STATE CONSUMER DISPUTES REDRESSAL COMMISSION OF TELANGANA :
At HYDERABAD
FA 86 of 2015
AGAINST
CC No. 234 of 2011, DISTRICT FORUM, WARANGAL
Between :
Sankella Vijaya Laxmi,
W/o Late Nagaraju,
Age : 453 years, R/o H.No. 7-149,
Ram nagar, Hasanparty Post and Mandal,
Warangal District .. Appellant/complainant
And
- The Branch Manager,
LIC of India, Warangal -1 Branch Office,
Opposite to MGM Hospital,
Warangal – 506 002.
- The Divisional Manager,
Life Insurance Corporation of India,
Divisional office, Jeevan Prakash,
Near Ambedkar Statute,
Balasamudram, Hanamkonda,
Warangal District .. Respondents/opposite parties
Counsel for the Appellant : M/s. K. Karunakar
Counsel for the Respondents : Sri K. Venkatesh Gupta
Coram :
Honble Sri Justice B. N. Rao Nalla … President
And
Sri Patil Vithal Rao … Member
Tuesday, the Seventeenth Day of April
Two Thousand Eighteen
Oral order : ( per Hon’ ble Sri Justice B.N.Rao Nalla, Hon’ble President )
***
1) This is an appeal filed under Section 15 of the Consumer Protection Act by the complainant praying this Commission to set aside the impugned order dated 07.05.2015 made in CC No. 234 of 2011 on the file of the DISTRICT FORUM, Warangal.
2) For the sake of convenience, the parties are described as arrayed in the complaint before the District Forum.
3). The case of the complainant, in brief, is her husband, Nagaraju, during his life time obtained Jeevan Mitra Policy bearing No. 686904956 with profits with DAB, covering Double/Thrible Risk with table 88 for the assured sum of Rs.75,000/- commencing from 28.04.2007 from the first opposite party and she is the nominee and her husband died on 24.05.2008 due to fever and vomitings. The claim submitted by her was repudiated vide letter dated 31.03.2010 on the ground of suppression of availment of sick leave on number of occasions in the proposal form, which, amounts to deficiency in service. Hence the complaint to direct the opposite parties to pay the assured sum of Rs.75,000/- under the above said policy, to pay Rs.75,000/- towards double risk coverage amount as per table 88 of the policy with interest @ 12% pa from 01.10.2008 to 30.04.201 1for Rs.46,500/-, to pay Rs.4,000/- towards bonus, to pay Rs.20,000/- towards mental agony, to pay Rs.1,500/- towards travelling expenditure, legal expenses and costs.
4). The opposite parties opposed the above complaint by way of written version, while admitting issuance of policy in question in favour of the deceased husband of the complainant under Salary Savings Scheme and she is the nominee, contending that the deceased life assured suppressed the availment of sick leave of 154 days on 12 occasions. As per the Patient Case sheet No. 119, dt. 23.05.2008 of Jaya Hospital, Hanamkonda, the life assured was admitted with symptoms of Fever, vomitings, slurred speech and he was also a Chronic Alcoholic. As per the leave records, the deceased life assured suffered from Enteric Fever, DVT : Cellulitis, Chickun Gunya, Head Injury RTA, CRAD on left eye during the above 12 spells of leave on medical grounds and he also suppressed the same in his proposal form. Hence they repudiated the claim. There is no deficiency in service on their part and therefore prayed to dismiss the Complaint.
5). During the course of enquiry before the District Forum, in order to prove her case, the complainant filed her evidence affidavit and got marked Ex.A1 to A 12 and the opposite parties filed their evidence affidavit and got marked Ex. B1 to B-5 and the District Forum marked Ex. X-1. Heard both sides.
6) The District Forum, after considering the material available on record, dismissed the complaint.
7) Aggrieved by the said order, the complainant preferred this appeal before this Commission.
8). Both sides have advanced their arguments reiterating the contents in the appeal grounds, rebuttal thereof along with written arguments.
09) The points that arise for consideration are,
(i) Whether the impugned order as passed by the District Forum suffers from any error or irregularity or whether it is liable to be set aside, modified or interfered with, in any manner?
(ii) To what relief ?
10). Point No. 1 :
There is no dispute that the husband of the appellant/complainant, by name, Nagaraju, during his life time obtained Jeevan Mitra Policy bearing No. 686904956 with profits with DAB, covering Double/Thrible Risk with table 88 for the assured sum of Rs.75,000/- commencing from 28.04.2007 from the first respondent/opposite party and she is the nominee and her husband died on 24.05.2008. There is also no dispute that the claim, submitted by the appellant/ complainant, was repudiated on the ground that the deceased life assured suppressed the availment of leave on medical grounds at the time of submission of proposal form.
11). The District Forum observed that the contents of the Chief Examination of the doctor correlates with the case sheet of Jaya Hospital vide Ex. A-1 and came to the conclusion that the deceased policy holder suppressed the facts, i.e., that he is a chronic alcoholic and he availed medical leave on 12 occasions prior to five years from the date of filling up of the proposal form and substantiated the repudiation of the claim.
12). A perusal of Ex. A-3, Case Sheet said to have been issued by Jaya Hospital, shows that he joined the hospital on 23.05.2008 at 9.21 pm with complaints of fever, vomitings, slurred speech and he was also a chronic alcoholic and he died on 24.05.2008 at 1.15 am. During the cross examination, PW.2 doctor asserted that he treated the deceased only for fever and vomittings. Generally, Government employees used to avail leave on medical/sick grounds by producing a certificate from qualified doctor when no leave sanctioned by their employer and whenever necessity arises and it is not a ground to repudiate the claim as there is no evidence on record to show that he took the treatment for the leave period applied by him to his employer. There is no evidence on record to show that the deceased policy holder is chronic alcoholic on the basis of the clinical tests. Further, there is no evidence on record to show that he was treated for alcohol. Even if we assume that he suppressed that deceased policy holder is chronic alcoholic, there is no evidence on record to prove that due to alcohol he died in the hospital.
13). If the respondents/opposite parties followed that they would not have given policy if the policy holder revealed that he is an alcoholic, no insurance policy would stand for test and they would not have done any insurance business. They have to make tests by their panel doctors before issuance of the policy and take stand whether they have to give policy or not at the time of submission of proposal form. Statistics reveal that no human being exists, now a days, without any disease due to various factors. The Insurance companies have to change their stand in considering whether the death is due to correlated disease which was suppressed by the policy holder or not for repudiation of the claim. Strictly speaking, generally, Insurance policies are used to take after attacking by some disease or the other and no person would think about the insurance policy as long as he is healthy. These facts are known to the insurance companies. Even then, they will not dare to take steps to test the health condition of the policy holder at the time of issuance of policy, but, they will search for grounds for repudiation after submission of claim. Knowing fully well, that the policy holder will hide some information, even then, the insurance companies would not hesitate to issue the policy, if pays, first premium without going into the health condition of the policy holder. The Government should make time frame for approval or non approval of the proposal form, at the admission stage itself, after thorough enquiry, through their panel doctors and investigators. When once the Insurance Company had accepted first premium, the policy holder would have confidence that the Insurance company had accepted his policy and that he will get insurable benefits. When the Insurance Company had accepted the first premium from the policy holder, it is to be deemed that it has perused the contents of the application and had accepted the same and had issued the policy. When it has accepted and issued the policy, how can it be repudiated after some time or some years that the policy holder had pre-existing disease. It should have time frame also for repudiation of the same. After approval of the policy, the Insurance company should adhere to the claim amount as per law. There are lapses on the part of the Insurance companies in issuing polices at the time of admission. If the policy holder died due to suppressed disease which he was having at the time of submission of proposal form, then, it comes under suppression of material fact. But, contrary to that, the Insurance companies are searching for the reasons to evade the insured amount. In the present case, the death of the policy holder is not correlated to the allegation that he is a chronic alcoholic. In view of the above, we do not agree with the contention that the appellant has suppressed the material facts and hence there is deficiency in service on the part of the respondents’ Insurance company.
14). After considering the foregoing facts and circumstances and also having regard to the contentions raised on both sides, this Commission of the view that repudiation of the claim amounts to deficiency in service and the appellant/complainant is entitled to the insured amount of Rs.75,000/- along with double risk coverage amount of Rs.75,000/- together with interest @ 9% pa from the date of repudiation, i.e, 31.03.2010 till the date of realization, to pay an amount of Rs.10,000/- towards compensation and costs of Rs.5,000/-.
15). Point No. 2 :
In the result, the appeal is allowed setting aside the impugned order dated 07.05.2015 in CC 234 of 2011 on the file of the District Forum, Warangal and consequently the complaint is allowed in part holding and directing the respondents/opposite parties 1 and 2 jointly and severally liable to pay the insured amount of Rs.75,000/- along with double risk coverage amount of Rs.75,000/- along with interest @ 9% pa from the date of repudiation, i.e, 31.03.2010 till the date of realization, to pay an amount of Rs.10,000/- towards compensation and costs of Rs.5,000/-. Time for compliance four weeks.
PRESIDENT MEMBER Dated : 17.04.2018..
