State Consumer Disputes Redressal Commission
Sankella Vijaya Laxmi, Warangal ... vs Bm, Lic Of India, Warangal And One ... on 23 April, 2013
A. P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION : AT HYDERABAD FA 209 of 2012 against CC 233/2011 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 : Mr. A. V. Satyanarayana Rao Coram ; Sri R. Lakshminarasimha Rao Honble Member
And Sri T. Ashok Kumar .. Honble Member Tuesday, the Twenty Third Day of April Two Thousand Thirteen Oral Order : ( As per Sri T. Ashok Kumar , Honble Member ) ****
1. This is an appeal preferred by the unsuccessful opposite parties as against the orders dated 09.01.2012 in CC 233/2011 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 husband, by name, Nagaraju, who is a Government employee and obtained LICs Bima Gold Policy bearing NO.688141066 from opposite party No.1 for sum assured amount of Rs.1,00,000/- commenced from 28-02-2008 during his life time died on 24-05-2008 due to fever and Vomiting and complainant is the nominee for the said policy. After death of her husband, the complainant had submitted it form along with relevant documents through Agent of opposite parties and requested to settle the claim. But the opposite parties did not settle the claim and repudiated the claim vide letter dated 31-03-2010 stating that the life assured has availed sick leave on number of occasions before the date of proposal and that he did not disclose the above said facts in the proposal and that he suppressed the material facts and it amounts to deficiency of service on the part of the opposite parties and hence the complaint to direct the opposite parties to pay the assured amount of Rs.1,00,000/- under the above said policy, with interest @12% p.a. from 01-10-2008 to 30-04-2011 for Rs.26,000/-, 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.
3. OP filed counter opposing the claim of the complainant and denying the allegations made in the complaint and the brief facts of the counter are as under
:
The deceased life assured had taken life insurance policy bearing No. 688141066 for an assured sum of Rs.1,00,000/- showing his wife, i.e. the complainant as his nominee under the said policy and the insured died on 24.05.2008. The said policy was issued under Salary Savings Scheme. The death of the life assured occurred within two years, which is very early claim, During the course of said 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 . 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.
4. Both sides filed evidence affidavit reiterating their respective pleadings and Ex. A-1 to A-11 were marked on behalf of the complainant and Ex. B -1 to B6 were marked for the OP.
5. Having heard both sides and considering the evidence on record, the District Forum dismissed the complainant.
6. Feeling aggrieved with the said order the unsuccessful complainant filed this appeal on several grounds and mainly contended that the District Forum failed to see and appreciate 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 alleged and repudiation of claim by Ops on the ground of suppression of fact illegal and that there is no cogent evidence to say that the life assured 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.
8. Now the point for consideration is whether the order of the District Forum is vitiated either in law or on facts.
9. There is no dispute that the complainants husband, by name, Nagaraju is a Government employee and obtained life insurance policy bearing No. 688141066 for an assured sum of Rs.1,00,000- 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-6, A-7 and A-8. 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 sick leave 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 and that 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 rightly 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 92012) CPJ 83 it was held hat medical certificate without supporting evidence 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 , it was held that 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 was held that 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. 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 22.05.2013.
MEMBER MEMBER DATED 23.04.2013