State Consumer Disputes Redressal Commission
G.Sahsi Kalavathamma W/O Late Kambam ... vs Life Insurance Corporation Of India And ... on 5 December, 2013
BEFORE
A.P STATE CONSUMER DISPUTES REDRESSAL COMMISSION AT HYDERABAD
F.A.No.871
OF 2012 AGAINST C.C.NO.96 OF 2012 DISTRICT FORUM KADAPA YSR DISTRICT
Between:
G.Sahsi Kalavathamma W/o late Kambam
Venkatanaryana Reddy
R/o D.No.41/82, Potladurthi Village & Post, Dharmal Rd., Yerraguntla
Mandal, YSR District
Appellant/complainant
A
N D
1. Life Insurance Corporation of India
Rep.
by its Senior Divisional Manager
Divisional
Office, Arts College Road
Kadapa
City-001
2. Life
Insurance Corporation of India
Rep.
by its Branch Manager
Branch
Office, Nagarajupet
Rly
Station Road, Kadapa City-001
Respondents/opposite parties
Counsel for the Appellants M/s L.J.Veera Reddy
Counsel for the Respondents M/s Hari Rao Lakkaraju
QUORUM:
SRI R.LAKSHMINARASIMHA RAO, HONBLE I/C PRESIDENT
SRI THOTA ASHOK KUMAR,
HONBLE MEMBER
AND SRI S.BHUJANGA RAO, HONBLE MEMBER THURSDAY THE FIFTH DAY OF DECEMBER TWO THOUSAND THIRTEEN Oral Order (As per Sri R.Lakshminarasimha Rao, Honble I/c President) ***
1. The unsuccessful complainant is the appellant.
The averments of the complaint are that during his life time, the appellants husband obtained two life insurance policies i.e.,
1. LICs Jeevan Saral (with profits) policy bearing NO.656043823 for an assured sum of `3,49,200/- on 20.08.2010 with half yearly premium of `6,025/- for 24 years period and 2. Jeevan Mitra (Triple cover endowment plan) with profits (with accident benefits) policy bearing No.656042727 for an assured sum of `1,00,000/- on 23.08.2010 with half yearly premium of `4,989/- for 15 years period. Under both the policies the appellant was the nominee.
On 19.08.2011 the husband of the appellant was died and by the time he paid two half yearly instalments of premium.
In the month of September 2011 the appellant submitted claim along with required documents to the respondents for assured sum under both the policies with bonus and other benefits. The respondent no.1 by its letter dated 31.03.2012 repudiated claim in respect of both the policies on the ground that the insured had furnished incorrect and false information regarding his health and the surgery he had undergone for periprosthetic fracture of femur bone prior to submission of proposal. The fracture of femur bone was not a disease. The insured is hale and healthy and the same fact was confirmed by the doctor who issued fitness certificate.
2. The respondents resisted the case contending that the insured suppressed the true facts about his health and previous health condition including hospitalization. The insured underwent a surgery at Sri Sai Nursing Home, Kadapa and took treatment as inpatient from 04.01.2009 to 12.01.2009. He also underwent another surgery for hip joint pain at Global Hospital, Hyderabad and took treatment as inpatient from 12.11.2009 to 17.11.2009. The medical record of Global Hospital disclosed that the insured met with road accident ten months ago. Prior to the admission of the insured he had a fall in bath room. The entire information was not stated by the deceased in the proposal forms. The cause of death is not mentioned in the complaint. The insured did not mention his past medical history while obtaining the policies. For the forgoing reasons, the respondents justified their repudiation.
3. The appellant filed her affidavit and the documents, Exs.A1 to A5. On behalf of the respondents, Exs.B1 to B6 were filed.
4. The District Forum dismissed the complaint on the premise that the appellants husband suppressed the material fact regarding his health that he was admitted in Global Hospital on 12.11.2009 and was discharged on 17.11.2009 for undergoing pre-prosthetic fracture of right femur with supra condylar nail right femur in SITU and had undergone surgical procedure for removal of supra condylar nail.
5. Aggrieved by the order of the District Forum the complainant has filed appeal contending that the District Forum has not appreciated the evidence in proper perceptive and it had not applied the correct legal principles to the facts of the case. It is contended that the respondent insurance corporation issued the insurance policy after getting examined the insured by its panel doctors. It is contended that the District Forum failed to notice that fracture is not a disease and it does not amount to suppression of the fact and that the fracture suffered by the insured is neither direct nor indirect cause for his death.
6. The point for consideration is whether the repudiation of the claim is justifiable?
7. The facts which have been admitted by both the parties are that the appellants husband during his life time was working as teacher in mandal prajaparishat elementary school at Potladurthi village YSR District and he had obtained two life insurance policies, Jeevan Saral (with profits) policy bearing No.656043823 for an assured sum of `2,49,200/-
and Jeevan Mitra (Triple Cover Endowment Plan (with profits) with accident benefits policy bearing No.656042727 for a sum of `1,00,000/-.
8. Jeevan Saral policy was issued on 20.8.2010 for a period of 24 years and the premium payable is half yearly whereas Jeevan Mitra insurance policy was issued on 23.8.2010 for a period of 15 years with half yearly premium of `4,989/-. For the sum assured under the both insurance policies, the appellant was appointed as the nominee of insured. The appellants husband paid two half yearly instalments of premium. He died on 19.8.2011. The respondents repudiated the claim on the premise that the appellants husband did not give correct answer as regards his health and he had furnished incorrect and false information suppressing the fact that he had under gone.
9. The learned counsel for the respondent corporation had contended that the insured had undergone surgery at Sai Nursing Home Kadapa and he was treated from 4.1.2009 to 12.1.2009 and thereafter he had undergone surgery for hip joint pain at Global Hospital and treated there as in patient from 12.11.2009 to 17.11.2009 and in the medical record of the Global Hospital he was shown to have met with road traffic accident 10 months prior to the date of admission and also that he fell down in the bathroom three days prior to the date of his admission in the hospital and that cause of death of the insured is not explained by the appellant.
10. A perusal of the medical record of Sai Nursing Home Kadapa would show that it is a copy of prescription and does not indicate any ailment the insured suffered from as also the cause for surgery the insured stated to have undergone. The medical record of Global Hospital does not bring any change in the position as it would also establish treatment the insured said to have undergone on account of his meeting with a road traffic accident and also accidental slip in his bathroom three days prior to the date of admission in the hospital. A perusal of the proposal form would show that the questionnaire was incorporated therein with an intention to elicit answers from the insured as to whether he was suffering from any disease or ailment.
11. Even according to the version of the respondent insurance corporation the insured has not suffered from any disease or ailment prior to or at the time of submitting the proposal for the purpose of obtaining the life insurance policies. The insurance policy is a contract of insurance between the insured and the insurer who would proceed on the premise of express terms as to the fact whether the insured had suffered from any disease or ailment which will adversely effect the quantum of premium payable as also the duration of the life insurance policy. In the instant case, there is no any concealment of disease by the insured while answering the questionnaire mentioned in the proposal form.
12. Interestingly, the respondent insurance corporation has not only filed copies of the medical record from Sai Nursing Home and Global Hospital not explaining the reason for not producing attested copies of the medical record therefrom, it has also failed to produce the original proposal form which are in its possession and no reason whatsoever has been forthcoming from the respondent insurance corporation for not filing the original proposal form which are very much in its possession. The respondent in the circumstances cannot be heard to say that the insured had concealed any material fact from it while submitting the proposal form.
13. In Venkata Naidu Vs LIC of India IV (2011) CPJ 6 (SC) the Honble Supreme Court held that the insurance company has to prove by cogent evidence that the insured did not disclose correct facts relating to his illness and in the absence of tangible evidence to prove that the deceased had withheld information about his hospitalization and treatment, the repudiation of claim is not justified. It was also held that there should be nexus between the cause of the death and the disease concealed by the insured.
14. In the case of repudiation of the claim, the burden of proof heavily lies upon the respondent- insurance corporation which had not adduced any contemporaneous evidence in order to support the repudiation of the claim. It has not even bothered to conduct investigation as to know the cause of death of the insured and proceeded to repudiate the claim on assumptions and presumptions as it has failed to establish proximity of cause of death of the insured with the surgery he had undergone on account of sustaining injury in an accident.
15. The District Forum committed error in recording a finding that the deceased had suppressed the fact of treatment at the time of submitting the proposal. The respondent insurance corporation has failed to establish the cause of death of the deceased and any disease that has proxity with the death of the insured. In the circumstances, the order of the District Forum is liable to be set aside.
16. In the result the appeal is allowed. The order of the District Forum is set aside. Consequently the complaint is allowed directing the respondents/opposite parties to pay an amount of `2,49,200/- towards the sum assured under the insurance policy bearing No. 656043823 and an amount of `1,00,000/-
towards the sum assured under the insurance policy bearing No.656042727 with interest @ 9% per annum from the date of filing of the complaint till payment together with vested bonus and costs of `5,000/-. Time for compliance four weeks.
Sd/-
I/C PRESIDENT Sd/-
MEMBER Sd/-
MEMBER Dt.05.12.2013 కె.ఎం.కె.*