BEFORE THE DISTRICT CONSUMER

       DISPUTES REDRESSAL FORUM, BAGALKOT.

COMPLAINT NO.  49/2017
DATE OF FILING: 06/06/2017

                           Date: 06^th day of March, 2018

   P r e  s e n t: 

01) Smt.Sharada.K.                                                    President…

     B.A.LL.B. (Spl) 

02) Smt. Sumangala.C.Hadli.                         Lady   Member…

                            B.A (Music)

                V/s

JUDGEMENT DELIVERED BY SMT.SHARADA.K., PRESIDENT

The Complainant has filed this complaint against the Opposite Party (herein after referred in short as OP) u/sec.12 of Consumer protection Act, 1986.

2.   Brief facts of the case are as follows:

       The complainant filed this complaint against the OP’s alleging that the complainant’s mother Sulochana W/o Shidramappa Karigar was purchased a life insurance policy product name SBI Life Shubh Nivesh it is whole life plan bearing No. 35029031206 on 30/10/2012 a quarterly premium Rs.16,800/- approximately had been paid regularly till her death a total sum of Rs.2,65,600/- had been paid unfortunately Sulochana (Complainant’s mother) died at Bilagi due to head injury on 30/09/2016 at her residence she fallen in the bathroom she had taken the treatment for 3 to 4 months as an indoor patient but treatment has been failed she died on the above said date.

Further, complainant submits that this accident had been intimated to the both the OP’s and their investigation officer visited the house of complainant and received the original policy bond and receipts along with medical reports on 19/10/2016 on that day they had taken the signature of the complainant on claim form as well as in some blank papers and assured that a sum of assured amount Rs.6,00,000/- reach to her as early as possible.  On 30/01/2017 OP No.1 and 2 issued the letter with final settlement of claim by paying Rs. 87,555/- and further OP stated in their letter in case of not satisfied with above decision and feel that you have not considered any particular fact you may send your representation for reconsideration of your claim to our claim review committee and this statement itself shows that OP’s are partly repudiated the claim of complainant.

Further complainant submits a that the deceased Sulochana i.e. Mother of the complainant had paid all the installment from 30/10/2012 to 30/09/2016 and paid an amount of Rs.2,65,600/- and the sum assured in Rs.6,00,000/-. Hence complainant issued the legal notice through his counsel on 19/04/2017 the legal notices was served to OP’s and OP’s replied the said notice and refused to pay the remaining amount, hence complainant prayed to order against the OP on sum assured of Rs.6,00,000/- along with 18 % interest till realization and further complainant prays to other reliefs against the OP’s.

3.      After receipt of notice, the OP-Counsel present before the Forum and filed Written Version of Ops.

        Written Version of OPs is as hereunder:

          The OP submits that the deceased Sulochana had purchased a policy with them and the term under the policy was of 15 years its commencement as 27/10/2012 a sum assured is Rs.6,00,000/- but the renewal premium due under the policy was on 27/04/2015 and the same was not received within the grace period and so the policy got lapsed further OP submits that for reviewing the policy the life assured should pay the un paid premium and interest along with a good health declaration confirming that she should not suffer from any illness or critical illness. But deceased Sulochana does not reveal correct information and subsequently the insurer comes to know about the suppression of the material fact.

          Further OP submits that on 28/10/2015 OP’s received a request for the revival of the policy along with a good health declaration and paid Rs.44,804/- towards the arrears of the premiums. Accordingly the said policy was revived based on the declaration of Good Health. The OP submits that based on the declaration the policy was revived in a good faith that on 30/09/2016 OP’s got information that insured Smt.Sulochana was expired.  So that the claim had been forwarded in the investigation in reveals that the deceased was suffering from Cancer and was under treatment for the same prayer to the date of revival of the policy but she did not disclose the same, the deceased had paid total 16 quarterly premium including the initial premium and total premium amount received under the policy was Rs.2,37,054/- and further submits that the claim was repudiated as per the terms and condition of the policy OP’s had refunded the amount of Rs.87,555/- by transferring to the account of the complainant as per the amended insurance law. The documents has been furnished to prove their case and prayed to dismiss the case with cost.

4.     The complainant has filed his chief affidavit along with 7 photo copy of the document, behalf of the complainant. The documents are as follows:

List of Documents

1. Photo copy of SBI Life insurance policy,

2. Photo copy of Endorsement,

3. Photo copy of Death certificate,

4. Photo copy of Legal heirs,

5. Photo copy of Aadhar Card,

6. Photo copy of Legal Notice,

7. Reply Notice.

5.      On the other hand OP’s filed their Chief affidavit along with the documents and the documents are as follows:

 List of Documents

Annexure-A : Copy of the Proposal Form,

Annexure-B : Copy of the Policy document,

Annexure-C : Copy of declaration of Good Health,

Annexure-D : Copy of the Revival letter,

Annexure-E : Copy of the Investigation report,

Annexure-F : Copy of the e-mail communication from

    Investigator,

          Annexure-G : Copy of CT Scan report dated 06/03/2013.

          Annexure-H : Copy of the Treatment papers dated 06/04/2013

          Annexure-I :  Copy of report dated 10/04/2013,

          Annexure-J :  Copy of the Preauthorization request for cashless

                                       hospitalization form.

          Annexure-K : Copy of the Histopathology report dated

                                      15/08/2013,

          Annexure-L : Copy of the Surgery discharge summary dated

                                      21/08/2013,

          Annexure-M : Copy of the Chemotherapy discharge summary

                                      Dated 01/10/2013,

          Annexure-N : Copy of the Chemotherapy discharge summary

                                      Dated 21/10/2013,

          Annexure-O : Copy of the Claim repudiation letter,

          Annexure-P : Copies of the Legal notice and Reply sent,

          Annexure-P : Copies of the Claim forms submitted

                                      by the complainant,

            6.      On the basis of above said pleading, oral and documentary evidence, the following points arises for adjudication are as follows:

1. Whether the complainant has proves that OP’s made deficiency in service?
2. Whether the complainant is entitled for relief?
3. What order?

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

Point No.1- Affirmative,

Point No.2- Partly Affirmative,

Point No.3- As per final order.

R E A S O N S

8. POINT NO.1 AND 2: In order to prove the deficiency in service on part of OP’s the complainant filed his affidavit evidence and retreated the facts of the case and claim of relief and compensation as stated in the complaint, it is the undisputed fact during the life time mother of the complainant had insured her life with OP’s on 30/10/2012 for Rs.6,00,000/- and subsequently she died on 30/09/2016 at her home.  But it’s the contention of OP’s that since the insured died within 1 year of revival i.e., The policy had been revised on 28/10/2015 complainant’s mother died on 30/09/2016 the insured guy died within short period after revival, the investigation U/s. 45 of Insurance Act, was done and it was revealed that deceased was suffering from cancer and was under treatment for the same prior to the date of revival of the policy but she did not disclose the same in proposal form submitted by insured and therefore claim is repudiated due to breach of policy.

On going through the records on the file complainant produced a letter from the Assistant Director of Social Welfare department, Vijayapur.  Furnishing the details that Smt. Sulochana (Insured) was working as a Asst. Cook at Anganwadi in Bilagi. She never took any medical leave during her service time till death but on the other hand OP filed an investigation report done by their investigator and filed the Hospitals report of Belgaum those reports which are not satisfied by any doctors or else it has not been attested by the any attested officer OP No.1 put the seal on those documents but OP’s not came forward to prove the same. In this case the burden is open the OP to prove that the insured had suppressed the material fact in the proposal form. The Hon’ble Supreme Court of India in the decision report in III (2012 CPJ 5(SC) (LIC of India V/s. Asha Goel and Another) had held in Para 12 that the burden of proof is on the insurer to establish that insured has suppressed the material fact prudently it was known to her at the time of revival.  It is further held that unless insurer is able to prove the same there is no question of repudiation of the claim u such ground. In another decision reported in IV (2011 CPJ 6 (SC) (P.Venkata Naidu V/s. LIC of India) the Hon’ble Supreme Court has held that insurance company has to be produced tangible and cogent evidence to prove that the deceased with held information about illness, hospitalization and treatment of insured.

In this case OP has not examined any combative doctor to say that the deceased Sulochana was suffering from cancer. The records produced by the OP it says that the Sulochana was admitted as an indoor patient in the cancer hospital Dharwad. In the summary report of the hospital produced by the OP in the summary report there is an thumb impression found but while arguing on the matter the advocate for complainant submits that the insured was well known to sign her signature but in the hospital record there was a thumb impression of the patient had been shown, while scanning on those record forum observe that in that document the signature of the doctor is not visible and while going through the record which had been filed by OP itself the declaration of good health they said Sulachana was signed in the paper in the year 2015 October.  The age has been mentioned in this record is 53 years where as the patient age had been mentioned 61 years in 2013 itself. Such being the fact these document cannot be considered moreover, OP is utterly failed to prove the defence with cogent evidence.

Moreover OP had not denied or even not filed any document to prove that the death deceased Sulochana (Insured) was died due to cancer. Hence it can be held that insurance Company has filed to establish that assured died due to cancer. The Act of repudiation of claim by the OP amounts to deficiency in service, the complainant is entitled for assured amount of Rs.6,00,000/- from the OP’s and further OP’s are liable to pay the said amount along with Rs.2,000/- towards mental agony and harassment and Rs.1,000/- towards cost of the litigation. Accordingly we answer point No.1 in affirmative and point No.2 partly in affirmative.

9.      POINT NO:3: For the reasons and discussion made above and finding on the above points,  we proceed to pass the following:

O R D E R

     Complainant’s complaint is allowed in part as follows;

1. The Op’s are directed to pay policy assured amount of Rs.6,00,000/- (Six Lakh Rupees) to the complainant deducting the paid amount of Rs.87,555/- with interest @ 7% per annum from the date of repudiation of the claim.

2.  Further Op’s are directed to pay Rs.2,000/- (Rupees two thousand) towards compensation and Rs.1,000/- (One thousand rupees) towards cost.

3.  The Ops are directed to pay the said amount within 45 days from the date of receipt of the copy of order failing which OP’s are liable to pay 12% interest on Rs.5,12,445/- till realization.
4.  Free copy of this order shall be sent to the parties immediately.

           (Dictated to the Stenographer directly on computer corrected by me and then pronounced in the open Forum on this 6^th day of March, 2018).