1^st  opposite party.  

The following issues are considered

1.Whether there is deficiency in service on the part of opposite parties?

2.If so, what is the relief?

Issue 1& 2

 It is an admitted fact that life assured was died within 18 months from the date of issuance of policy. As per Ext B5 medical records from Amritha Institute Of Medical Science And Research Centre on 12-4-2008 deceased- life assured i.e.  husband of complainant was admitted in hospital for the treatment of Bipolar Affective Disorder (mania), Systemic Hypertension and Type 2 Diabetes Mellitus. On 3-2-2011 he was again admitted in the same hospital for the treatment of right inguinal hernia. Life assured has taken policy on 7-3-2011 without disclosing the actual health condition from the 1^st  opposite party i.e. after one month from the date of discharge from the hospital. He miserably suppressed material facts at the time of taking of the policy. It cannot be said that it was not within his knowledge when he took policy. He withheld this vital information deliberately from the 1^st  opposite party. Insurance is a contract requiring a person disclose all material facts in response to questions mentioned in proposal form.  Contract of insurance is based on utmost good faith. Deceased-life assured has given wrong answers about previous treatment in proposal forms. 1^st  opposite party established the suppression of material facts by producing Ext.B5 medical record before the forum. 

1^st  opposite party submitted in their version and affidavit that by treating the claim of the complainant as a special case and gesture of goodwill, GRC had decided to make an ex-gratia payment of Rs.94,709/- to the complainant. These facts are willfully concealed from the complaint by the complainant.  Ext.B6 letter revealed that the 1^st opposite party was ready to pay Rs.94,709/- to the complainant. 

In the above circumstances we cannot  attribute deficiency in service on the part of 1^st  opposite party. Since 1^st opposite party was ready to pay         Rs.94,709/- to the complainant, we partly allowed the complaint and direct 1^st  opposite party to pay a sum of Rs.94,709/- (Rupees Ninety four  thousand seven hundred and nine only) to the complainant within one month from the date of this order.  No order as to cost. 

Order shall be complied within a period of one month from the date of receipt of order, failing which complainant is eligible for 9% interest per annum for the whole amount from the date of order, till realization. 

Pronounced in the open court on this the 21^st  day of March  2016.

       Sd/-

                      Shiny.P.R.

                      President   

                            Sd/-

                      Suma.K.P.

                      Member

                         Sd/-

    V.P.Anantha Narayanan

                 Member

Appendix

Exhibits marked on the side of complainant

Ext.A1 –  Photocopy of application for issuance of Insurance Policy

Ext.A2  - Photocopy of death claim slip

Ext.A3  – Photocopy of reply sent by the opposite party dated 29/12/12

Ext.A4  – Photostat copy of representation by the complainant to the opposite

              party dated 28/2/2013.

Ext.A5 –  Photostat copy of reply sent by the opposite party dated 18/03/2013

Exhibits marked on the side of complainant

Ext.B1 – Photostat copy of policy proposal form

Ext.B2 – Photostat copy of policy terms and conditions

Ext.B3 – Photostat copy of claim intimation form

Ext.B4 – Photocopy of the hospitalization documents of life assured prior to

             issuance of policy

Ext.B5 – Photocopy of the claim repudiation letter dated 29/12/2012 issued by

             opposite party

Ext.B6 – Photocopy of letter dated 18/03/2013 issued by opposite party to the

             complainant

Cost   

No cost allowed

Forwarded/By Order,

Senior Superintendent