Date of Filing: 23.04.2016
Date of Order:12.06.2019
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM – I, HYDERABAD
P r e s e n t
HON’BLE Sri P.VIJENDER, B.Sc. L.L.B. PRESIDENT.
HON’BLE Smt. D.NIRMALA, B.Com., L.L.B., MEMBER
ON THIS THE WEDNESDAY THE 12th DAY OF JUNE, 2019
C.C.No.223 /2016
Between
Sri Sathi Srinivasa Reddy
S/o.Sri Viswanatha Reddy,,
Aged about 45 Years, Occ: Business,
R/o. H.No. Lakshmi Flat No.201,
Prabhava Mansion, Navodaya Colony,
Yellareddyguda, Hyderabad-500073. ……Complainant
And
- The Zonal Manager,
LIC of India, SC Zonal Office,
Secretariat Road, Hyderabad – 500 063
- Divisional Manager,
Divisional Office, Jeevan Prakash, 5-9-21,
Secretariat Road, Hyderabad – 500 063. ….Opposite Parties
Counsel for the complainants : Sri G.Chandra Sekhar
Counsel for the Opposite Party : Sri D.Thirupathaiah & Associates.
O R D E R
(By Sri. P. Vijender, B.Sc., LL.B., President on behalf of the bench)
1) This complaint has been preferred under Section 12 of Consumer
Protection . Act, 1986 alleging that the rejection of the claim of the complainant by the opposite parties amounts to deficiency in service. Hence a diction to the opposite parties to pay assured a sum of Rs.10,00,000/- in the medical policy and a sum of Rs.9,80,000/- as compensation for causing inconvenience and mental agony to the complainant by repudiated the claim and to award costs of this complaint.
2) The complaint averments in brief are that :
The complainant’s wife Smt. Jhansi Lakshmi took Mediclaim policy from the opposite parties in policy bearing No.648366995 on 14.8.2012. On 23.9.2012 suddenly she was admitted in KIMs hospital at Secunderabad for primary case of acute Melynel Lucamical and secondary case leukemia. While undergoing treatment she died on 11.10.2012. The complainant filed claim before opposite party No.2 and same was repudiated on the ground that at the time of taking policy deceased Smt. Jhansi Lakshmi did not disclose existing ailment and suppressed the material information regarding to her health and gave false answers in the proposed form submitted on 14.8.2012. The opposite parties did not properly look into the medical record of the deceased at the time of collecting the premium and while receiving the proposal form did not raise any objection.
Smt. Jhansi Lakshmi had no indication or effects or results of the decease mentioned in the discharge summary issued from KIMs hospital at Secunderabad. She did not face any symptom even before one month of admitting into the hospital. The repudiation of the claim is based on assumptions and presumptions on the part of opposite party No.2. While repudiating the claim opposite party No.2 did not show any credible information relating to the ailments of the deceased while taking the policy. The repudiation intimation was sent to the complainant on 29.3.2014 granting 3 months time to prefer an appeal before the opposite party No.1. On 28.7.2014, complainant got issued a legal notice to opposite party No.1 for which Chief Manager of opposite party No.1 sent intimation stating that already letter was sent to the complainant and if complainant disagrees with the decision he can file fresh representation to opposite party No.1.
On 8.10.2014 the complainant preferred an appeal before opposite party No.2 stating that repudiation of the claim is illegal and baseless. The opposite party No.2 received the appeal filed by the complainant and dismissed it and an intimation of it was sent to the complainant on 21.1.2015. The complainant thinking that the appeal was still pending with opposite party No.2 got issued a legal notice to the Manager of the claims on 1.7.2015. He received a letter dt.21.11.2015 from the opposite parties enclosing copy of orders in the appeal. In the similar circumstances the claim of the deceased was settled by Canara SHBC Oriental Bank of Commerce life Insurance company Limited.
The opposite parties have not raised any objection at the time of issuing the Mediclaim policy to the complainant’s wife and did not insist to conduct any test but after the death of the policy holder and filing of the claim petition they raised several objections without any material to support it. Hence the present complaint.
3) A common written versions has been filed by the opposite parties admitting issuance of policy to the wife of the complainant on 14.8.2012 but denied the rest of the allegations of the complaint. The contentions raised by the opposite parties are that deceased Smt. Jhansi Lakshmi took the policy bearing No.648366995 on 14.8.2012 and within 2 months thereafter she died on 11.10.2012 after being diagnosed Acute Melynel Lucamical Lucami. Hence the opposite parties ordered for claim investigation to enquire into the claim. On enquiry it was found that deceased Smt. Jhansi Lakshmi was admitted in KIMs hospital on 23.9.2012 after being unwell for 10 days. She was also suffering from Hypothyroidism for 7 years as per death summery issued from KIMs hospital. Smt. Jhansi Lakshmi while submitting the proposal for insurance on 14.8.2012 has not mentioned physical ailments with which she was suffering from. She suffered with Hypothyroidism for 7 years but did not disclose the same in the proposal form. The death of the deceased as admitted by the complainant was primarily due to Actute melynel Lucamia and secondary cause is leukemia which is commonly known as cancer. It is a type of cancer of blood and bone marrow that affects immature blood cell growth. The symptoms of such dangerous and fatal decease are observed at least six to eight months prior to death. Had the deceased mentioned the correct details of her past ailments and the symptoms with which she suffered from , the opposite parties would have subjected her to rigorous medical examinations and would have sought special medical reports of opinions and diagnosis before accepting the risk. By not disclosing the diseases with which deceased was suffering the opposite sparty is denied an opportunity to assess risk correctly and non-disclosure of medical ailments amounts to suppression of material facts.
The contract of insurance are contracts of Ubberimafides, where utmost good faith should prevail on the contracting parties. The insurer enters into the contract purely basing upon the information given by the life assured. But in the instant case the life assured clearly suppressed her health condition and the medical ailments with which she was suffered . Thus it is a crystal clear case of suppression of existing cancer disease which eventually lead to her death and only out of such anticipation, she took the said policy thereby playing fraud on the company and willful suppression of material facts vitiates contract. The opposite parties after thorough investigations of facts repudiated the claim of the complainant and communicated the same by letters dated 29.3.2014 and 22.4.2014.
To the complainant’s legal notice dated 25.7.2014 and a reply was issued on 2.8.2014. Because of suppression of fatal information by the life assured the opposite parity was denied its right to assess the risk correctly. Hence repudiation of the claim is legally justified and the opposite parties are very much in compliance with the law established following principle of natural justice. As such there is no deficiency of service on their part. Hence the complaint is liable to be dismissed.
4) In the enquiry stage the complainant got filed his evidence affidavit which is nothing but a replica to the complaint itself. He also got exhibited 14 documents. Similarly for the opposite parties evidence affidavit of one Sri H.Muthaiah stated to be Manager of opposite party No.1 is got filed and substance of the same is in line with the defense set out in the written version. 5 documents are exhibited on behalf of the opposite parties. Both sides filed written arguments and made oral submissions.
5) On consideration of material on the record the following points have emerged for determination:
- Whether repudiation of the claim submitted by the complainant amounts to deficiency of service and if so the complainant is entitled for the amounts claimed?
- To what relief?
6) Point No.1: The issuance of a policy covering risk of deceased and payment of the premium are not in dispute. The other un-disputed fact is the life assured Smt. Jhansi Lakshmi died of cancer while undergoing treatment in KIMs hospital. on 11.10.2012 i.e. within 2 months of issuing of policy by opposite parties. The reason for repudiation of the claim submitted by the complainant after the death of the life assured is deceased had not disclosed the existing ailments in the proposed form submitted for obtaining the medical policy. It is denied by the complainant stating that his wife had no indications or effects or results of the deceased mentioned in the summery issued by KIMs hospital where she died. So there was no suppression of material facts on the part of the deceased while taking the policy from the opposite parties. The opposite parties have filed Exhibit B3 extract of the proposed form filled and signed by the deceased. A cursory look into this form shows deceased had s answered all the questions relating to her health “as no” as if she was healthy as on the date of the purchase of the policy. Medical record issued from the KIMs hospital where deceased was admitted and underwent treatment till her demise does not support the plea taken by the complainant. The discharge summary revealed that the deceased Smt. Jhansi Lakshmi was suffering with cancer for 7 years prior to her death. Exhibit B4 is the certificate issued by Dr.Sakunthala stating that deceased was under her treatment during the year 2012. So the medical record clinchingly established that the deceased Smt. Jhansi Lakshmi suffered with Hypothyroidism for 7 years before her admission into the KIMs hospital and that she suppressed this fact while obtaining the policy from opposite parties. It is sought to be urged for the complainant that deceased took a policy from Canara SHBC Life Insurance and said company settled the claim for Rs.2,50,000/- and in evidence of it filed Exhibit A4 which shows that deceased Smt. Jhansi Lakshmi obtained the policy from said company on 14.8.2012 for Rs.2,50,000/- and on demise the claim was settled the claim. The settlement of claim by one company does not mean that opposite parties are also liable to settle the assured amount. The policy is an independent contract and the complainant’s claim shall be within the limits of subject policy terms and conditions of which clearly shows suppression of any material fact vitiate contract. Hence based on Exhibit A4 document complainant cannot argue that the opposite parties are liable to settle the claim for amount . Since material placed on record has clearly proved that the deceased by suppressing the existing ailment obtained subject policy and very fact that she died within 2 months of taking of the subject policy shows that she knowing fully well that is going to die with the decease with which she was suffered obtained the policy. Hence repudiation of the claim in the instant case by the opposite parties does not amounts to deficiency in service. Accordingly the point is answered
7) Point No.2: Since repudiation of the claim does not amount to deficiency in service the complainant is not entitled for any of the claims mentioned in the complaint. The complaint is dismissed.
8) In the result the complaint is dismissed. No order as to costs.
Dictated to steno , transcribed and typed by her and pronounced by us on the 12th day of June, 2019.
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
WITNESS EXAMINED
NIL
Exhibits filed on behalf of the Complainant:
Ex.A1 – Policy bearing No.648366995 dt,14.8.2012
Ex.A2 – Death Certificate. Dt. 11.10.2012
Ex.A3 – Claimants requisition for claim forms for consideration of death claim
Ex.A4 – Death claim under the policy No.648366995, dt.29.3.20214
Ex.A5 – Legal notice to the opposite parties , dt. 25.7.2014
Ex.A6 & A7 - Postal receipts
Ex.A8 – Postal acknowledgement
Ex.A9 – Appeal before Respondent No.2 dt.18.10.2014.
Ex.A10 Postal acknowledgement
Ex.A11 –Letter issued by Sr.Divisional Manager
Ex.A12 – Legal notice to opposite party No.1, dt.1.7.2014
Ex.A13 – Letter by Manager (Claims) to the Opp.Parties
Ex.A14 - Client settlement letter issued by CANARA–HSBC-OBC, DT.21.1.2013.
Exhibits filed on behalf of the Opposite parties:
Ex.B.1 – Copy of Proposal Form
Ex.B2 – Death certificate.
Ex.B3 - Form for obtaining medical opinion from DMR/ZMR
Ex.B4 – Copy of Process record/ Doctor’s orders
Ex.B5 – Copy of letter addressed to the complainant dt.29.3.2014
MEMBER PRESIDENT
