BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM RAICHUR.
COMPLAINT NO. (DCFR) CC. 76/2014.
THIS THE 23rd DAY OF DECEMBER 2014.
P R E S E N T
1. Sri. Gururaj, B.com.LLB. (Spl) PRESIDENT (In charge)
2. Smt. Pratibha Rani Hiremath,M.A. (Sanskrit) MEMBER
*****
COMPLAINANT :- Sri.K.Srinivas S/o. late K.Sriramalu age 30 years,
Occ: agr., R/o. Venkatagiri camp, Po: Roudakunda village. Tq. Sindhanoor.
//VERSUS//
OPPISITE PARTY :- The Branch Manager, Bajaj Allianz Life
Insurance Company Ltd., Near ICICI Bank Sindhanoor, Dist: Raichur.
Date of institution :- 09-09-2014.
Date of disposal :- 23-12-2014.
Complainant represented by Sri. Prasanna Sharma, Advocate.
Respondent represented by Sri. Vishwanath Pattanasetty, Advocate.
JUDGEMENT
By Sri. Gururaj (Incharge) President:-
This is a complaint filed by the complainant Sri. K.Srinivas S/o. late K.Sriramalu against the Op U/sec. 12 of Consumer Protection Act for to direct the Opposite to make the payment of Rs.15,00,000/- and Rs.1,00,000/- along with interest at the rate of 2% and Rs.1,00,000/- as a damage and other benefits of the said policy.
2. The brief facts of the complainant case are that, the father of the complainant by name K.Sriramulu had insured his life with the Op under policy No.0282168911 for an amount of Rs.5,00,000/-. The deceased was required to pay a premium amount of Rs.26,310/- p.a. and accordingly he has paid premium for the said policy during his lifetime. The complainant of the present case he being a son has nominated as a nominee of the said policy.
It is the case of the complainant that, the policyholder K.Sriramulu died on 24-01-2013 and after his death the complainant he being a nominee requested respondent to settle the claim benefits of the said deceased but the Op’s Insurance Company did not settle the claim. The complainant got issued a legal notice dt. 02-06-2014 calling upon the Op to settle the policy amount, even inspite of service of the said notice the Op has neither come forward to settle the death claim nor replied to the said notice and thereby the Op extended the act of deficiency of service. Hence the present complaint has been filed for the reliefs sought under the complaint.
3. After filing the complaint, the notice has been issued against the Op on 15-09-2014 the said notice has been served on 25-09-2014. The Op appeared through his counsel and filed written version contending that, the complaint filed by the complainant is misconceived; mis-construed, contrary between the parties therefore it is untenable in law and deserves to be dismissed. Further it is contended that, the life assured was suffering from cancer earlier to obtaining the policy but he has not disclosed the fact prior to making the proposal of the policy in question. The same thing was investigated by the investigator by name Lavanya & company Sripuram Bangalore. From the said investigation it is came to know that, during 03-09-2012 to 05-09-2012 the life assured was hospitalized for treatment for Carcinoma penis (recurrent) with past history of penectomy but the said fact was not disclosed by the life assured it amounts to non-disclosure of material facts. Further it is aloes contended that, as per the information given by the villagers the life assured was suffering from cancer and was taken treatment at Naryana Cancer Hospital, Bangalore and also taken treatment at NTR Hospital, Hyderabad and Aurvedic treatment at Maharastra. These are all the facts have not disclosed by the life assured or the complainant. Apart from that he has given false information that, the life assured i.e, the father of the complainant was taken treatment for his heart problem at Manipal Hospital, through Yeshashiwini Card in the year October-2011 and his father was died on 24-01-2013 at about 10:am with chest pain and cremated on 24-01-2013. The act of the complainant and life assured is clearly goes to show that they played fraud in getting false policy to get false claim against this Op. Further it is contended that, deceased had knowledge of his pre-existing disease and other matters but he did not disclose it particularly while answering in the proposal form. The Op’s company after rejection of claim on the basis of pre-existing diseases the complainant preferred appeal before the claim review committee Bajaj Allianz Life Insurance Company Ltd., Yerwada Pune. The said Review committee has s also accepted the repudiation of Op as correct and the same was also informed to the complainant but the complainant instead of appearing from the Ombudsman he has filed the present complaint just to harass the Op. Under the above circumstances the Op’s company comes to the conclusion that the claim of the complainant is illegal and there is no deficiency in service on the part of the Op’s company the repudiation is on valid and justifiable ground. The company has repudiated claim after due application of mind to the facts & circumstances of the case. By considering the above all facts and reasons the OP’s company sought for the dismissal of the complaint with exemplary cost.
4. In-view of the facts and circumstances of this case. Now the points that arise for our consideration and determination are that:
1. Whether the complainant proves that, there is a deficiency in their services on the part of the Op’s company as alleged.
2. Whether complainant is entitled for the reliefs as prayed in this complaint.
3. What order?
5. Our findings on the above points are as under:-
- In the affirmative against Op.
- As discussed in the body of this order.
(3) In-view of the findings on Point Nos- 1 & 2, we proceed to pass the final order for the following :
REASONS
POINT NO.1 & 2:-
6. In order to prove the facts involved in these two points, affidavit-evidence of complainant was filed, who is noted as PW-1. Documents at Ex.P-1 to Ex.P-4 are marked. On the other hand, the Op’s company has filed affidavit-evidence of In charge Manager of Op’s Company by name Vinay Kumar has been filed he has noted as RW-1 and also filed affidavit-evidence of one R.Ashwini Kumar who is noted as RW-2. Totally in all 13 documents at Ex.R-1 to R-13 are marked on behalf of Op’s Company.
7 It is the case of the complainant that, , the father of the complainant by name K.Sriramalu had obtained the policy vide policy No. 0282168911 for Rs.5,00,000/- by paying yearly premium amount of Rs.26,310/-. On 24-01-2013 the policyholder said K.Sriramalu was died, after his death the complainant being a nominee approached the Op’s Company for to settle the claim but the Op’s Company has not settled the claim on the ground that, the K.Sriramalu was suppressed material facts i.e, earlier he was suffering from cancer by suppressing this fact obtained the policy hence claim has been repudiated by the Op’s Company.
8. We have perused the record and pleadings of the parties. It is not in dispute that, K.Sriramalu was obtained the policy from Op’s Company for a sum assured amount of Rs.5,00,000/- which is commencing from 28-09-2012 as per Ex.R-2. Further it is not in dispute that, the father of the complainant was died on 24-01-2013 as per Ex.P-4 i.e, death certificate and further it is also not in dispute that, claim of the complainant has been repudiated by the Op’s Company through repudiation letter dt.10-02-2014 vide Ex.P-1.
9. The Op’s Company has repudiated the claim of the complainant on the ground that, the father of complainant was suffering from cancer prior to obtaining the policy and was taken treatment at MRD Gandhi Hospital, Secunderabad (AP), and died because of the said disease, but his fact was not disclosed by the father of the complainant while obtaining the policy and thereby suppressed the real fact and obtained the policy. Hence the claim of the complainant has been repudiated. The Op’s Company in order to prove their defence they have mainly relied upon the document produced under Ex.R-5 & R-6 to R-9.
10. On perusal of Ex.R-6 i.e, Statement of villagers we have gone through the said document no doubt in the said document the villagers have stated that, the father of the complainant was suffering from cancer and it is also stated that, he has taken treatment in Bangalore, Hyderabad and also in Maharastra. No doubt the Statement of the villagers has been made available before this forum for to establish the claim of the Op’s Company but we do not find any reasons to believe that, why the Op’s Company has not taken any pain or interest to lead the evidence of any one of the witnesses those who are alleged to the villagers of life assured K.Sriramalu to prove their statement in the absence of such evidence it is very difficult to believe that, said statements have been given by the said persons who have signed in it and they are the villagers of the said K.Sriramalu and they have know about the pre-existing disease of the life assured and it is also very difficult to understand that, where he has taken treatment and for what disease. Further, the said Ex.R-6 is also not clear that, who has written the said document and before whom they have signed on it. In the said document it is appears that they have signed only as a witness and they are not the author of the said document. Further it is also not cleared that, when that document has been written and where that has been written the said document carries no date and place. Under these circumstances, the documents itself is creating so many doubts and also not giving clear picture about its birth, in the absence of that, the credibility of the said documents is itself doubtful hence the Op’s Company reliability on the said documents holds no good and the conclusion of its contents as supportive evidence of their opinion cannot be accepted even for the sake of argument, we have come to the conclusion that, the document is proper that has not been proved by evidence. Hence, we have not accepted the same.
11. We have perused the Ex.R-9 i.e, investigation report submitted by Op’s Company the entire investigation report is depending upon the statement of the villagers i.e, Ex.R-5 and the Ex.R-9. We have perused the Ex.R-9 the case sheet of MRD Gandhi Hospital, Secunderabad. After perusal of the entire case sheets at no page the said case sheet has been signed by any one of the doctor who has alleged to be treated to the life assured K.Sriramalu. Further it is also very clear that, there are two thumb impression on the case sheet apart from that, there is no any prove that, the said case sheet has been belongs to K.Sriramalu except the name mentioned in it, there is no evidence to show that, the thumb impression which are appearing on the said case sheet or belongs to K.Sriramalu. Further the said case sheet is also not discloses neither the name of the doctor nor signature or seal on it. The Op’s Company though they are mainly depending upon the said document they have not made any efforts to lead the evidence of treated doctor. In the absence of that, once again the credibility of the said document will remain under doubtful. Under the above circumstances, the question before us will arise that, whether the medical report of the MRD Gandhi Hospital, Secunderabad will give clear support to the case of the Op’s Company. But in our view no. Further on perusal of the said document it is also very clear that, who have issued the said document for that also there is no evidence by the Op’s Company. Hence we have not accepted the Ex.R-9 as a proper and valid document to prove the case of the Op’s Company.
12. When these two documents in our view holds no good to prove the case of the Further on perusal of the said document it is also very clear that, who have issued the said document for that also there is no evidence by the Op’s Company. By relying on the same document if, the investigator investigated the case of the life assured and given report regarding pre-existing disease holds no good at all.
13. The Op’s Company relied upon the investigation report which has been based on the Ex.R-6 & R-9 and come to the conclusion that, the investigation has been conducted earlier to the repudiation of the claim and on the basis of investigation the pre-existing disease came to know to the Op’s Company but regarding the said Ex.R-6 & 9 we have clearly stated our view and come to the conclusion that, said documents are not believable as they are having lot of ambiguity about their existence and its contents. Unless otherwise the said documents have been proved by the Op’s Company with proper evidence they cannot be treated as a supportive document of the investigation report. Mere depending upon the said doubtful documents filing the investigation report by the Op’s Company and coming to the conclusion that there is a material fact to hold that, there is a pre-existing disease cannot be accepted. Hence we have not accepted the investigation report as it is based on unreliable document under Ex.R-6 & R-9.
14. On perusal of the Ex.R-2 i.e, Insurance policy produced by Op’s Company it appears that, the policy has been taken for sum assured of Rs.5,00,000/- it is an huge policy which has been taken by the life assured. The Insurance company at the time of issuing of the policy definitely they are suppose to ask for clear medical checkup of the life assured and they have to accept the proposal form according to the complainant the Op’s Company has taken due care and after relevant tests and examination only they have got issued the policy. The Page-3 of the Ex.R-1 at para-18 it is very clear that, medical information has been gathered by the Op’s Company and why they have not taken proper care or why the disease was not identified by the Op’s Company at the time of issuing the policy is a big question which we do not find any answer by the Op’s Company. In the absence of such information the Op’s Company cannot deny the claim on the suppression of material fact. In this regard the Hon’ble National Commission in Bajaj Allianz Life Insurance company LTd., V/s. Rajkumar’s case clearly held that, authored doctor of insurance examined insured assessed fitness and after complete satisfaction of policy was issued__ it cannot be presumed that insured/deceased was aware of multiple myeloma/ blood cancer and he concealed previous illness __repudiation not justified. If we gone through the said ruling the case in hand is closely matchup with the above said case and the version of the Op’s Company cannot be reliable from the case in hand.
15. The complainant in his letter dt. 18-03-2014 requested the Op’s Company to settle the claim by denying the entire version of the Op’s Company, this letter itself speaks that, there is no any admission by the complainant regarding pre-existing disease and documents made available in that regard by the Op’s Company. Under such circumstances it is the bounded duty of the Op’s Company to prove the same by proper evidence. In the absence of that, version of the Op’s Company cannot be believed as they are true and relevant.
16. No doubt the Op’s Company has referred the matter to their review committee for to settle the claim and in turn the committee has refused the claim of the complainant. But in the said repudiation also the review committee has come to the conclusion that, the suppression of material fact is the only ground to repudiate the claim of the complainant. But how they have come to the conclusion to give the said verdict against the complainant, in absence of other reasons we could believe that, the review committee has taken the decision only on the basis of survey report. In our view the said survey report holds no good as we stated supra. Therefore the decision of the review committee and Op’s company is in our view just baseless as it is borne out of the doubtful and unbelievable documents.
17. No doubt the life assured has lost his life, now the question is how is death has been caused the complainant in his complaint has clearly stated that, he has died due to chest pain and not by cancer as contended by the Op’s company. No doubt the Op’s company filed two documents to show that, he has died due to cancer but that was not proved by any evidence and apart from that the documents what Op’s company has field are doubtful and unbelievable one. If at all Op’s company wants to prove his case it is his duty to prove that what is the reason for the cause of death and how the pre-existing disease was the life assured was having and died for the same, in absence of any evidence the version of the Op’s company cannot be believed. Hence, we have hold that, the death of the life assured is not due to pre-existing disease and due to chest pain as contended by the complainant.
18. No doubt the Op’s company has filed almost all (17) rulings in support of his case but the jist of all the said rulings were regarding repudiation of claim on the ground of suppression of material facts, wrong answers while taking policy and death in short period etc., but the facts of the case in hand and the facts involved in the said rulings are quite different hence with great respect we have not accepted the said rulings.
19. The complainant in support of this case filed ruling of Hon’ble National Commission cited in 2011 CPJ wherein it has held that, Insurance Company not able to prove allegations of fraudulent concealment pertaining to health of disease then the repudiation cannot be justified on the ground of suppression of material facts. In the present case the Op’s company has utterly failed to prove the material facts which has been suppressed by the complaisant hence the reputation cannot be justified. This version ample applicable to the case of the complainant, hence we have accepted the same.
20. Viewing from all angles, facts and documents made available before this forum, we are of the opinion that, the Op’s company has utterly failed to comply the claim of the complainant. Hence we are of the opinion that there is a deficiency in service on the part of the Op’s company. So we have answered in Point No.1 & 2 affirmative.
21. The complainant in his complaint has claimed Rs.15,00,000/.- along with Rs.1,00,000/in respect of policy in question and also interest at the rate of 2% and Rs.1,00,000/- towards damages, expenses etc., But on perusal of Ex.R-2 policy the sum assured is only Rs.5,00,000/- and it is a policy Bajaj Allilanz Invest Gain Diamond Plan. Under such circumstances, no doubt the complainant is entitled to recover the sum assured amount of Rs.5,00,000/- along with benefits arise out of the said policy under the Bajaj Alllianz Invest Gain Diamond Plan and also he is entitled to recover interest at the rate of 9% p.a. on Rs. 5,00,000/- and total benefits arising out of the said policy. The complainant is also entitled to recover Rs.5,000/- towards cost and deficiency in service. The complainant in his complaint as sought Rs.1,00,000/- as damages, but the claim of the complainant is high and exhorbitant one. Hence, we have rejected the same.,accordingly we answered point No.2.
POINT NO.3:-
22. In view of our finding on Point No-1 & 2, we proceed to pass the following order:
ORDER
The complaint filed by the complainant is partly allowed with cost.
The Opposite Party is directed to pay the sum assured amount of Rs.5,00,000/- along with benefits arising out of the said policy plan with interest at the rate of 9% p.a. and also entitled to recover Rs.5,000/- towards cost and deficiency in service.
One month time is given to the Opposite Party to comply the above said order from the date of this order.
Intimate the parties accordingly.
(Dictated to the Stenographer, typed, corrected and then pronounced in the open Forum on 23-12-14)
