Andhra Pradesh

East Godwari-II at Rajahmundry

CC/33/2015

Smt.Jujjavarapu Sesha Ratnam - Complainant(s)

Versus

The Sr. Zonal Manager, L.I.C of India - Opp.Party(s)

P. Sambhu Prasad

04 Dec 2015

ORDER

                                                                                                                       Date of filing:   12.05.2015

                                                                                                Date of Order: 04.12.2015

 

BEFORE THE DISTRICT CONSUMER FORUM-II, EAST GODAVARI

DISTRICT AT RAJAHMUNDRY

 

          PRESENT:   Sri A. Madhusudana Rao, M.Com., B.L.,  .. President (FAC)

                                Sri S.Bhaskar Rao, M.A., B.L., D.P.M.,    .. Member

                               

                                                  Friday, the 4^th day of December, 2015

 

C.C.No.33 /2015

Between:-

 

Smt. Jujjavarapu Sesha Ratnam, W/o. late J. Radha

Krishna, aged about 55 years, D.No.3-15-58,

Plot No.F-3, Balaji Paradise, Hukumpeta, Morampudi,

Rajahmundry, E.G. District.                                                                                                                     …        Complainant

 

                                    And

 

1)  The Sr. Zonal Manager, South Central Zonal Office,

      L.I.C. of India, Saifabad, Hyderabad – 500463.

 

2)  The Divisional Manager, L.I.C. of India,

      Morampudi Junction, Rajahmundry – 533103.                                                                                …        Opposite parties

                        

 

 

            This case coming on 03.12.2015 for final hearing before this Forum in the presence of Sri P. Sambhu Prasad, Advocate for the complainant and Sri P.L.N. Prasad, Advocate for the 1^st & 2^nd opposite parties, and having stood over till this date for consideration, this Forum has pronounced the following:  

 

O R D E R

[Per Sri S. Bhaskara Rao, Member] 

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.5,00,000/- under Policy No.804261317; to pay Rs.500/- towards legal notice charges and pay Rs.2,00,000/- towards damages for physical and mental agony.

2.         The case of the complainant is as follows:-  It is submitted that the complainant’s husband i.e. J. Radha Krishna, Rajahmundry during his life time took life insurance policy, bearing Policy No.804261317 on 28.6.2010 at L.I.C., Rajahmundry branch and the said policy valid for a period of 12 years as per the scheme, and it commenced from that date onwards.  The insurer paid annual premium at Rs.24,020/- every year, regularly, the said policy sum assured of Rs.5,00,000/- excluding bonus and other benefits etc.  During the pendency of the policy, unfortunately, the policyholder died on 8.3.2013 due to cardio respiratory arrest.  As per the policy, the complainant is a nominee of the policyholder. After his death, the complainant submitted claim form, death certificate, insurance policy along with all the relevant papers to the opposite parties for claim of Rs.5,00,000/- as per the insurance amount as death insurance benefits under the policy.  Inspite of the repeated demands and requests made by the complainant, finally, to the utter shock and surprise to the complainant, the opposite parties addressed a letter of repudiation dt.29.1.2014 with false and baseless allegations.  Further, the said letter of repudiation issued only to avoid opposite parties contractual liability in order to cause wrongful loss to the complainant and wrongful gain by the opposite parties.  As the policyholder died due to natural cause, but not due to other cause, due to repudiation of the claim of the complainant. The opposite parties committed deficiency of service and unfair trade practice with the consumers. The opposite parties without settling the present policy claim and dragging the matter with some pretext.  The complainant issued legal notice dt.23.8.2014 through her counsel to the opposite parties.  The 1^st opposite party acknowledgement not yet returned to the complainant counsel till today. The 2^nd opposite party received the notice, but not issued any reply notice to the complainant. The 2^nd opposite party not paid the insurance amount to the complainant and kept quiet.  Hence, the complaint.

3.         The 2^nd opposite party filed its written version and the same was adopted by the 1^st opposite party and denied all the allegations made by the complainant.  It is submitted that the complainant is not a consumer and this Hon’ble Forum has no jurisdiction to entertain the present complaint and the same is dismissed in limini.  It is true that this opposite party issued Policy No.804261317 to the deceased J. Radha Krishna for a sum assured of Rs.5,00,000/- under table and terms 165 and 12, date of commencement from 28.6.2010 and the date of risk commencement from 15.7.2010 on yearly mode of premium amount, premiums received up to 06-2012 and 1^st unpaid premium is due on 28.6.2013.  The complainant is nominee under the policy. This opposite party received the death intimation on the policy from the complainant as the policyholder expired on 8.3.2013.  It is submitted that since the claim was arisen within 2 years 7 months 23 days from the date of admission, this opposite party made thorough investigation and found that the policyholder had suppressed his health condition as per the following evidence:

(a)  He had kidney transplantation on 26.2.2011 at Seven Hills Hospital, Visakhapatnam and as per the case sheet before transplantation, he was on regular dialysis since 14.12.2010 had chronic kidney disease since 2007 type-II diabetic since 22 years had Hypertension BP since 8 years;

(b)  Moreover as per the details given by Queens NRI Hospitals, Visakhapatnam where the policyholder was treated during last days, he had chronic kidney disease post renal transplant-2011 type-II DM Chronic Liver Disease, Thrombocytopenia and HCV+Ve (Hepatitis-C);

(c)  All these details are clearly evident from the case sheet obtained from Seven Hills Hospital, Visakhapatnam, this opposite party has taken repudiation action and there is no lapse in service on the part of this opposite party.

As per the above details of suffering from Diabetics, hypertension and chronic kidney disease which the deceased policyholder had prior taking the proposal were not disclosed by him, the claim was repudiated. The repudiation is rightly made by this opposite party after thorough investigation and communicated to the same on 29.1.2014, which shows that there is no deficiency of service on the part of this opposite party.  Hence, this opposite party prays that the Hon’ble Forum may be pleased to dismiss the complaint with costs.

4.         The proof affidavit filed by the complainant and Exs.A1 to A7 have been marked. The opposite parties 1 & 2 filed proof affidavit and Exs.B1 to B7 have been marked.

5.         Heard both sides.

6.         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?

7.  POINT Nos.1 & 2:  As per the available record, the complainant herein is the nominee of L.I.C. Jeevan Saral Policy obtained by her husband i.e. the deceased life assured on 28.6.2010 vide Policy No.804261317 for an assured amount of Rs.5,00,000/- and paid a yearly premium amount of Rs.24,020/- under Ex.A1 on submission of Ex.B1 proposal form by the deceased life assured. Ex.A2 is the renewal premium receipts dt.9.8.2011 and 16.8.2012. Ex.A4 is the family members details as per household card issued by the Revenue authorities, Kadiyam. During the currency of the policy, the deceased life assured died on 8.3.2013 as per the death certificate issued by the Municipal Corporation, Visakhapatnam under Ex.A3.  Ex.A5 = Ex.B4 is the repudiation letter dt.29.1.2014 issued by the 2^nd opposite party divisional office, Rajahmundry stating that the deceased life assured had been suffering from type-II diabetes mellitus since 22 years, hypertension since 8 years, and chronic renal failure since 2007 i.e. prior to the date of commencement of risk of the policy as the proposal was submitted on 22.6.2010.  Ex.A6 is the legal notice dt.23.8.2014 got issued by the complainant/nominee demanding for payment of the assured claim amount of Rs.5,00,000/-, Rs.2,00,000/- towards damages and Rs.5,000/- towards notice charges and Ex.A7 is the acknowledgement issued by the 2^nd opposite party.

The Ex.B2 is the admission record of the DLA dt.21.2.2011 issued by the Seven Hills Hospital, Visakhapatnam and Ex.B3 is the medical record of Queens NRI Hospital, Visakhapatnam where the deceased life assured treated before his death. The opposite parties filed claim statement, hospital treatment certificate, medical attendants certificate, identity certificate and burial or cremation and confidential report by the agent under Ex.B5. Ex.B6 is the DMR report stating the death claim as not admissible. Ex.B7 is the Dispute redressal committee proceedings of Rajahmundry Rural Branch of opposite parties in respect of the deceased life assured.      

            It is observed that the opposite parties repudiated the claim of the present complainant due to non-disclosure of material information in the proposal for assessing the risk and accepting the risk. We further observed that as per Ex.B1 proposal form submitted by DLA on 28.6.2010 at the time of obtaining the insurance policy stated in negative in his personal history for the questions vide column 11(d) Are you suffering from or have you ever suffered from ailments pertaining to liver, stomach,  heart, lungs, kidneys, brain or nervous system? and under column No.11(e) Are you suffering from or have ever suffered from diabetes, tuberculosis, high blood pressure, low blood pressure, cancer, epilepsy, hernia, hydrocele, leprosy or any other disease?  Further, the DLA declared that he is aware of contents of the proposal form and further signed before the medical examiner at the time of submission of proposal for obtaining the present insurance policy.

            But, as per Ex.B2 medical record of Seven Hills Hospital, Visakhapatnam, the deceased life assured admitted in their hospital on 21.2.2011 and discharged on 7.3.2011 after kidney transplantation by the hospital on 26.2.2011. As per this medical record, the provisional diagnosis is that the deceased life assured was a chronic renal failure for kidney transplantation. The self explained history of DLA’s complaint as per Seven Hills Hospital medical record, the deceased life assured had history of CRF (chronic renal failure) since 2007 and on dialysis since 14.12.2010. Further, the DLA had a history of hypertensive and diabetes mellitus. We further observed that as per Ex.B3 medical record of Queens NRI Hospital, Visakhapatnam where the DLA was diagnosed as CKD, Post renal transplant 2011, type-II DM, CLD, HCV +ve and Thrombocytopenia.  The DLA was admitted in ICU on 6.3.2013 with history of headache followed by sudden loss of consciousness. On examination, the doctors found that the general condition of the DLA is poor, unconsciousness with BP recorded as 200/100 mm Hg. and RBS at 168 mg./dl. and the deceased life assured J. Radhakrishna declared expired at 4-45 PM on 8.3.2013 and the cause of the death was mentioned as Cardio respiratory arrest secondary to CLD related to Thrombocytopenia, IC breed.

            As per the record, the deceased obtained the policy No.804261317 for Rs.5,00,000/- and the date of commencement of the policy is 15.7.2010 and by the date of death of deceased life assured, the policy was 2 years 7 months 23 days old. The opposite parties established that the deceased life assured suppressed material information of history of diabetes for 22 years, HTN for 8 years and CKD for 4 years and was on dialysis with related medical record and the complainant failed to file any contra evidence that their claim is admissible under the facts and circumstances of the case.

The opposite parties relied on the following decisions in support of their contention.

1. Manager, LIC, Madhugiri Branch, Bangalore Vs. Muddu Lakshmi, R.P.No.4770/2013 NCDRC,
2. LIC of India, Machilipatnam Vs. Murala Siva Parvathi, R.P.No.602/2009, NCDRC,
3. Smt. Malla Devi Vs. Sr. Divisional Manager, Jaipur & another, Appeal No.1657/2006 SCRDC, Rajasthan,
4. LIC of India, Mumbai Vs. Smt. Poonam Surendra Sharma, First Appeal No.1642/2007, MSCDRC,
5. Regional Manager, LIC of India Vs. Shri Shahaji Sattapa Kamble, First Appeal No.A/99/1099, MSCDRC,
6. LIC of India & Anr Vs. Smt. Vimla Verma, R.P.No.2386/2007, NCDRC.

In all the above citations, it was held that any fact, the knowledge or ignorance of which would materially influence, an insurer estimating the degree and character of risks in fixing the rate of premium is a material fact. So, all the above said decisions are applicable to the facts and circumstances of the case on hand. Hence, we cannot attribute any kind of negligence or deficiency on the part of the opposite parties and the complaint is liable to be dismissed.                 

8.   POINT No.3:  In the result, the complaint is dismissed, without costs.

 

Typed to dictation, corrected and pronounced by us in open Forum, on this the           

4^th day of December, 2015.

    

                 Sd/-xxx                                                                                           Sd/-xxx

              MEMBER                                                                              PRESIDENT(FAC)

         

 

APPENDIX OF EVIDENCE

WITNESSES EXAMINED

 

FOR COMPLAINANT: None.                                                                                              FOR OPPOSITE PARTIES: None.

 

DOCUMENTS MARKED

 

FOR COMPLAINANT:

 

Ex.A1    Attested copy of Photocopy of insurance policy dt.28.6.2010 stands in the name of J.

  Radha Krishna, Policy No.804261317.

Ex.A2    Renewal Premium receipt (two) dt.9.8.2011 and 16.8.2012.

Ex.A3    Attested copy of death certificate of late J. Radhakrishna, his death was 8.3.2013.

Ex.A4    Attested copy of Household card of the complainant.

Ex.A5    Repudiate letter dt.29.1.2014 issued by the opposite parties.

Ex.A6    Office copy of legal notice dt.23.8.2014 issued by the complainant’s advocate to the

  opposite parties 1 and 2 with two postal receipts.

Ex.A7    Postal acknowledgement card of the opposite party No.2.

 

FOR OPPOSITE PARTIES:-  

 

Ex.B1    Attested copy of the policy.

Ex.B2    Seven Hills Hospital, Visakhapatnam treatment details (attested copy).

Ex.B3    Queens NRI Hospitals, Visakhapatnam treatment details (attested copy).

Ex.B4    Repudiation letter dt.29.1.2014 (attested copy).

Ex.B5    Attested copy of claim forms A, A1, B, B1 and C.

Ex.B6    Attested copy of DMR opinion.

Ex.B7    Attested copy of Redressal committee proceedings.

 

                  Sd/-xxx                                                                                         Sd/-xxx

              MEMBER                                                                              PRESIDENT(FAC)