This case coming on 20.01.2015 for final hearing before this Forum in the presence of P.V.L. Prasanna Kumari, Advocate for the complainant and Sri K. Bharani Kumar, Advocate for the opposite parties 1 to 3 and the opposite party No.4 having been set ex party and Sri P.L.N. Prasad, Advocate for the opposite party No.5, and having stood over till this date for consideration, this Forum has pronounced the following: 

O R D E R

(Per Sri B. Vinay Kumar, President) 

          This is a complaint filed by the complainant U/Sec.12 of Consumer Protection Act 1986 to direct the opposite parties to pay the insurance amount of Rs.33,000/- to the complainant together with interest @ 24% per month from the date of complaint till date of realization, pay damages of Rs.60,000/- towards mental agony, pay Rs.7,000/- towards legal expenses and costs.

2.         The case of the complainant is as follows:- The complainant stated that his sister by name Gundavarapu Ramalakshmi joined as a member in group on 6.5.2006 in the Velugu Scheme, Gokavaram division of Zilla Mahila Kranthi Scheme, Kakinada and on the same day, she joined as a member in Group Insurance Policy under Janasri Bhima Yojana and paid premium amount to the concerned authorities, for which the authorities issued receipt bearing No.068457 dt.6.5.2006.  As per the scheme, after the death of the members of the said scheme, the family members are entitled an insurance amount of Rs.30,000/- through Janabhimayojana.  After joining the member in JBY policy, she died on 2.6.2006.  On 29.4.2006, the deceased Smt. Gundavarapu Ramalakshmi tendered the premium amount to the concerned authorities, but they refused to receive the same unless the member produced the medical certificate after checkup by the competent doctor.  Thereupon on 28.4.2006, the said member underwent medical examination by Dr. G. Chinasathiraju, Sri Venkateswara Hospitals, Rajahmundry and the said doctor certified that the member was keeping good health and she is very healthy.  Later the member produced medical certificate to the concerned authorities, the concerned authorities received the premium amount from the member on 6.5.2006 by that time, she was keeping good health.  Gundavarapu Ramalakshmi died on 2.6.2006, her death certificate was issued on 12.6.2006 by the Panchayat Secretary, Gokavaram of E.G. Dt. and the said death certificate does not disclose the cause of death was due to typhoid fever.  As per the receipt dt.6.5.2006, I.D. number was mentioned as 068457.  But as per L.I.C. of India, P&G.S. Unit, Vijayawada, the I.D. number of Gundavarapu Ramalakshmi was mentioned as 29564.  While so on 17.7.2006 the complainant herein submitted claim from to the L.I.C. of India, P&G.S. Unit, Vijayawada, but they did not settle the claim of the complainant till today on some pretext or the other. 

            On 19.10.2006, the Branch Manager, L.I.C. of India, P&G.S. Unit, Vijayawada addressed a letter to the Secretary Zilla Samakhya, Kakinada, in the said letter, the I.D. number of the G. Ramalakshmi was mentioned as 29564 and JBY number was mentioned as 330461.  After verification of the papers through the authorities, it is learnt that by the time of her enrolment, she was not keeping good health.  While so, on 12.10.2010, the complainant submitted an application to the Project Director, O/o.D.R.D.A., Kakinada, E.G. Dt. under Right to Information Act seeking information about the policy claim of her deceased sister.  Thereupon the said authority furnished copy of letter dt.19.10.2006 addressed by the Branch Manager, L.I.C. of India, P&G.S. Unit, Vijayawada to the complainant.

            While the matter stood thus, the complainant herein got filed the P.L.C. No.244/2011 claiming insurance amount of her deceased sister before District Legal Services Authority, Rajahmundry.  In the said proceedings, the Divisional Manager, L.I.C. of India, Rajahmundry submitted their written reply to the above said authority.  In the said written reply it was mentioned that the medical certificate dt.1.3.2004 was issued under the head of high risk.  But as per the medical certificate dt.28.4.2006, the deceased was keeping good health by the time she joined as member in group policy JBY.  The insurance authorities simply considering the old certificate issued in the year 2004 rejected the claim of the complainant herein by ignoring the latest Medical age certificate of the deceased dt.28.4.2006.  Later the proceedings were closed before the D.L.S.A., Rajahmundry. The conduct of the opposite parties amounts to deficiency of service.  Hence, the complaint. 

3.         The 2^nd opposite party filed written version and adopted the same by the 1^st & 3^rd opposite parties.  This opposite party contended that all the allegations made by the complainant in the complaint are not true and correct and the complaint is liable to be dismissed on facts or on law against this opposite party.  This opposite party submitted that as per the scheme after demise of the insurer, her family members entitle benefit of insurance of Rs.30,000/-.  This opposite party submitted that the said G. Rama Lakshmi expired on 2.6.2006 and that upon claim form submitted by the complainant through the President, Zilla Samakhya, Kakinada forwarded the same to the Life Insurance Corporation of India, P & G S Unit, Vijayawada for the claim of deceased G. Rama Lakshmi and the opposite parties 1 to 3 are only facilitators to look after the policies of the Government runned by the Nodal Agencies in proper manner or not and working under the control of Collector and District Magistrate, Kakinada.  This opposite party submitted that this opposite party and the opposite parties 1 and 3 not responsible for any act of alleged deficiency of service alleged by the complainant and also not a proper and necessary parties to the proceedings.  This opposite party submit that the complainant filed the complainant without showing the Senior Branch Manager, LIC of India, P & G S Unit, Vijayawada, who is proper and necessary party to this proceedings and the complaint will be liable to be dismissed due to non-joinder and necessary party.  Therefore, there is no deficiency in service on the part of this opposite party and the complaint is liable to be dismissed.

4.         The 5^th opposite party filed written version contended that this complaint is not maintainable either under law or on facts.  The claim of the complainant is time barred.  This opposite party submit that the deceased Smt. G. Rama Lakshmi joined as a member in Group Janasree Bhima Yojana (JBY) bearing ID No.29564 under Master Policy holder Zilla Samkhya DRDA, Kakinada vide Policy No.536641 dt.31.5.2006.  As the proposal was under non-medical scheme, no medical examination of the life proposed was conducted and LIC relied on the statements made by the proponent in the proposal and declaration of good health.  After joining the member in JBY Policy, the deceased died on 2.6.2006.  At the time of joining the deceased is member in JBY Policy, the deceased produced medical certificate issued by the para Medical Officer, PHC, Gokavaram as her age proof.  In the said certificate, it reveals that the deceased suffering from gross “Anemia” and the certificate was issued under the head of High Risk Case since the death was occurred within two days from the joining the policy and the member was not in good health as on the day of joining in the scheme and the same was suppressed by her, while submitting the proposals for the policy.  It is further submitted that after receiving the claims forms from the Master Policy holder Zilla Samkhya DRDA, Kakinada along with death certificate, this opposite party immediately informed to the Master Policy holder Zilla Samkhya, DRDA, Kakinada on 19.10.2006 through its letter that the claim is not settled that the deceased suffering from gross “Anemia” and the certificate was issued under the head of High Risk Case and that the death claim of the deceased Smt. G. Rama Lakshmi repudiated since the death was occurred within two days from the joining the policy and the member was not in good health as on the day of joining in the scheme and the same was suppressed by her, thus the insurer can repudiate the same under general law of contract with special reference to the law of insurance.  The insurer will not be having any information as to age, health, habit and income of the life to be assured and hence entirely depending upon the information given by the life to be assured in the proposal form.  When the insurer deliberately gives false information, it amounts to avoidance of the legal and moral duty on the part of the insured.  In the final analysis, therefore, the suppression of material fact would hold good for repudiation of the claim as the contract becomes void.  Hence, there is no deficiency in service on the part of this opposite party and the complaint is liable to be dismissed.

5.         Proof affidavits filed by both parties . Exs.A1 to A11 has been marked on behalf of the complainant. Exs.B1 and B2 marked on behalf of the 5^th opposite party.

6.         Heard both sides.

7.         Points raised for consideration are:

1. Whether there is any deficiency in service on the part of the opposite parties?

2. Whether the complainant is entitled for the reliefs asked for?

            3. To what relief? 

8.  Point Nos.1 & 2:- As per the record, the complainant is the nominee and legal heir as per Exs.A5 and A3 of one Smt. Gundavarapu Ramalakshmi, who was a member of Velugu Scheme and member of Janasri Bhimayojana Policy of L.I.C. obtained by Zilla Mahila Velugu Samakhya, East Godavari District vide Master Policy No.536641 dt.31.5.2006. The deceased member was given I.D. No.29564 and paid the premium of Rs.55/- on 6.5.2006 as per the receipt issued by IKP authorities vide Ex.A1.  The said member of Janasri Bhimayojana died on 2.6.2006 while the policy was in force as per Ex.A2 death certificate. On that, the complainant preferred claim being the nominee of the deceased member on 17.7.2006. The claim was repudiated by the 4^th opposite party Regional Manager as per Ex.A6 stating that the deceased member was not in good health vide Ex.A7 dt.19.10.2006 at the time of joining in the Janasri Bhimajojana Scheme as per the doctor certificate. The said letter was addressed to the Secretary, Zilla Samakhya, Kakinada only.  As this fact was not known to the nominee, who preferred the claim after the death of the deceased G. Ramalakshmi, he addressed a letter to the 3^rd and 4^th opposite parties under Right to Information Act vide Exs.A10 and A11 dt.18.9.2010 and 23.9.2010 and obtained information from the 3^rd opposite party as per Ex.A7.

            Further, the complainant preferred a claim with Chairman, District Legal Services Authority, Rajahmundry for settlement of claim vide PLC No.244/2011.  The 5^th opposite party herein contested the said P.L.C. and alleged that they enquired into the bonafides of the claim preferred by the complainant and then only repudiated the claim as the insurance contracts are based on uberrima fides where the parties to the contract should be disclosed all material facts and they have no information with regard to the age, health and habits of the deceased and so, they repudiated the claim.

            We observed that the 5^th opposite party filed Ex.B1 policy conditions of Janasri Bhimayojana Master Policy, a Social Security Scheme.  As per the conditions, eligibility criteria under Rule 4 for the scheme of Janasri Bhimayojana is 18 to 60 years whether the member is a male or female.  Further, as per Rule 5, the Nodal Agency shall ensure that evidence of age satisfactory to the Corporation is furnished by every member at the time of his joining the scheme.  It is further observed that the admission of member into the scheme as per Rule 6 is if the declaration of health made by the Member and other particulars in the application form are found to be satisfactory, the Nodal Agency shall admit him into the scheme.  The decision of the Nodal Agency in this regard shall be final. The Nodal agency shall maintain one copy of the register of members covered under the scheme and submit one copy thereof to the Corporation.  In the present case, the deceased member was 35 years old as per Ex.B2 issued by the Para Medical Officer of Gokavaram Primary Health Centre, East Godavari dt.1.3.2004 and the same was sent to the Insurance Company along with letter addressed by the A.P.M., Gokavaram dt.24.3.2006 appended in Ex.B2. 

            We observed that the 4^th opposite party Regional Manager, Janasri Bhimajojana Scheme, Vijayawada repudiated the claim that the deceased was suffered gross anemia, which was a high risk case and the same was not revealed at the time of proposal. We observed that the authority, who issued Ex.B2 medical certificate dt.1.3.2004 only wrote the symptoms as gross anemia, but never stated that it was high risk case, but on the certificate, it was printed as high risk.  Further, we observed that the said certificate was issued on 1.3.2004 whereas the deceased died with typhoid on 2.6.2006 and there was a gap of more than two years between sufferings from gross anemia to the death of deceased due to typhoid. We further observed that the deceased was issued medical certificate that she was in good health on 28.4.2006 by one Dr. Goli China Sathiraju of Rajahmundry prior to joining the Janasri Bhimayojana Scheme. The deceased paid the premium and joined as member in the Janasri Bhimayojana Insurance Scheme on 6.5.2006. So, she was in good health at the time of joining in the J.B.Y. Scheme as per doctor’s certification and to the satisfaction of Nodal Agency with regard to age and health.  Under these circumstances and facts, there is no meaning in the allegation of bad health at the time of joining the deceased member in Janasri Bhimayojana Scheme. It is not proper on the part of the 4^th and 5^th opposite parties insurance authorities to rely on a certificate issued by Para Medical Officer, Primary Health Centre, Gokavaram way back in the year March, 2004 to repudiate the claim of the complainant, if the insurance authorities repudiate the claim, they have to prove that the deceased was not keeping in good health at the time of joining as a member in the insurance scheme with cogent evidence. So, it is evident that the claim of the complainant was repudiated in an arbitrary and unlawfully manner by the 4^th and 5^th opposite parties insurance authority without placing any reliable evidence in with regard to ill health of the deceased before or after joining in the insurance scheme.  The claim against the opposite parties 1 to 3 is dismissed as they are only facilitators to the Janasri Bhimayojana Scheme introduced by the 4^th and 5^th opposite parties.          

9.  Point No.3:-  In the result, this complaint is allowed, directing the 4^th and 5^th opposite parties to pay Rs.30,000/- as claim amount with interest @ 9% p.a. from the date of original complaint i.e. 24.9.2012 till realization to the complainant. We further direct the 4^th and 5^th opposite parties to pay Rs.1,000/- towards costs of this complaint to the complainant. Time for compliance is two months from the date of this order.

Dictated to the Stenographer, typed to my dictation, corrected and pronounced by us in open Forum, on this the 6^th day of February, 2015.

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       MMEMBER                                   MEMBER                                PRESIDENT

APPENDIX OF EVIDENCE

WITNESSES EXAMINED

FOR COMPLAINANT:  None.                                                                                                     FOR OPPOSITE PARTIES:  None.

DOCUMENTS MARKED

FOR COMPLAINANT:

Ex.A1    Receipt No.068457 dt.6.5.2006 issued by Zilla Samakya, Indira Kranthi

              Padhaka, East Godavari District, Kakinada in favour of Gundavarapu Rama

              Lakshmi.

Ex.A2    Death Certificate of Gundavarapu Ramalakshmi dt.14.7.2006 issued by

              Secretary, Gokavaram, East Godavari District.

Ex.A3    No Objection Certificate dt.17.7.2010 issued by Tahsildar, Gokavaram, East

              Godavari District.

Ex.A4    Medical Certificate dt.28.4.2006 issued by Dr. G. China Sathi Raju, Sri

              Venkateswara Hospitals, Rajahmundry in favour of Gundavarapu Rama

              Lakshmi.

Ex.A5    Claim form dt.17.7.2006 submitted by the complainant to the L.I.C. of India,

              P&G. S, Vijayawada.

Ex.A6    Letter dt.8.11.2006 addressed by the Zilla Samakya, D.R.D.A., Kakinada, East

              Godavari District to the Mandala Samakya, Gokavaram, E.G. District.

Ex.A7    Letter dt.12.10.2010 addressed by the Additional Project Director, D.R.D.A.,

               E.G. District, Kakinada.

Ex.A8    Application submitted by the complainant to the Chairman, D.L.S.A.,

              Rajahmundry.

Ex.A9    Written reply submitted by the opposite party in P.L.C. No.244/2011 to the

             DLSA, Rajahmundry.

ExA10   Requisition dt.18.9.2010 submi9tted by the complainant to the LIC of India, P &

              G.S., Vijayawada under R.T.I. Act.

ExA11  Requisition dt.23.9.2010 submitted by the complainant to the Project Director,

           Indira Kranthi Padhakam, Kakinada under R.T.I. Act.

FOR 5^th OPPOSTIE PARTY:-

Ex.B1    Janashree Master Policy with terms and conditions.

Ex.B2    Letter dt.24.8.2006 addressed by the A.P.M., to the Zilla Samakya, Kakinada

              along with medical report.

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      MEMBER                                       MEMBER                                PRESIDENT