This case is coming for final hearing on 04-09-2014 in the presence of Sri G.A.Raju, Advocate for Complainant and Sri C.Syama Sundara Rao, Advocate for Opposite parties and having stood over till this date, the Forum delivered the following.                                                                                                                                                                                                                                                                                                                                                                                           

: O R D E R :

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

1. The present complaint is filed by the complainant on 30.01.2013 under C.P.Act against Opposite Parties 1 & 2 and requested the Forum (1) to direct the Opposite Parties to pay an amount of Rs.4,00,000/-for the 3 insurance policies in which she is the nominee (2) to pay an amount of Rs.20,000/- towards compensation for causing mental agony (3) to award costs (4) to grant any other relief or reliefs basing upon the circumstances of the case.

2. The version of the complainant is as follows: The Complainant is the wife of Sri Neelapu Prasad Reddy who has obtained three Insurance Policies viz (1) Policy No.695136650, dt. 28.06.2009 (which is an accident benefit policy for value of Rs.1,05,000/-) (2) Policy No.695894176 dated 2.7.2010 valued for Rs.95,000/- at maturity period (3) Policy No.692759768 dt.22.09.2010 for the policy amount of Rs.2,00,000/ at the time of maturity for all the three policies, the complainant is the nominee. The complainant requested the Opposite Parties for clearing of the Insurance Policies claim and as the Opposite Parties as required some medical attendance certificates of the complainant’s husband the same was submitted to the Opposite Parties by the Complainant. Thereafter the 1^st Opposite Party issued Notice dt. 27.09.2012 to the Complainant with false allegations. The complainant states that her husband is worked in BSNL office and as the Opposite Party did not file any objections to have the 3 policies from the Complainant’s husband now at the stage of the claiming the same, the Opposite Parties could not allege the complainant or could not deny the Insurance claim that it was not payable to the Complainant.  Finally the Complainant got issued Legal Notice to the Opposite Party on 5.1.2013 for claim  of the 3 Insurance policies for which she is entitled. The Opposite Parties received the same but kept quiet without any reply. Hence the Complainant filed the present complaint seeking the reliefs as sought for.

3. Notices were served to the Opposite Parties and as the Opposite Parties has not filed counter for three adjournments, treating no counter on part of Opposite Parties, the complaint is posted for complainant evidence. The Opposite party filed I.A 135/2013 along with the counter of the 2^nd Opposite Party. The said I.A. was allowed and the counter filed by the 2^nd Opposite Party was adopted by the 1^st Opposite Party vide adoption memo. Smt.Satyavathi in the capacity of the Manager on behalf of 2^nd Opposite Party filed Counter and stated as after the Opposite Party has received the claim form from the complainant and observing the record, the Opposite Party came to know that the Complainant’s husband was taking treatment for ill-health which was not disclosed at the time of taking 3 policies within a span of 1 ½ years. As per the Section 45 of Insurance Act, the policy will be null and void and nothing is payable as per declaration by the life assured, if there are mis-suppression of the facts. The contract of insurance is based on the utmost good faith known as uberrima fides as it is the duty of the assured to make full disclosure of the material facts to the Opposite Party at the time of taking policies. Having suffering with the ill-health and taking treatment, he has suppressed the said fact and obtained the policy and thereby complainant is not entitled for the claim of the insurance policies and the complaint filed by the complainant is liable to be dismissed with costs.

4. Observing the pleadings of both sides, the Forum framed :

   1. Whether there is any deficiency of service on the part of Opposite parties

   2. To what relief.

5. The complainant filed her Evidence Affidavit and on her behalf Ex.A1 to A10 were marked. The Opposite Party filed Evidence Affidavit and on behalf of Opposite Parties 1 & 2 Ex.B1 to B11 were marked. The complainant and the Opposite Parties field Written Arguments and receiving the Written Arguments of Opposite Parties, Complainant filed additional Written Arguments in support of his reliefs as sought for along with the Written Arguments. The Complainant has filed 3 case laws (1971) O AIR (AP) 41 ; 2005 (3) ALT 9 (CPA); (2000) 8 Supreme 521 & 2 pages of Law of Life Insurance Act 1938. The Opposite Party has not filed any case laws in support of their defense.

6. Point Nos.1 & 2: The complainant has filed the present complaint against the Opposite Parties for claiming the amount of Rs.4,00,000/- for 3 policies, as the Opposite parties has not cleared the Insurance claim. The Opposite Parties after receiving notice stated that the complainant has suppressed the actual facts of ill-health suffered by her husband and thereby suppressing the said facts, her husband has obtained the policies, so complainant is not entitled for the policy amounts.

7. < > is the copy of the Policy for Policy No. 695136650 in which the Complainant is the nominee. Ex.A2 is the copy of the Policy No. 695894176 in which Complainant is the nominee. Ex.A3 is the copy of the Policy No. 692759768 for value of Rs.2,00,000/- in which the Complainant is the nominee. Ex.A6 is the Death Certificate of the Complainant’s husband issued by the Registrar of Births and Deaths. Ex.A4 is the Family Member certificate issued by Tahsildar, Visakhapatnam (U) in which the Complainant is the wife of the insured in the 3 policies. Ex.A7 certificate of the employer discloses that the Complainant is on leave from 11.05.2009 to 10.06.2011 for 8 times. Ex.A8 is the medical attendance certificate, Claim statement and Certificate of Hospital treatment. The copy of the claim statement i.e. Ex.A8 reveals that Complainant’s husband died due to Heart-attack. Ex.A9 Certificate of employer for the Policy No.692759768 reveals that from 12.05.2009 to 10.06.2011 the Complainant is on leave for 8 times. In the said employers certificate it was mentioned as “YES”. In the column in case of sick leave where medical certificate produced. The claimant statement pertaining to Insurance Policy No. 692759768 reveals that the reason for the death of complainant’s house is he died due to heart-attack. For the Policy No. 692759768 also it reveals that the complainant’s husband died due to  heart attack. Ex.A10 is the data collection of the Opposite Parties for the Policies 695136650, 695894176; 692759768 in which it reveals that the Complainant’s husband has mentioned ‘NO’ in the Question No.11 (a) that during the last 5 years – Did you consult a Medical Practitioner for any ailment requiring treatment for more than a week? Even Observing the Question No.2 that you have admitted into Hospital at any point of time Complainant’s husband Stated ‘NO’. The question No.(i) mentioned for the Policy No. 695136650 which discloses that, what has been your usual state of health. For that Complainant’s husband has answered ‘GOOD’.
8. < > is the Policy copy for the 3 Policies, copies are marked as Ex.B1, in which in the Personal History column it reveals that the Complainant husband has mentioned ‘NO’ in all the questions mentioned and Cl.8, 8(a) & 9(b) of the Policy copies. Ex.B2, B3, B4, B5, B6, B7, B8, B9, B10 reveals that the Complainant’s husband has obtained leave on medical  grounds since from 12.05.2009 and in Ex.B10 letter dt.30.09.2010, Ex.B7 letter dt.20.07.2010, dt. 12.05.2010, 27.04.2010 it clearly reveals that the Complainant’s husband has submitted the joining report to the duty after conducting fitness certificate to attend the duties.
9. The Complainant in the Complaint stated that her husband is hale and healthy and died due to heart attack and the allegations leveled by the Opposite Party that her  husband was suffered with ill-health and for that she has furnished 3 case laws in support of his claim where (1) in case law 2005 (3) ALT 9 (CPA) between Oriental Insurance Co. Ltd. V. Ch.Venkatesham in FA 930/2003 and CD No.68/2000 decided on 8.4.2004 it was stated that the burden of proof lies upon the Insurer about the misrepresentation of facts about his health at the time of obtaining policies.(2) In the case of (2000) 8 Supreme 521  Life Insurance Corporation of India Vs Smt.Asha Goel & Anr, it was held that the “burden of proof is on insurer” to establish these circumstances and unless the insurer is able to do so there is no question of the policy being avoided on ground of misstatement of facts does not arise. (3) In case of (1971) O AIR (AP) 41 between Life Insurance Corporation of India, South zone, Madras Vs.Bhogadi Chandravathamma decided on 3.4.1970 it was held that, the appellant-Corporation has not examined either its agent or Medical Officer, as the case may be, who recorded the answers in the proposal forms. The answers were faithfully recorded after interpreting in Telugu the questions in the proposal forms and that the insured fully understood the meaning of the questions. Without examining those who were responsible for recording the answers in the language not known to the insured. So with regarding to this case and observing the 3 policy copies mentioned in Telugu enclosed with the Ex.B2, the Opposite Party has taken appropriate steps questioning the complainant’s husband in Telugu language. The Hon’ble Supreme Court in the case of Satvant Kaur’s Sadhu Vs New India Assurance Co., CA 276/2002 decided on 10.07.2009 observing the Carter Vs Boehmn Lordman’s filed case with regarding to the duty of the disclosure by the assured it was held that the appellant found to be fraudulent. Being an Advocate by profession after completing the necessary formalities insured by himself owned mediclaim policy provided by respondent suppressed the facts and obtained the policy from the Respondent, having the fraudulent intention on part of the appellant we are of opinion that there is no useful purpose be served by remanding the matter to the National Commission for furnish adjudication. As there are no merits in the appeal, the appeal is accordingly dismissed without costs.

10. Observing the case law 2005 (III) ALT 9 CPA, filed by the Complainant and C.A.No.2776/2002 decided on 10.07.2009 along with Exhibit A10 with regarding to the Complaint policies obtained by her husband (observing the question and answers), and certificate of the Employer enclosed with Ex.A1, Ex.A7 Certificate of the Employer, Ex.A9, Certificate of the Employer for Policy No. 692759768 (date of leaves) along with Ex.B1 to B10 documents filed by the Opposite Party which shows that complainant is on medical leaves continuously since 12.05.2009 onwards and viewing the policy copies of the 3 policies, we hold that the Complainant’shusband suppressed the actual facts stated that he has not undergone any treatment or admitted in any hospital and his health is very good which amounts to suppression of the facts and violation of the Terms and Conditions of the Insurance policy.

11. The Complainant having known about the facts i.e. health grounds about her husband and not reveal the facts of medical leaves obtained by her husband and claiming the 3 insurance claims for Rs.4,00,00/- is unfair on part of her which amounts to wrongful gains from the Opposite Party. Hence, we conclude that there is no deficiency of service on the part of Opposite Parties and the Complaint is liable to be dismissed without costs. Accordingly point Nos.1 & 2 are answered.

12. In the result the complaint is dismissed without costs.

    Dictated to the Shorthand Writer, transcribed by him, corrected and pronounced by us in the open Forum on this the 18^th day of September, 2014.

     

          Sd/-                                                                     Sd/-

    President (FAC)                                                         Member           

                                                                       District Consumer Forum-I

                                                                                Visakhapatnam

     

    APPENDIX OF EVIDENCE

     

    Exhibits Marked for the Complainant:

13. Ex.A1

    28.06.2009

    Policy Bearing no.695136650 New Janaraksha Plan with Profits (with accident benefit) installment premium payable Rs.2613/- and maturity amount of Rs.1,05,000/-

    Photostat copy

Exhibits Marked for the Opposite Parties:   

       Sd/-                                                                    Sd/-

President (FAC)                                                         Member           

                                                                   District Consumer Forum-I

                                                                            Visakhapatnam