Complaint filed on 06.08.2012
Compliant disposed on 10.11.2014
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM ::AT:: KARIMNAGAR, TELANGANA STATE
PRESENT: HON'BLE SRI B.SURESH, B.A., LL.M., Ist ADDL. DIST. & SESSIONS JUDGE AND PRESIDENT (FAC)
AND
SRI G.SREENIVASRAO, M.Sc.,B.Ed.,LL.B., PGADR (NALSAR), MEMBER
MONDAY, THE 10TH DAY OF NOVEMBER,TWO THOUSAND FOURTEEN
CONSUMER COMPLAINT NO.158 OF 2012
Between:-
Podila Mallesham S/o.Durgaiah, Age 50 years, Occu: Agriculture R/o. Somaram Village of Saidapur Mandal, Karimnagar Dist.
... Complainant
AND
1.The Branch Manager, Bajaj Allianz Life Insurance Company Ltd., #4-2-128 & 129, Devi Kishan Complex, Rajeev Chowk, Near Aslam Maszid, Karimnagar.
2.Bajaj Allianz Life Insurance Company Ltd., R/by ATTN – SANTHI – CLAIMS DEPT. Sri Vari Shopping Mill, Old.No.2/91, New No.258/5, Third Floor, 2nd Block, New Bus Stand Road, Meyyanur, Salem – 630004, Tamilnadu State.
… Opposite Parties
This complaint is coming up before us for hearing on 15-10-2014, in the presence of Sri R.Kishan Singh Advocate, counsel for complainant, and Sri P.Veeresham Advocate, counsel for opposite parties and on perusing the material papers on record, and having stood over for consideration till this day, the Forum passed the following:
::O R D E R::
This complaint is filed U/s.12 of C.P.Act to direct the opposite parties to pay the claim amount of Rs.2,50,000/- with compensation of Rs.1,00,000/- per the mental agony along with costs and interest @ 18% p.a. on the said amount till realization.
Brief facts of the case:
1 The complainant son by name Mr.Podila Raju had obtained an insurance policy from opposite parties no.1 by paying an amount of Rs.12,500/- as annual premium. The term of the policy bearing no.0098960894 is 20 years which commenced on 16.05.2008. The second premium was paid on 30.06.2009 whereas the 3rd and 4th premiums were paid together on 10.06.2011 to opposite party no.1. The son of the complainant was pursuing MBA Course who died on 15.08.2011 due to high fever while undergoing treatment. The said policy carries a risk coverage of Rs.2.50 lakh if the policy holder dies naturally.
The complainant (father) being the nominee forwarded the required documents to opposite parties no.2 on 07.09.2011. Further additional documents were also sent to opposite party no.2 as per his communication Dt: 14.09.2011 for processing of the death claim amount.
The opposite party no.2 rejected the claim vide his letter Dt: 19.10.2011 stating that due to non-disclosure of material facts, the claim has been repudiated by declaring revival Dt: 10.06.2011 as void with a reason that “hospitalization & Medical investigations since 01.06.2011 for fracture of shaft left femur (thigh bone) and underwent treatment and this was not disclosed to them (Opposite Parties) in the DGH (Declaration of Good Health) form Dt: 10.06.2011”. The complainant stated that this fact was disclosed to the branch office (OP1) at the time of payment of 3rd & 4th premiums on 10.06.2011. Therefore, the repudiation of the claim on said ground does not arise. The complainant averred that only to evade claim payment the opposite parties have taken a false and fictitious plea thus resulting in deficiency of service on the part of opposite parties. Even a legal notice Dt: 20.06.2012 was also sent to opposite parties no.1 & 2 but the opposite parties neither paid the claim amount nor issued any reply. Hence, the complaint is before the Forum for redressal.
2. The opposite parties no.1 & 2 together filed their written version, in which they denied the complaint and stated that it is misconceived, misconstrued and contrary to the contract between the parties. They stated that the claim was repudiated on the ground that the facts amount to non-disclosure of material facts. The deceased had knowledge that he was suffering from diseases, undergoing medical treatment even at the time of making DGH (Declaration of Good Health) form towards revival of the policy. They also submitted that the policy holder and the company are bound by the terms and conditions of the insurance policy which was issued by their company.
The opposite parties have also emphasized on the point that the life insurance policy issued to the life assured is barred on the principles of utmost good faith and accordingly rely on the declaration & statements made in the proposal form and then the company issued the policy. In the Proof Affidavit of the opposite parties they have specifically denied allegations of the complaint para-wise and sought for strict proof of the same.
The opposite parties point out that the policy of the complainant was revived by suppressing medical facts with malafide intention. Hence it was rejected by them. They have also cited that there is no deficiency in service on the part of respondents as per Ravneet Singh Bagga Vs KLM Royal Dutch Airlines (2000) 1SCC66, wherein the Hon’ble Supreme Court laid down the test of deficiency in service by stating that the deficiency cannot be alleged without attributing fault, imperfection, short coming or inadequacy in the quality, nature and manner of performance which is required to be performed by a person in pursuance of contract or otherwise in relation to any service. The rendering of deficient service has to be considered and decided in each case according to the facts of that case for which no hard and fast rule can be laid down. Finally the opposite parties intimated that the complaint is frivolous, vexatious and prayed to dismiss with costs.
3. The complainant’s evidence was marked as Ex.A1 to A14 and the exhibits of opposite parties were marked as Ex.B1 to B8. Heard both the counsels.
Now the point for consideration is, Whether the opposite parties have caused any deficiency in service, if so, To What relief?
POINT:
4. There is no dispute that the deceased obtained a policy and paid 3rd & 4th premiums together on 10.06.2011 to the opposite parties. Whereas the deceased as per the version of the complainant-nominee (father) died on 15.08.2011 due to high fever while undergoing treatment. As the policy carries a risk coverage of Rs.2,5 lakhs if the policy holder dies naturally. Accordingly, the father/complainant, forwarded the death claim benefit papers to the opposite parties no.2 on 07.09.2011 and 14.09.2011 for processing at their end.
5. The said claim was repudiated by the opposite parties on the ground of non-disclosure of material facts. The deceased had knowledge that he was suffering from diseases, undergoing treatment even at the time of making DGH (Declaration of Good Health) form towards revival of the policy. As such he suppressed medical facts with malafide intention at the time of revival. Hence no deficiency in service on their part. They also cited Hon’ble Supreme Court reference to that of test of deficiency in service in the judgment of Ravneet Singh Begga Vs KLM Royal Dutch Airlines (2000) 1 SCC 66 and there is no hard & fast rule to decide the deficiency in service and it depends on the facts of the case concern.
6. On perusal of the documentary evidence of the complainant the Ex.A1 is the copy of the policy bearing no.0098960894 which commenced on 16.05.2008 inclusive of risk covered and the term of the policy is for 20 years and sum assured is Rs.2.5 lakhs with minimum death benefit of Rs.2.5 lakhs and Sri Mallesham father being the nominee. The Ex.A3 is the receipt for Rs.25,000/- on account of renewal premium. The Ex.A4 to A6 Dt: 13th and 14.08.2011 are the diagnostic reports showing that the deceased was suffering from high fever, vomiting, diarrhea, dehydration etc. and Ex.A7 & A8 are the claim related correspondence with opposite parties. The Ex.A9 is the Rejection of Claim of the policy citing the reference to non-disclosure of material facts by declaring revival Dt: 10.06.2011 as void. Whereas the Ex.A10 is the proof of payment of calim Dt: 16.09.2011 for Rs.2,52,828/- by the LIC under policy no.681059501 to the deceased. The Ex.A11 is the Legal Notice issued to opposite parties along with postal receipts & acknowledgements (Ex.A12 & A13). Finally the Ex.A14 is the cheque bearing no.064370 Dt: 22.11.2013 for Rs.43,707/- issued by the opposite parties in favour of complainant – nominee during the Court/Forum proceedings.
7. The evidence of opposite parties Ex.B1 is the same as Ex.A9: the Ex.B2 (4 sheets) is the claim notes & decisions: Ex.B3 (2 sheets) is the claim summary sheet; Ex.B4 is the Re-underwriting opinion: Ex.B5 (2 sheets) is the Declaration of Good Health for revival of lapsed policies; Ex.B6 (8 sheets) is the investigation report; Ex.B7 is the discharge card of Guardian Multispecialty Hospital, Warangal and Ex.B8 is policy booklet containing 10 sheets in original
8. On analysis of the evidence it is true that the Ex.B7 (Discharge Card of the hospital) proves that the deceased undergone operation for the femur shaft (thigh bone) from 7.6.2011 to 18.6.2011 and Ex.B6 (7th & 8th sheet) are the Medical Lab reports for the period 13-14th August 2011 for high fever, vomiting, Diarrhea etc. But the Ex.A3 is the receipt Dt: 10.06.2011 for 3rd and 4th premium together amounting to Rs.25,000/- which is considered as renewal premium. Moreover as per the clause 5 b(ii) (non-payment of regular premium & forfeiture) of the policy booklet (Ex.B8) there is a provision for revival of policy within a revival period of two years. Adding to it, the contention of opposite parties about Declaration of Good Health (DGH) Certificate is not mentioned in any of the 40 clauses of the policy document (Ex.B8). Further it is observed on the last sheet of Ex.B8/policy document under the caption UL Accident permanent total/partial disability benefit, which allows the risk cover from the entry age group of 18 yrs to 50 yrs, upto the age of 65 yrs. The deceased is just an MBA student so he is eligible under this provision also.
We are of the considered view that as per the provisions of the policy under the caption “Bajaj Allianz New Unit Gain” it was revived and the deceased who had undergone operation and treatment for just 12 days (7-18 June, 2011) for his femur shaft (thigh bone) which was an accident, but after nearly two months, he died on 15.08.2011 suffering from high fever, vomiting and diarrhea for two days (13-14 Aug, 2011) which is a routine feature and not a suppression of fact. In such circumstances, the contention of the opposite parties on the ground of non-disclosure of material facts at the time of revival of policy on 10.06.2011 cannot be accepted.
In a recent judgment of Hon’ble National Commission in Abdul Latheef Vs LIC of India in RP No.2370/2012 Dt: 04.07.2014, it was held that:
“It is unfortunate that on one hand LIC raises the voice of utmost good faith, but in contrast, the faith will be lost while not settling the genuine claims for some or other reason. It is the exploitation of the policy holder. The consumers are literally under fear or dilemma that, whether, after death the beneficiaries ever certainly get any fruits from the LIC”.
It is clearly observed from the above that the opposite parties have made elaborate investigations at the time of the claim which proves only technicalities but the yardstick of utmost good faith was not applied while settling the claim. In such circumstances it was absolutely no wrong on the part of the complainant in claiming death benefits for his son. He is entitled for the sum assured along with accident benefit too. So the point is answered against the opposite parties and in favour of the complainant.
In the result, the complaint is allowed and the opposite parties jointly & severally directed to pay the complainant/nominee the sum assured Rs.2,50,000/- in addition to pay Rs.50,000/- for the mental agony and hardship along with Rs.10,000/- for the costs of the litigation. The complainant is advised to return back the opposite parties cheque Dt: 22.11.2013 for Rs.43,707/- (Ex.A14).
Time for compliance 30 days.
Typed to my dictation by Stenographer and after correction the order pronounced by us in the open court this the 10th day of November, 2014.
Sd/- Sd/-
MEMBER PRESIDENT(FAC)
NO ORAL EVIDENCE HAS BEEN ADDUCED ON EITHER SIDE
FOR COMPLAINANT:
Ex.A1 is the photo copy of Policy bearing no.0098960894 Dt: 17.05.2008.
Ex.A2 is the photo copy of Premium Receipt Dt: 30.06.2009.
Ex.A3 is the photo copy of Premium Receipt Dt: 10.06.2011.
Ex.A4 is the photo copy of reference letter from Dr.Sathtaiah addressed to NIMS Hospital Dt: 14.08.2011
Ex.A5 is the photo copy of Medical Prescription Dt: 13.08.2011
Ex.A6 is the photo copy of Lab Report issued by Madhu Diagnostic Center Dt: 14.08.2011.
Ex.A7 photo copy of claim notification Dt: 07.09.2011.
Ex.A8 is the photo copy of Death Claim Dt: 14.09.2011.
Ex.A9 is the photo copy rejection of claim Dt: 19.10.2011.
Ex.A10 is the copy of payment of the claim by the LIC of India Dt: 16.09.2011.
Ex.A11 is the office copy of Legal Notice Dt: 19.06.2012.
Ex.A12 contains postal receipts (2).
Ex .A13 contains served acknowledgment cards (2).
Ex.A14 is the original copy of Cheque for an amount of Rs.43,707.56/- issued by opposite parties.
FOR OPPOSITE PARTY:
.B1 & A9 are one and the same documents.
.B2 is the photo copy of Claim Notes and Decisions Dt: 14.10.2011.
.B3 is the photo copy of Claim Summary Sheet Dt: 12.10.2011.
.B4 is the original copy of Re-under writing opinion Dt: 13.10.2011.
.B5 is the photo copy of Declaration of Good Health Dt: 10.06.2011.
.B6 is the original copy of Investigation Report Dt: 23.09.2011.
Ex.B7 is the original copy of Discharge Card issued by Guardian Multi Specialty Hospital.
Ex.B8 is the original copy of Policy issued by opposite parties Dt: 17.05.2008.
Sd/- Sd/-
MEMBER PRESIDENT(FAC)
