State Consumer Disputes Redressal Commission
Metlife Insurance Company Ltd., ... vs Smt.P.Bhagya Lakshmi, Medak-1 on 23 January, 2013
BEFORE THE A BEFORE THE A.P.STATE CONSUMER DISPUTES REDRESSAL COMMISSION: AT HYDERABAD. F.A.No.285/2011 against C.C.No.30/2010 District Forum, Medak at Sangareddy Between Metlife Insurance Company Ltd., Rep. by its General Manager (Claims Department) Brigade Seshamahal 5, Vani Vilas Road, Basavanagudi, Bangalore-560 004. ..Appellant/ opposite party And Smt.P.Bhagya Lakshmi W/o.late P.Kumar Aged about 38 years, Occ:Housewife, R/o.H.No.4-28, Ghanpur Village, Patancheru Mandal, Medak-502 001. Respondent/ Complainant Counsel for the Appellant : M/s V.V.S.N.Raju Counsel for the Respondent : Mr.M.Sudhakar QUORUM: SMT.M.SHREESHA, HONBLE Incharge President AND SRI S.BHUJANGA RAO, HONBLE MEMBER.
WEDNESDAY, THE TWENTY THIRD DAY OF January, TWO THOUSAND THIRTEEN Order (Per Smt.M.Shreesha, Honble Incharge President) *** Aggrieved by the order in C.C.No.30/2010 on the file of District Forum, Medak at Sangareddy, opposite party preferred this appeal.
The brief facts as set out in the complaint are that the complainants husband, namely, P.Kumar while working as constable at Patancheru Police Station obtained a policy bearing No.1200900835032 for an amount of Rs.2,51,000/- and the premium amount being Rs.25,100/- for the period from 18-3-2009 to 18-3-2029. The complainant submitted that her husband died due to sudden chest pain and was admitted in Yashoda hospital on 20-6-2009 and on 21-6-2009 at 2.00 p.m the hospital doctors declared him dead. The complainant submitted that immediately after the death of her husband, she approached the opposite party and submitted her husbands death certificate but they have not given any positive response even after lapse of 9 months. The complainant submitted that she received the amount of Rs.66,840/- covered under policy No.643076892 and also Rs.88,443/- under policy No.641661609. The complainant therefore got issued a legal notice dated 17-3-2010 through registered post acknowledgement due demanding the opposite party to pay the amount and it replied with false and baseless allegations. Hence the complaint for a direction to the opposite party to pay the insurance amount of Rs.2,51,000/- together with compensation of Rs.50,000/-.
Opposite party filed written statement resisting the complaint. It submitted that the complaint filed by the complainant does not fall within the definition of consumer dispute as there is neither any unfair trade practice nor deficiency in service. Opposite party submitted that the Forum has no territorial jurisdiction to entertain the complaint as the opposite party does not have branch office at Medak and also the complainant had raised issues which involves questions of fact as well as law and cannot be disposed in a summary procedure. Opposite party submitted that the policy of insurance is a contract of utmost good faith and that the complainant was admitted in Yashoda hospital for a surgical operation of his left leg with complaint of pain and non healing ulcer i.e. from 28-7-2008 to 01-8-2008. It further submitted that the complainant was suffering from diabetes mellitus for the past 1 year prior to his demise and this was not disclosed by the policy holder in the application form dated 09-3-2009 submitted by him at the time of taking the insurance policy and fraudulently suppressed the correct facts with regard to his health and habits. Opposite party submitted that the onus lies on the complainant to show that the relief as contemplated U/s.14 can be given for deficiency in service provided to the complainant and submitted that there is no deficiency in service. Opposite party denied that the policy holder died on 21-6-2009 due to cardiac respiratory arrest and submitted from the progress sheet, it is revealed that he was suffering from diabetes from past one year and during the course of investigation at Yashoda hospital, it was found that the deceased policy holder underwent a surgery for varicose ulcer in his left limb on 29-7-2008 and the discharge summary dated 01-8-2008 revealed the surgery. The opposite party submitted that a claim of the complainant was repudiated by the opposite party after thorough investigation vide letter dated 16-11-2009 and the opposite party paid an amount of Rs.19,404/- being the fund value which was available in the policy account by cheque bearing No.273865 dated 13-11-2009. The opposite party submitted that the complainant had issued a letter dated 9-3-2010 requesting it to reconsider the decision of repudiation and the complainant herself admitted in her letter dated 09-3-2010 that the deceased life assured was known to have been suffering from diabetes. Opposite party further submitted that the policy issued by LIC was issued to the deceased policy holder in 2001 which is prior to 01-8-2008 and submitted that there is no deficiency in service and prayed for dismissal of the complaint.
Based on the evidence adduced i.e. Exs.A1 to A9 and B1 to B9 and the pleadings put forward, the District Forum allowed the complaint directing opposite party to pay to the complainant the policy amount of Rs.2,51,000/- after deducting the amount of Rs.19,404/- (which is stated to have been paid by the opposite party towards fund value through cheque dated 13-11-2009) with interest at 9% p.a. from 21-6-2009 i.e. the date on which the insured died, together with compensation of Rs.10,000/- and costs of Rs.5,000/-.
Aggrieved by the said order, opposite party preferred this appeal.
Both sides filed written arguments.
It is the complainants case that her late husband had taken a policy for Rs.2,51,000/- for the period 18-3-2009 to 18-3-2029 covering a period of 20 years and suddenly died due to chest pain on 21-6-2009 when the policy was in force. The complainant made a claim with the opposite party but there was no response for a period of 9 months. It is the further case of the complainant that her husband had another LIC policies in which she received Rs.66,840/- and 88,443/- on 22-2-2010 from LIC but this opposite party insurance company did not pay her the amount inspite of issuance of legal notice dated 17-3-2010.
It is the appellant/opposite partys case that the insured suppressed diabetes and therefore they repudiated the claim on 16-11-2009 and refunded the premium amount of Rs.19,404/- vide cheque dated 13-11-2009. They relied on the hospital treatment record of Yashoda hospital in which it was mentioned that the insured was suffering from diabetes as on 21-6-2009 and the policy period commences from 18-3-2009. It is not in dispute that the policy holder died on 21-6-2009 due to cardiac arrest. A brief perusal of the progress sheet (Ex.B4) of Yashoda hospital and the history of past illness as stated in the progress sheet show that there is a history of diabetes for the last one year and also underwent surgery for varicose ulcer. He was admitted in Yashoda hospital on complaint of chest pain. The preliminary investigations done by Yashoda hospital do not anywhere show that he was highly diabetic or if there was a direct nexus with diabetes and his heart attack. It is also an admitted fact that it is only in the records of progress sheet of Yashoda hospital that it was stated that the insured was suffering from diabetes since one year.
The counsel for the appellant relied on a judgement of Apex Court in Civil Appeal No.2776/2002 between SATWANT KAUR SANDHU v. NEW INDIA ASSURNACE COMPANY LTD., reported in 2010 ACJ 265 = (2009) 8 SCC 316 in which the insured had suppressed diabetes which is a material fact for suppression and therefore the repudiation of the insurance company was justified. In that case the facts are different in the sense that the insured had chronic renal failure/diabetic nephropathy and was on regular haemo dialysis and was diabetic for 16 years and thereafter died due to cardiac arrest. There the suppression was established by the insurance company and there was also nexus between the chronic case of diabetes and the death, whereas in the present case, the insurance company has failed to establish by way of any documentary evidence, that the insured was suffering from chronic diabetes which led to his death.
Admittedly the application was signed by the policy holder on 09-3-2009 and the policy was issued from 18-3-2009 whereas the insured died on 21-6-2009. The entire treatment record does not anywhere state that it was the diabetic condition of the patient which had led to the heart attack. It is also pertinent to note that the opposite party failed to establish that the patient was in the knowledge of having diabetes and has deliberately or wilfully suppressed it which the opposite party has to establish as provided U/s.45 of the Insurance Act. Therefore we see no reason to interfere with the well-considered order of the District Forum.
In the result this appeal fails and is accordingly dismissed. Time for compliance four weeks.
Sd/-Incharge President.
Sd/-Member.
JM Dt.23-1-2013.