State Consumer Disputes Redressal Commission
Sankella Vijaya Laxmi, W/O Late ... vs Lic Of India, Warangal And One Another on 22 May, 2013
A. P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION : AT HYDERABAD FA 210/2012 against CC 234 of 2011 on the file of the District Consumer Forum, Warangal. Between: Sankella Vijaya Laxmi, W/o late Nagaraju, Age: 43 yrs, R/o H.No.7-149, Ram Nagar, Hasanparthy Post and Mandal, Warangal District. Appellant/complainant And 1) The Branch Manager, LIC of India, Warangal I branch office, Opposite to MGM Hospital, Warangal 506 002. 2) The Divisional Manager, Life Insurance Corporation of India, Divisional office, Jeevan Prakash, Near Ambedkar Statue, Balasamudram, Hanamkonda, Warangal District. Respondents/Opposite Parties Counsel for the Appellant : Mr. K Karunakar Counsel for the Respondents : M/s. A. V. Satyanarayana Rao Coram ; Sri R. Lakshminarasimha Rao Honble Member
And Sri T. Ashok Kumar .. Honble Member Wednesday, the Twenty Second Day of May Two Thousand Thirteen Oral Order : ( As per Sri T. Ashok Kumar , Honble Member ) ****
01. This is an appeal preferred by the unsuccessful complainant as against the orders dated 09.01.2012 in CC 234/2011 on the file of the District Consumer Forum, Warangal. For convenience sake, the parties as arrayed in the complaint are referred to as under :
02. The brief facts of the complaint are that the complainant is the wife of the deceased Nagaraju, who died on 24-05-2008 due to fever and Vomtings. During his life time the deceased Nagaraju obtained Jeevan Mitra with Profits with DAB, covering Double/Thrible Risk with table 88 bearing NO.686904956 from opposite party No.1 for an assured sum of Rs.75,000/- commenced from 28-04-2007 for which the complainant is the nominee. After the death of her husband, as nominee, the complainant submitted the claim form along with relevant documents through Agent of opposite parties for settlement of the claim. But the opposite repudiated the claim vide letter dated 31-03-2010 on the ground that the life assured has availed sick leave on number of occasions before the date of proposal and he did not disclose the above said facts in the proposal and he suppressed the facts and given false answers and it amounts to deficiency of service. Hence filed this complaint praying to direct the opposite parties to pay sum assured amount of Rs.75,000/- under the above said policy, to pay Rs.75,000/- towards double risk coverage amount as per table 88 of the policy with interest @12% p.a. from 01-10-2008 to 30-04-2011 for Rs.46,500/-, to pay Rs.4,000/- towards bonus, to pay Rs.20,000/- towards mental agony, to pay Rs.1,500/- towards traveling expenditure to award legal expenditure of Rs.2,000/- with costs.
03. OP filed counter opposing the claim of the complainant and denying the allegations made in the complaint but admitted that the deceased Nagaraju obtained a life insurance policy No.686904956 for sum assured amount of Rs.75,000/- under Salary Savings Scheme and the wife i.e, complainant is the nominee. It is further contended that as per the intimation received by Hanamkonda Branch office of the opposite parties corporation, the life assured died on 24-05-2008, since the death of the life assured occurred within two years, treating the same as very early claim, as per the rules of opposite parties corporation, on investigation, it came to the light that the deceased life assured had availed leave on sick grounds on 12 occasions prior to date of proposal under the aforesaid policy. On 01-07-2005 the deceased availed EL for 7 days, on 12-07-05 he availed CML for 15 days, on 31-12-05 he availed EL for 10 days, on 15-02-2006 he availed 10 days, on 02-04-2006 he availed 41 days, on 15-06-2006 he availed 5 days, on 18-10-2006 he availed 21 days, on 14-12-2006 he availed 10 days, on 17-01-07 he availed 10 days, on 27-03-2007 he availed 10 days, on 6-04-2007 he availed 5 days on 2-11-07 he availed 10 days, total he availed 154 days. . As per Patient Case sheet NO.119 dt.23-05-208 of Jaya Hospital, Hanamkonda the life assured was admitted with symptoms of Fever, Vomtings, Slurred speech and he was also a Chronic Alcoholic. As per the leave records the deceased life assured suffered from Enteric Fever, DVT: Cellulitis, Chicken Gunya, Head Injury RTA, CRAO on left eye during the above 12 spells of leave on medical grounds, which he suppressed in his proposal form. The deceased life assured wrongly answered to the crucial question No.11 that he has not availed any leave on sick grounds in the last five years prior to date of proposal inspite of the fact that he had availed sick leave on 12 different spells. Since the deceased suppressed the material facts, Under Section45 of Insurance Act the complainant is not entitled to the insured claim and hence they repudiated the her claim and that there is no deficiency in service on their part and thus prayed to dismiss the complaint.
04. Both sides filed evidence affidavit reiterating their respective pleadings and Ex. A-1 to A 12 were marked on behalf of the complainant and Ex. B -1 to B5 were marked for the OP.
05. Having heard both sides and considering the evidence on record, the District Forum dismissed the complaint.
6. Feeling aggrieved with the said order the unsuccessful complainant filed this appeal on several grounds and mainly contended that that the District Forum failed to see that Ex.A-6. A-7 and A-8 and that mere production of doctors certificate does not prove that the deceased suffered from the diseases and liable the Ops repudiation of claim on the ground of suppression of fact and that there is no cogent evidence to say that the life assured was suffered from the ailments as mentioned by Ops and that the order passed by the District Forum is against to law and justice and thus prayed to allow the appeal and set aside the impugned order.
7. Heard both sides with reference to their respective contentions in detail and counsel for Ops/R1 and R2 filed written arguments so also counsel for appellant/complainant filed written arguments.
8. Now the point for consideration is whether the order of the District Forum is sustainable ?
9. There is no dispute that the complainants husband, by name, Nagaraju is a Government employee and obtained life insurance policy bearing No. 686904956 for an assured sum of Rs. 75,000/- commencing from 28.4.2007 under the Salary Savings Scheme during his life time and that the complainant is the nominee for the said policy and that the insured died on 24.05.2008 and that the policy was in force as on the date of his death. The contention of the complainant is that after death of her husband she submitted claim under the said policy to the Ops but it was repudiated on the ground of suppression of material facts, i.e., life assured has availed sick leave on number of occasions before the date of proposal. She further contended that mere production of Medical certificate without cogent evidence it does not prove that he has suffered with the ailments mentioned by the opposite parties and that the District Forum failed to appreciate Ex. A-7, A-8 and A-9. Whereas, the contention of the opposite parties is that the life assured has availed leave on sick grounds on 12 occasions and the deceased life assured availed 154 days in total. As per Patients Case sheet NO.119 dt.23-05-208 of Jaya Hospital, Hanamkonda the life assured was admitted with symptoms of Fever, Vomtings, Slurred speech and he was also a Chronic Alcoholic. As per the leave records the deceased life assured suffered from Enteric Fever, DVT: Cellulitis, Chicken Gunya, Head Injury RTA, CRAO on left eye during the above 12 spells of leave on medical grounds but the same were suppressed by the life assured and hence Under Section 45 of Insurance Act the claim of the complainant was repudiated. In a decision reported 1 (2009) CPJ 161 (NC) in Vanita Ben Vs. LIC of India, so also, in another decision in Trilok Chand Khanna Vs. United India Insurance co. Ltd reported in I (2012) CPJ 83 it was held that medical certificate without supporting of doctor who examined the insured was not sufficient. Therefore the said medical certificate etc. marked by OP cannot be relied upon to decide the issue with regard to suppression of previous ailment. In another decision reported in 2012 (2) CPR NC 214 between LIC of India Vs. N.P. Nagaratna , a breach of an insurance policy between two parties would justify repudiation of the insurance claim. In II (2012) CPJ 310 (NC) between Tata AIG Life Insurance Company Limited Vs. Orissa State Co Operative Bank and another it is an obligation on the part of the insured to disclose material facts but when Ops did not examine the doctor who said to have issued the medical certificates and also the concerned authority who said to have granted leave on medical grounds in proof that the deceased life assured was suffering from ill health prior to taking of the policy the said decisions are not helpful for the opposite parties. Dismissal of the complaint relying upon the said medical certificate etc without supporting evidence is not justified. Hence, in the circumstances of the case and for a just decision in the matter, the evidence of the medical officer who said to have issued medical certificate marked by the Ops in proof of the alleged ailments of the deceased life assured so also the official who said to have granted leave on medical grounds is essential, so also, rebuttal evidence of the complainant in the said context. In the written arguments the complainant submitted several decisions of this Commission so also the decisions of Honble National Commission reported in III (2011) CPJ 232 (NC) between LIC of India and another Vs. Ranjit Kaur so also decision reported in 2010 (1) CTC 192 between LIC of India VS. Anasuya Bai and a decision in RP 3504/2009 dt. 24.11.2009 between LIC of India Vs. Laxmi bai Byavahre but in view of the said decisions and discussions described supra they are not helpful for the complainant to decide the case in her favour and direct the Ops to answer her claim positively. Since valuable rights of the parities to the proceedings and public money are involved we are inclined to remit back the matter to the District Forum giving an opportunity to the Ops to examine the said doctor and other witness by setting aside the impugned order enabling them to establish their defence. It is needless to say that the complainant has right to cross examine the said doctor and other witness to impeach credit of their evidentiary value. Thus, the point is answered accordingly.
10. In the result the appeal is allowed, order of the District Forum is set aside and the complaint is remitted back to the District Forum for fresh disposal after giving opportunity to both sides after adducing further evidence keeping in view of the observations made in the order. Parties shall bear their own costs of the appeal. The complainant and Opposite parties shall not insist for fresh notice after remand and they shall appear before the District Forum on 21.06.2013.
MEMBER MEMBER DATED 22.05.2013.