State Consumer Disputes Redressal Commission
Smt. Parvathapu Mangamma vs The Aviva Life Insurance Company India ... on 17 January, 2022
BEFORE THE TELANGANA STATE cONSUMER DISPUTES
REDRESSAL COMMISsION ; HYDERABAD.
CC.NO.58 OF 2019
Between:
Smt.Parvathapu Mangamma
W/o.Late Narsaiah Chary,
Age: 36 years, Oc: Household,
R/o.H.No.13-51, Yadav Bazar,
Huzurnagar Village and Mandal of
Nalgonda District -508204.
....Complainant
And
The Aviva Life Insurance Company India
Ltd., Rep. by its Manager,
Aviva Tower, Sector Road,
Opp: Golf Course, DLF Phase V,
Sector-43, Gurgaon - 122003,
Haryana State.
.Opposite Party
Counsel for the Complainant :M/s.Gopi Rajesh 8 Associates
Counsel for the Opposite Party: M/s.G.Nagesh
QUORUM: SRI JUSTICE M.s.K.JAISWAL, HON"BLE PRESIDENT
HON BLE SMT.MEENA RAMANATHAN .. LADY MEMBER
MONDAY, THE SEVENTÉENTH DAY OF JANUARY TWO THOUSAND TWENTY TWO k****** Order
1. This is a complaint filed by the Complainant under Section 17 (1) (a) () of the Consumer Protection'Act, 1986, praying this Commission to direct the Opposité Party:
(a) to pay Rs.25,00,000/- (Rupees twenty five lakhs only) along with interest 18% p.a: from the date of repudiation i.e., 30.06.2014 till the date of realization;
(b)
(b) to pay compensation of Rs.2,00,000/- by the Opposite Party to the Complainant towards mental agony and loss caused punitive and also pay Opposite Party the acts of the of the Consumer Protection Act; damages U/s. 14(1)(d) (C) to award costs of Rs.5,000/.
2. The brief facts of the case are that, the Complainants Shield husband late Parvathapu Narsaiah Chary took 'Aviva Life for a Advantage' policy during his life time from the Opposite Party sum of Rs.25,00,000/- bearing No.ALA 3131951. The annual term of 22 wa_ Rs.22,834/- for a premium for the said policy years. The said policy period was from 31,03.2013 to 31.03.2034 and the Complainant was the nominee. It is further submitted that, the Complainant's husband was a. tailor by profession and while doing his work he got chest pain süddenly and was admitted in NIMS hospital on. 16.12.2013. While undergoing treatment, he died on 09.04.2014. It is submitted that, prior to death he was hale and healthy did not have any ailment. After the death, the Complainant being nominee. made a claim to the Opposite Party, but to her surprise her claim was repudi ted by the Opposite Party on 30.06.2014 after lapse of three months from the date of claim. The Opposite Party repudiated the claim on the ground that, the Complainant's husband was a diabetic mellitus and hypertension.
3. I t is further submitted that, the Complainant made a representation to the Opposite Party Review Committee and requested to settle the claim, but the said Claim Review Committee declined the claim. The Complainant submitted that, the Opposite Party repudiated the claim solely on the ground that the insured has suppressed that the deceased 'was suffering from diabetes mellitus and hypertension in the proposäl form. In spite of several letters and representations, the Opposite Party repudiated the claim. With these allegations, the Complainant alleges deficiency in service and unfair trade practice on the part of the Opposite Party and prayed to allow the complaint.
3 version denying the
4. The Opposite Party filed written
they issued
averments of the Complainants. It is admitted that,
No.ALA3131951 to
"Aviva Lifeshield Advantage' policy bearing
31.03.2013
deceased on
Mr.Parvathapu Narsaiah Chary, the
was
Smt.P.Mangamma,
wherein his wife who is the Complainant assured sum of named as nominee. The policy was for an was payable for a Rs.25,00,000/- for which the annual premium the deceased expired sum of Rs.22,834/-. It is contended that, issuance of the date of only within a short span of 9 months.from as per the the policy. Hence, Opposite Party investigated the claim, it investigation and a s s e s s m e n t of. procedure. During and correct the deceased did not provide true was found that his form with respect to information while filling up the proposal revealed that, he was suffering from medical history. It was treatment and was under
Diabetes Mellitus and Hypertension since 2011 i.e., prior to the issuance of the policy. The Opposite treatment records of various hospitals which clearly Party procured material fact regarding establishes this fact. By concealing this to issue .
medical history, the deceased induced the Opposite Party contended that, even after the in his favour. lt is further policy DLI from grave DM & HTMT aware that he was suffering being at not disclosing the 'medical history opted for the policy by the undue advantage out of the same proposal stage in order to get form. Thus, the and provided false information in the proposal repudiated the claim of the Opposite Party had rightly false information at the Complainant on the ground of providing the time of filling up the proposal. form. With these contentions, Opposite Party denies deficiency in service on their part and prays to dismiss the complaint.
5. The Complainant filed evidence affidavit and produced documents Ex.A1 to A11 to prove her case. The Opposite. Party filed evidence affidavit and Ex.B1 to B7 marked on their behalf.
The Complainant filed written arguments.e Both parties advanced oral arguments.
6 Heard both sides. The point that arise for consideration is, whether there is a deficiency in service on the part of the Opposite Party and if so, to what relief?
7. Alter having heard the submissions of the learrned counsel appearing for the, Complainant and the Opposite Party/Insurance Company, what is required to be seen is, as to whether the life assured is guilty of having suppressed, material information irom the Opposite Party at the time when. he obtained the insurance policy.
.8.
The admitted fact.is that, the life assured aged about 4 years has taken the policy from the Opposite.Party for a sum of Rs.25.00 lakhs on 31.03.2013 by paying premia oithe annual Rs.22,834/-. Even before the due date for the second premia was due,. the life. assured fell sick and he admitted in NIMS was Hospital on 16. 12.2013 and. died due to cardiac .arrest on 09.01.2014. Since the death was within period of one year, a a thorough investigation was done during the course of which it came to be noticed that the life assured has suppressed the fact that he had undergone treatment for the cardiac problem two years prior to taking the policy by getting himself treated in NIMS. Suppressing the said fact, it is alleged that the life assured has declared himself be hale and to healthy in' the proposal form, believing which the Opposite Party/Insurance Company has issued the policy.
9. The legal position this àspect' is well settled. The contract on of the insurance in between the life assured and the insurer is based on the principle of utmost good faith. If it is shown that the life assured has taken the policy by. suppressing existence of a material ailment: which was wel within his knowledge and obtaining the policy and ultimately succumbs to that ailment after the policy is issued, he will be held to be responsible for having suppressed the material information from the Insurunee Company thereby making the lusurance Company to acocept the proposal. It no satislactory cvidençe is produced to show that prior to the proposal and issuanee of the poliey, the lile assured had any ailment which was well within his knowledge, underwent treatment there for, did' not disclose the same and subsequently resulting in the death and it there is a nexus between all these three, then only the lnsurance Company can be heard saying that the claini of the lile assured is liable to be repudiated on the ground of suppresio varic.
10. In the instant case, the repudiation letter is marked as Ex.A8 is cquivalent to Ex.B5 the lnsuranee Company repudiated the claim observing as under:
"As per the records procured by us during claim evahuation, the deceased life assured was suffering from Diabetes Melitus and hypertension and was under treatmerit since 2011 which is prior to proposal".
It is further mentioned in the said repudiation letter that, since that information was suppressed, the claim is repudiated,
11. As already stated, if the Insurance Company can establish by producing cogent' and convincing evidence to show that before the proposal was submitted, the life assured was suffering with ailments which he has not disclosed in spite of there being a specific query to that effect in the proposal, then the Insurance Company is justified in repudiating. In the instant case, the documents that are produced by the Insurance Company do not convincingly establish that before the taking of the policy, the life assured was suffering with any serious ailmont which was well within his knowledge and he has suppressed the same. The'only document that is relevant is dated 22.01.2011 and the document shows that the deceased was .suspectod to be DM Type 2 and Hypertension. 2D Echo was normal, BCG was done and everthing was found tobe normal and the medicine that is prescribed as per the said document is Brufen & Rantac,which to our knowledge do not prescribe for either the deceased was diabetic, hypertension or cardio vascular disease. Thàt apart this document do not inspire any confidence for the teason that it is not The evidence that satisfactorily produced.
is produced on behalf of the Opposite Party/ Insurance Company is far from assured has satisfactory for holding that the lit suppressed the existence of any seriqus ailmen thereby mis-representing the facts to the obtaining the Insurance Company and policy. Therefore, the Insurance repudiation as made by the Company cannot be sustained and the be set same is liable to aside. The Opposite Party/Insurance Company is bound to satisfy the claim of the assured has Complainant in view of the fact that life died due to Cardiac Arrest after Hospital for nearly three weeks. undergoing treatment in NIMS answered. The point is accordingly
12. In the result, the Party to pay the complajnt is allowed directing the Opposite sum assured to the interest thereon @ 6% Complainant together with p.a. from payment. The Comnplainant is also 01.07.2014 till the date of Time for entitled to costs of compliance is 30 days. Rs.5,000/-.
PRESIDENT LADÝ MEMBER
Dt: 17.01.2022.
UC
APPENDIX OF EVIDENCE
WITNESS EXAMINED
Evidence
affidavit of Parvathapu
Mangamma, Complainant herein. Evidence affidavit on
behalf of Opposite
Party
For Complainants EXHIBITS MARKED
Ex.A1 Copy of
First Premium Receipt dated 31.03.2013. Ex.A2 Copy of Schedule of Policy dated 31.03.2013. Ex.A3 Copy of Policy information Ex.A4 Copy of list of Insurance Ombudsman Ex.A5 Copy of Terms & Conditions of Insurance Policy Ex.A6 Copy of Proposal Form dated 31.03.2013. Ex.A7-Copy of Death Summary along with Case Sheet and medical records of the deceased/life assured, issued by NIMS, Hyd. Ex.A8 -
Copy of the letter dated 30.06.2014 addressed to the Complainant by the Opposite Party. Ex.A9 Copy of letter dated 26.09.2014 addressed to the Complainant by the Claims Review Committee of Opposite Party.
Ex.A10 -Copy of letter dated 16.10.2014 addressed to the Complainant by the Opposite Party. Ex.A11 -Copy of letter dated 17.11.2014 addressed to the Complainant by the Opposite Party.
For the Opposite Parties:
Ex.B1 Copy of Proposal Form dated 31.03.2013.
Ex.B2 Copy of Schedule of Policy Ex.B3 Copy of Death Claim Form (DCF) Ex.B4 Copies of Investigation Report along with medical reports.
Ex.B5 Claim repudiation letter dated 30.06.2014.
Ex.B6 Letter dated 26.09.2014 addressed by the Complainant to the Opposite Party regarding death claim. Ex.B7 Letter dated 17.11.2014 addressed by the Opposite Party to the Complainant.