State Consumer Disputes Redressal Commission
1.The Chief Manager Lic Of India, vs 1.Ropolu Kumari on 3 November, 2023
1
BEFORE THE TELANGANA STATE CONSUMER DISPUTES
REDRESSAL COMMISSION : HYDERABAD.
F.A.No. 375 OF 2019
AGAINST ORDERS IN C.C.48/2017
DISTRICT CONSUMER COMMISSION, KHAMMAM
Between:
1.The Chief Manager, LIC of India, NST Road, Khammam Town & District.
2. The Divisional Manager, LIC of India, Balasamudram, D.O.Warangal Town & District.
.......Appellants/ Opposite Parties And:
1. Ropolu Kumari, W/o Late Ropolu Mallaiah, Aged about 40 years, Occ.: Housewife, R/o H.No.5-156/A, Mallupalle, Konijerla Mandal, Khammam District, 507305.
2. Dumpa Kethamma, W/o Dumpa Ramesh, D/o Late Ropolu Mallaiah, Aged about 22 years, Occ.: Housewife, R/o H.No.5-56, Mallupalle, Konijerla Mandal, Khammam District, 507305
3. Ropolu Vasundara, D/o Late Ropolu Mallaiah, Aged about 20 years, Occ.: Student, R/o H.No.5-156/A, Mallupalle, Konijerla Mandal, Khammam District, 507305 ........Respondents/ Complainants Counsel for the Appellants/Opposite Parties: M/s. KRL Sharma Counsel for the Respondents/Complainants : Called absent QUORUM :
HON'BLE SMT. MEENA RAMANATHAN, I/c PRESIDENT & HON'BLE SRI. K. RANGA RAO, MEMBER - (JUDICIAL) FRIDAY, THE 03rd DAY OF NOVEMBER TWO THOUSAND TWENTY THREE ********** Order : (PER HON'BLE SRI. K. RANGA RAO, MEMBER - JUDICIAL)
1. This appeal is filed by the Appellants/Opposite Parties U/s. 15 of the Consumer Protection Act, 1986, praying this State Commission to set aside the order of the District Forum, Khammam, dated 13.05.2019 passed in CC No.48/2017 by allowing the First Appeal with entire costs and pass necessary 2 orders in the interest of justice, otherwise the appellants/opposite parties will be put to irreparable loss and hardship.
2. For the sake of convenience, the parties are referred to as arrayed in the complaint. The Appellants are the Opposite Parties and Respondents are the complainants in the C.C.48/2017.
3. The succinct facts of the complaint are that the complainant No.1 is the wife of the deceased Ropolu Mallaiah and the complainant No.2 & 3 are their children. The husband of the complainant No.1 by name Ropolu Mallaiah, died on 04.11.2015.
During his lifetime he has taken LIC policy bearing No.689504217, for value of Rs.1,00,000/- from the opposite party No.1 and the complainants are the legal heirs for the said policy. As the husband of the complainant No.1 died due to chest pain, she applied for the claim under the policy, but the opposite party No.2 vide letter dated 15.12.2016, repudiated the claim by stating that the deceased has suppressed the material fact with regard to his health which is, the deceased had the history of "Chronic Kidney disease" prior to proposal and therefore, denied liability under the policy. Vexed with the attitude of the opposite parties, the complainants got issued a legal notice, dated 03.06.2017 which was received by the opposite parties and got issued reply to the said notice on 05.06.2017 by denying the claim for death of the deceased. The same amounts to deficiency of service on the part of opposite parties. Due to non-payment of the claim amount the complainants suffered a lot and underwent untold mental agony. Hence, the complaint.
4. The opposite parties filed their written version admitting the issuance of policy to the husband of the complainant No.1. They submitted that the policy of the deceased was lapsed for non- payment of premiums for 01/2014 to 01/2015 i.e. two yearly premiums. The said policy was revived on 21.10.2015 basing on the personal statement of the deceased regarding his health. As 3 per the information received by them the deceased life assured died on 04.11.2015 which is within three years from the date of the revival of the policy i.e. 21.10.2015. Since, the claim is an early one which is within three years from the revival of the policy, they investigated into the same during which it came to light that the deceased life assured had intentionally suppressed his pre- proposal ill-ness relating to chronic kidney disease on maintenance of Hemo dialysis , for which he had undergone treatment at Mamatha Super Speciality Hospital, Khammam, as per the medical record/ case sheet dated 11.03.2015. The final diagnosis as seen from the said case sheet is "CKD ON ESRD", which means chronic kidney disease on End Stage Renal Disease.
The opposite parties further submitted that Sec.45 of the Insurance Act, 1938 has been amended as per which the Insurance Company can question any claim/policy if the claim is early one within three years from the date of the policy/revival. Since, the deceased suppressed the material fact with regard to his undergoing treatment for the above mentioned disease, they repudiated the claim of the complainants and intimated the same to the Complainant No.1 vide letter dated 15.12.2016 by Opposite party No.2 office. There is no deficiency of service on their part and therefore, prayed to dismiss the complaint.
5. The complainant No.1 filed the supporting affidavit along with the complaint by repeating all the averments of the complaint in the same.
6. Before the District Forum on behalf of the complainants Ex.A1 to A7 were marked. On behalf of the opposite parties Ex.B1 to B14 were marked.
7. The District Forum after hearing and considering the material available on record, allowed the complaint in part, directing the opposite parties to pay the policy amount of Rs.1,00,000/- (Rupees one lakh only) together with interest @ 9% p.a. from the date of complaint i.e. 03.11.2017 till realization, within one month from the date of receipt of this order. On such deposit the complainant No.1 is 4 entitled to withdraw an amount of Rs.50,000/- with accrued interest on Rs.1,00,000/- and complainant No.2 and 3 are entitled to withdraw the amount of Rs.25,000/- each. Accordingly the CC is allowed.
8. Aggrieved by the above order of the District Forum, the Appellants/Opposite parties filed the present appeal FA No.375/2019 with the following grounds of appeal:-
The order of the District Forum is contrary to law, the weight of evidence, facts of the case and the terms of the policy. The District Forum ought to have dismissed the complaint basing on the medical records of Mamatha Hospital, pertaining to the deceased as the same show that the deceased suppressed the material fact with regard to his health in his personal statement, given for the revival of the lapsed policy.
The District Forum without appreciating the facts and evidence on proper lines erroneously allowed the complaint, which is not sustainable under law.
The District Forum not considered the point that the insurance company has a right and is entitled to repudiate the claim when the deceased policy holder suppressed the disease suffered by him and the treatment underwent by him for the same. The deceased as per the medical records suffered from chronic kidney disease on End Stage Renal Disease. He suppressed the same in his personal statement, given for the revival of the policy as such the repudiation of the claim by the insurance company is legal. With the above grounds the appellants/opposite parties prayed to allow the appeal and to set aside the impugned order of the District Forum.
9. For the sake of clarity it is to be mentioned that Respondents No.1 & 2/complainants did not chose to make their appearance before this Commission despite service of notice on them in this appeal. As the notice sent to Respondent No.3 was returned unserved, the appellants filed IA No.1641/2019 praying this 5 Commission to permit them to make publication in the newspaper "Andhra Prabha" Khammam District for the appearance of Respondent No.3. Despite the said publication Respondent No.3 did not appear before this Commission.
As the Respondents/Complainant No.1 to 3 did not appear before this Commission, right from the inception of the appeal, we heard the arguments of the appellants and reserved the appeal for judgment so as to decide the stand of the Respondents/Complainants No.1 to 3 on merits.
The appellant also filed the written arguments. A perusal of the same shows that the contentions of the opposite parties submitted in the written version are repeated. The counsel for the appellants in his oral arguments by and large reiterated the epitome of the written arguments.
10. The point that arises for consideration is whether the impugned order passed by the District Forum suffers from any error or irregularity or whether it is liable to be set aside, modified, or interfered with, in any manner? To what relief?
11. To decide the point for consideration, we have scrupulously and meticulously examined the whole material borne by the record and the same would manifest that the following are undisputed facts:-
The deceased husband of the complainant No.1 had taken Ex.B5 Jeevan Anand (with profits) (with accident benefit) insurance policy from the opposite parties during his lifetime for an assured sum of Rs.1,00,000/-, the risk of which commences from 28.01.2013. For the said policy a sum of Rs.7,682/- is the yearly premium which was paid by the deceased to the opposite parties.
The life assured died on 04.11.2015. After the death of her husband, the complainant No.1 and her two daughters complainant No.2 & 3 being the legal heirs of the deceased submitted the claim form along with the required documents to the opposite parties, claiming the death benefits under Ex.B5 policy, but opposite parties repudiated the claim vide Ex.B2 letter dated 6 15.12.2016 on the ground of suppression of material fact by the deceased with regard to his undergoing treatment for the alleged ill-ness which is chronic kidney disease on End Stage Renal Disease at Mamatha Super Speciality Hospital, Khammam. On that the complainants filed the present complaint.
12. It is the contention of the opposite parties that the deceased life assured failed to pay two yearly premiums for the years 2014 and 2015 due to which Ex.B5 policy was lapsed. The said policy was got revived by the deceased life assured by submitting Ex.B3 personal statement regarding his health on 21.10.2015. It is the main and specific contention of the opposite parties that since the claim of the complainants is an early one which is within three years from the date of the revival of the policy, the opposite parties processed the claim during which it came to light that husband of the complainant No.1 had taken treatment in Mamatha Super Speciality Hospital, Khammam on 11.03.2015 with the complaint of Chronic Kidney Disease on End Stage Renal Disease. They filed Ex.B12 and B14 Discharge summaries and Ex.B13 Case Sheet of the deceased issued by Mamatha General and Super Speciality Hospital, Khammam and the same establishes the deceased taking treatment for the above disease. But he in his personal statement (Ex.B3) given for the revival of the policy on 21.10.2015 suppressed the said fact regarding his health, as such they rightly repudiated the claim of the complainants.
13. The law is settled that when Life Insurance Corporation of India (LIC) repudiates the claim under any policy, on the ground of suppression of material fact by the deceased about the state of his health, burden lies on the Life Insurance Corporation of India to prove the same, as held by the Hon'ble Supreme Court of India in the case of LIC of India Vs. Asha Goel (2001) (2) SC 160.
14. In the case on hand the opposite parties placed reliance on Ex.B12 and B14 Discharge Summaries and Ex.B13 Case sheet issued by Mamatha General and Super Speciality Hospital, 7 Khammam, contending that the same belongs to the deceased and as per the said medical record insurance company has proved its contention that the deceased suppressed the material fact of his suffering from chronic kidney disease on End Stage Renal Disease, but he suppressed the said fact in his Ex.B3 personal statement given for the revival of the policy on 21.10.2015.
15. At this juncture, we feel it relevant to mention that in the case of M/s. ICICI Prudential Life Insurance Co. Ltd., V/s. Mrs. Veena Sharma, in the backdrop of the facts that the complainant filed three separate consumer complaints in relation to three insurance policies taken by her late husband. In all the three cases, her complaint was allowed by District Consumer Forum, Panipat. Appeals against the same have been rejected by Haryana State Consumer Commission. Therefore, ICICI Prudential Life Insurance Co. Ltd., has challenged the same in three separate Revision Petitions, the Hon'ble National Commission at para No.2 & 3, held as follows:
Para No.2: While allowing the complaint, the District Forum held that the Opposite Party had totally failed to prove its case with any cogent and credible evidence to show that the insured had knowing suppressed the fact that he held suffering from Diabetes Mellitus prior to submission of the proposal form. It observed that:-
"In the present case only question is to be determined whether the insured has knowingly suppressed the material facts at the time of submitting the proposal form. Onus to prove contention of suppression was on the insurance company. In order to prove his case opposite parties filed the affidavit of Senior Manager Ex.RW1/A in her affidavit she only deposed that statement made in all the paragraphs of the reply are true and correct. Nothing else has been deposed with regard to ailment of deceased. Opposite party only relied on medical treatment record Ex.R3. Counsel of the opposite party argued that in Ex.R3 in patient history it is written "A known patient of Diabetes Mellitus Type-2 was admitted". Patient Deepak was admitted on 13.04.2010 and he was discharged on 24.04.2010 according to Ex.R3. Except this document opposite party did not produce any other record of treatment of insured".
Para No.3: "The appeal challenging the above order was dismissed by the State Commission. The State Commission has held that repudiation of the claim was sought to be justified on the basis of contents of the Discharge Card of G.C. Gupta Hospital, which showed that the insured was hospitalized there from 12th to 24th April, 2010. In this document (Ex.R3), Diabetes Mellitus is mentioned 8 as part of patient's history. The State Commission, relying upon the decision in Tarlok Chand Khanna Vs. United India Insurance Co. Ltd., I (2012) CPJ 84 (NC), observed that mere production of Discharge Card was not enough. OP/Insurance Co. was also required to prove with credible evidence that the Complainant was suffering from the pre-existing disease and had knowingly failed to disclose the same".
16. The Hon'ble National Commission after examining the whole material dismissed the three revision petitions upholding the order of District Forum and State Commission of allowing the complaint.
The proposition of law enunciated in the above case makes it pellucid that mere filing of the case sheet/Discharge Card is not sufficient for proving the suppression of material fact with regard to the state of health of the policy holder but the insurance corporation should prove the same by cogent and credible evidence. In the case on hand opposite parties placed reliance on Ex.B12 & B14 Discharge summaries and Ex.B13 Case Sheet to prove their contention of the material suppression of the fact by the deceased life assured regarding his health. "Mere production of Ex.B12 to B14 would not support the contention of the opposite parties, more particularly when there is no affidavit of the said Doctor, nor the competent person of the said hospital such as superintendent of the said hospital, was examined to prove the authenticity of the medical treatment provided to the deceased in the said hospital under Ex.B12 to B14. It may be noted here that production of document is different from proof of the same. In case of repudiation of claim, the burden of proof heavily lies upon the Insurance Company. Except treatment record, no other evidence or material to show that the deceased was suffering from such disease was filed. As such we are of the considered opinion that the mere allegation of concealment of material fact by the opposite parties is not acceptable in the absence of any evidence in support thereof and therefore, we hold that the repudiation of claim by the opposite parties is not justifiable".
917. As seen from the material borne by record, it is the consistent stand of the complainants that the deceased died at home due to Chest pain. At this juncture, it is relevant to mention that Ex.B6 is the statement of complainant No.1 wherein, it is categorically mentioned that the death of the deceased was a sudden death due to chest pain and the same is certified by Medical Officer, MPHC, Konijarla, Khammam District and also by gazetted Head Master, ZPSS, Pallipadu, Konijarla Mandal, Khammam District. The said Ex.B6 Statement of Complainant No.1 is also signed by one T.Srinu, the LIC agent of the opposite parties with code No.4628653. The opposite parties have failed to rebut this consistent version of the complainants about the nature of the death of the deceased.
18. No doubt, as per Sec.45 of the Life Insurance Act, 1938, the Insurance Company is entitled to call in question of any claim/ policy, if the said claim is an early one i.e. within three years from the date of the policy. The learned counsel for the insurance company in his arguments submitted that the said period of three years is to be reckoned from the date of the revival of the policy which is 21.10.2015. But, the Hobn'ble Supreme Court of India in Mithoolal Nayak V/s. Life Insurance Corporation of India, AIR 1962 Supreme Court 814 held "that for the purpose of Sec.45 of the Life Insurance Act, 1938, the period of two years (now three years after the amendment of Sec.45 of the Insurance Act from the date 26.12.2014), has to be counted from the date on which the policy was originally effected and not from the date of the revival of the policy".
19. In the case on hand, admittedly the Insurance Policy was commenced on 28.01.2013. It is not the case of the opposite parties that the deceased suppressed the material fact regarding his health on the above date of issuance of the policy. Even as per the version of the opposite parties, the deceased alleged to have been undergone treatment for the alleged disease on 11.03.2015 at the alleged hospital. Thus, from the same it can be concluded that the deceased has not suppressed any material fact with regard to 10 his health in the Proposal Form submitted basing on which having satisfied, the insurance company issued the insurance policy in favour of the deceased with commencement of risk from 20.01.2013. Having issued the insurance policy, the insurance company is expected to honour the same and shall not dispute the same under the lay causes of the so called suppression of material fact only to avoid the genuine claim. Insurance Companies are expected to realize the very purpose and object of taking insurance policy by anybody such as deceased in the case on hand and fulfill the said object by honouring the claim on the death of the Insured.
20. In view of our aforestated discussion, we are of the considered opinion that the insurance company has miserably failed to discharge its onus, with regard to the alleged suppression of the material facts by the deceased life assured as such this appeal is liable to be dismissed. Nothing appears to us to interfere in the well-reasoned order of the District Forum, Khammam, as such we hereby confirm the order of the District Forum, Khammam.
21. In the result, the appeal is dismissed. There is no order as to costs.
Sd/- Sd/-
I/c PRESIDENT MEMBER-JUDICIAL
Dated : 03.11.2023
*AD