State Consumer Disputes Redressal Commission
Kodurupaka Vijayalaxmi vs 1.The Branch Manager, Lic Of India, on 6 September, 2022
Commission
Before the State Consumer Disputes Redressal
Protection Act, 2019)
(constituted under the Consumer
Khairathabad at Hyderabad
of Telangana, Eruvaka Building,
OF 2015
FANO.136 OF 2018 AGAINST CC NO.34 WARANGAL
ONTHE FILE OF DISTRICT cOMMISSION,
Between:
1) The Branch Manager,
LIC of India, Parkal Branch office,
Jeevan Jyothi,
Hanamkonda road,
Parkal Post and mandal,
Warangal district.
2) The Senior Divisional Manager,
Life Insurance Corporation of India,
Divisional Office: Jeevan Prakash,
near Dr.B.R. Ambedkar Statue,
Balasamudram, Hanamkonda (P & M),
Warangal district- 506 001.
..Appellants/0pposite parties
And
Kodurupaka Vijayalaxmi
W/o late Shekaraiah, aged 43 years,
Occupation: Household,
R/o H.No.1-24, Chainpaka (P & V),
Chityal (M), Warangal district 506 356.
-
...Respondent/Complainant
Counsel for the Appellants Sri G.Anand Kumar
Counsel for the Respondent Sri Kunamalla Karunakar
cORAM:
*****
Hon'ble Sri Justice MSK Jaiswal .. President
and
Smt Meena Ramanathan Member
Tuesday, the Sixth day of September Two Thousand Twenty-Two Oral Order *** This is an appeal preferred by the Opposite parties aggrieved by the orders dated 21.12.2017 passed by the District Consumer Forum, Warangal in CC No.34/2015 in allowing the complaint and directing the Opposite parties therein jointly and severally to pay a sum of with interest @ 7.5% per sum assured along towards KS.1,00,000/- 22.04.2015 till date of complaint i.e., annum from the date of filing and also to pay as per the policy realisation; to pay death benefits, if any, ol one Rs.2,000/-, granting time costs of damages of Rs.5,000/- and month for compliance referred to a s arrayed sake of convenience, the parties are
2) For the in the complaint.
is the wife of one
It is the case of Complainant that she
3)
Shekaraiah, who died on 05.07.2014 due to fever. During the lifetime
No.689181821 from the
her husband, he obtained the policy bearing
which
Opposite party No. I for an assured sum of Rs.1,00,000/-
commenced on 28.04.2011, to which, she is shown as nominee. After
death of her husband, she made claim with the Opposite parties, at which time, the Opposite party No.1 obtained her signatures on printed lorms by affixing revenue stamps without cxplaining the contents thereof. Though she approached the Opposite parties on numerous occasion, they failed to settle the claim but instead vide letter dated 23.01.2015 they repudiated the claim. Hence, complaining deficiency of service filed the complaint with a prayer to direct the Opposite parties to pay Rs. 1,00,000/- towards sum assured; Rs. 10,000/. towards vested bonus; to pay interest @ 9% p.a. from 01.12.2014 to 22.04.2015; to pay and compensation of Rs. 10,000/; to pay travel expenses of Rs.1,000/- legal expenses of Rs.2,500/-
4) Opposite parties filed their written version admitting issuance of for the policy on the name of Shekaraiah vide policy No.689181821 assured sum of Rs.1,00,000/- which commenced on 28.04.2011 and also admitting the Complainant to be its nominee. The life assured died on 05.07.2014. The policy was in lapsed condition for non-payment of due 4/2013, which was revived on 28.01.2014 on the premium on strength of personal statement. The life assured had suffered CVA (R) Hemiplegia and took treatment at Rohini Hospital, Hanamkonda on 23.10.2013 which is prior to the revival of the policy, which fact was no deficiency of service suppressed at the time of revival. Hence, there is on their part and accordingly prayed to dismiss the complaint.
order to
before the District Forum, in
5 During the course of enquiry
PW1 and
filed her affidavit evidence as
prove her case, the Complainant On behalf of Opposite parties, documents Ex.Al to A16.
got marked the
Administrative Officer (Legal & HPF) filed his
one B.V.Pushparaju, their
to B3.
marked the documents Ex.B1
affidavit evidence a s RW1 and got IA No.253/2016, parties bearing On an application filed by the Opposite the the Commission below summoned by orders dated 21.11.2016, K.Shekaraiah, IP No.RAS 2191, sheet/treatment record of original case Medicare Private Hospitals, Rohini 23.10.2013 from Rohini dated and the same is Hanamkonda, Warangal Limited, # 2-5-742, Subedari, marked as Ex.X1.
on Forum after considering the material available
6) The District orders dated CC No.34 of 2015, by record, allowed the complaint bearing No. 1, supra.
21.12.2017, as stated, at paragraph the present the Appellants preferred
7) Aggrieved by the said orders, below failed to appreciate the fact that appeal contending that the forum the insurance contract is a contract of utmost good faith wherein the his health, proponent is duty bound to disclose everything concerning within his knowledge. It failed to habits and other related matters the life consider the fact that there is a suppression on the part of assured which goes to the root of the case. Hence, prayed to allow the appeal by setting aside the orders impugned.
The point that arises for consideration is whether the impugned
3) order as passed by the District Forum suffers from any error or modified or interfered irregularity or whether it is liable to be set aside, with, in any manner? To what relief?
What is the effect of a life assured falling sick or being admitted in
9) the hospital for more than a week during the interregnum when the original policy issued lapsed and its revival is the point for determination in the present appeal.
10) The facts in brief are that the husband of the Complainant by name Shekaraiah has taken the policy from the Opposite party on 28.04.2011 by paying the annual premia. Ex.B3 is the original policy issued by the Appellants/Opposite parties. The premia which fell due on which was due in April, 2013 2012 was also paid, however, the premia 28.01.2014, by lapsed. Subsequently, on Was not paid and the policy got In between assured got the policy revived. paying the premia, the life was lapsed and 28.01.2014 28.04.2013 i.e., the date when the policy in Rohini assured was admitted when the policy was revived, the life Ex.AT is borne-out from Hospital from 23.10.2013 to 01.11.2013 as Forum from the which is a medical record summoned by the District policy was revived on the basis of the sel hospital authorities. The declaration which is Ex.B2 certifying that the life assured was of good suffered from any illness or the disease health; that he has never and that he never underwent requiring treatment for a week or more investigations such as X-ray, ECG, etc., When Ex.X1 is carefully perused, it is manifest that what is
11) mentioned in Ex.B2 by the life assured at the time when the policy was incorrect and that amounts to being revived on 28.01.2014 is suppression of material fact, which will affect the life assured getting the policy revived.
12) The learned counsel appearing for the Respondent/ Complainant submits that since the policy commenced more than two years prior to the alleged suppression, in view of Section-45 of the Insurance Act, the insurance company cannot repudiate the claim on the ground of In support of this contention, the learned suppressing the material fact. counsel appearing for the Respondent/Complainant has relied upon the following authorities.
Sunita Devi versus Branch Manager, Life Insurance Corporation of
(i) India and another, in R.P.No.3234 of 2018, decided on 20.08.2019 Redressal Commission, New by the National Consumer Disputes Delhi. A similar point fell for consideration. The facts in the case before the NCDRC when juxtaposed with the facts of the present In the before the NCDRC, the case are quite at variance. case policies lapsed in November 2001 and they were revived in June 2002. Before revival, he was subjected to medical examination by and only after he was the panel doctors of the insurance company found the fit, was revived.
policy However, the life assured is said the life assured applied for to have died on 24.05.2005 i.e., after 2006. In revival butbefore the policy could be revived in June transplant which between this period, the life assured had kidney to obtaining the policies Was the development subsequent whether before the NCDRC was originally. Therefore, the question concealed the for revival, he a t the time when the insured applied affected the does it in any way actum of his illness and if he has, issued to him in the year 1997. validity of the policies which were Court in the decision of the Supreme The NCDRC has relied upon Insurance Corporation of India, AIR "Mithoolal Nayak Life versus Court in Judgment The Supreme 1962 SC 814 (V-48 C-117)".
under:
referred to above held as before the commencement "No policy of life insurance effected the date of the expiry of two years from of this Act shall after Act and no policy of life insurance c o m m e n c e m e n t of this the the coming into force of this Act shall, after effected after be the date on which it w a s effected, expiry of two years from insurer on the ground that a called in question by an insurance or in any report statement made in the proposal for or referee, or friend of the insured, or in of a medical officer, issue of the policy, was document leading to the any other inaccurate or false, unless the insurer shouws that such statement was on_a material_matter or suppressed facts that it was fraudulently which it was material to disclose and policy holder knew at that the made by the policy-holder and statement was false or that it thetime of making it that the disclose." suppressedfacts uwhich it was material to (emphasis supplied) NCDRC held that since there was the Relying upon the above authority, material facts before the policy was issued, the no suppression of any Insurance under Section-45 of the period of two years as contemplated issuance of original policy, Act is to be computed from the date of repudiation cannot be made, recent decision of the Supreme Court on
(i) However, there is another similar subject which is a Judgment reported in Reliance Lfe Insurance Co., Ltd., and another v e r s u s Rekhaben Nareshbhai SCJ 712. The relevant paragraph is Rathod, reported in 2019 (6) extracted.
13, which can usefully be "The cumulative effect of Section-45 is to restrict the right of insurance after a period the insurer to repudiate a policy of life which the policy w a s effected. of two years of the date on Beyond two years, the burden lies on the insurer to establish mAteriul matler or themacurucu orfulsity of a stalement nA Morroper, n addition to this facts.
ie Sppession of material has the insurer to establish that this non quirement,or, disclosure as the case may be, the submission of or false information was fraudulently made and acurate that the policy holder while making it Anetw of the Jalsity of the Statemet or of the suppression of facts vhich uCE material todisclose"
The Branch (11i) Subsequently, in another decision reported in Manager, Bajaj Alllans Lfe Insurance Company Limtted and others versus Dalbir Kaur, SLP (C) No. 10652 of 2020, the Supreme Court held as under.
T7he medical necords which have been obtained during the course of investigation indicate that the deceased was suffering from a serious pre-eristing medical condition which was not disclosed to the insurer". This authority also lays down the same proposition of law that if the proposer has sufered from any ailment and undergone treatment and if he does not disclos e the same and if subsequently the insurance company can produce cogent evidence to the effect that the proposer has fraudulently suppressed material information affecting the contract, the same cannot be acted upon".
13) What could be culled-out from the above authorities is that when there is no doubt about the calculation of the period of two ycars for repudiating the claim on the ground of suppression in view of Section-45 of the Insurance Act, but, both the authorities have clearly laid down that it is not as though that beyond two years, the insurance company cannot repudiate the claim on the ground of suppression of existing ailment. As a matter of fact, in the portions of the orders highlighted in the Judgments referred to supra, the Supreme Court has clearly laid down that if the repudiation on the ground of suppression is to be made beyond two years, the burden lies on the insurer to establish the inaccuracy or falsity of a statement on a material matter or the suppression of material facts The insurance company is further required to establish that this non-disclosure or submission of inaccurate or false information was fraudulently made and that the policy holder while making it knew of the falsity of the statement or of the suppression of the facts which were material to disclose.
14) Applying above authoritative pronouncements to the facts of the instant case, what is required to be seen is as to whether the life assured was revived.
has suppressed the material fact at the time when the policy show that the As already stated supra, the facts of the case clearly the material information deceased life assured was guilty of suppressing for revival of irom the insurance company when he submitted the request in April 2013 and the policy. In the instant case, the policy was lapsed life assured was was revived on 28.01.2014. In between this, the from Ex.XI 01.11.2013 as is borne-out hospitalised from 23.10.2013 to which cannot be doubted.
which is a medical record, the authenticity of Hanamkonda Private Limited, Ex.X1 is the case-sheet of Rohini Medicare treatment for Warangal, wherein the deceased has undergone "Haemorrogic stroke CVA right Hemiplegia'.
submits that
15) The learned counsel appearing for the Complainant is Ex.X1 which is the main of the case of the Insurance Company stay in this connection, he notin respect of the deceased life assured and assured is inconsistently submits that the name of the deceased life there under was mentioned and that as per Ex.X1, the patient treated aged about 65 years.
date of
16) The learned counsel further submits that on the alleged admission under Ex.X1 and when the age of the DLA was compared with the proposal-Ex.A 1, he would not have been more than 45 to 48 years of documents that are age. If this contention is to be accepted, the other relied by the Complainant in support of the claim have also to be discarded on the same ground. For example, Ex.A3 is the study, conduct and date of birth certificate issued by the Head Master of the school where the deceased life assured is said to have studied from class 6th and 7th, In this crucial document, there is a overwriting in the column of date of birth which ought not to have been the case if all was well with the claim of the Complainant. The year 1966 is tampered and interpolated both in words, alphabets and also when the same is written in words, it is clear that the word 'six' is overwritten after erasing some word underneath that. Significantly, the original of Ex.A3 is not produced to see as to whether the tampering was done and if so by whom. Ex.A9 is another document which falsify the claim of the Complainant. It is an Identity Card issued by the Election Commission which was issued on 15.12.1995 and as per the said Election Commission Identity Card, as on 01.01.1995, the age of the deceased life 8 consideration, in the year into assured was 45 years. If this is taken will be 65 years.
2014 when he died, the age of the life assured the claim documents referred to above, Ex.A12 is
17) As against the the Insurance submitted to statement made by the Complainant herself and in this the Complainant Company. It is the claim made by view of the as 58 years. In she has described the age of her husband that are between the documents above, there is a clear inconsistency in the to what the age of produced by the Complainant herself to show as or when deceased life assured was either at the time of taking the policy from he died. Therefore, no benefit can be derived by the Complainant shown as the fact that in Ex.X1 the age of the patient admitted there is 65 years.
The other submission of the learned counsel appearing for the
18) the medical record Ex.X1 shows the name of Complainant is that Shankaraiah as against the name of Shekaraiah. This submission also is devoid of substance for the reason that the entire Ex.X1 consists of several pages and in many of the pages the name is correctly mentioned as Shekaraiah but only in few pages, the name is written as Shankaraiah. That apart, the name of the father of the patient admitted therein is K.Mogalaiah which is correctly mentioned. Therefore, we see no reason to hold that Ex.X1 is not in respect of the deceased life assured as has been submitted.
19) The learned counsel appearing for the Complainant further submits that there is no nexus in between the alleged suppression and the cause of death. In support of this contention, he relied upon several authorities. A detailed reference to said authorities need not be made for the reason that there is no quarrel with the legal proposition that when the insurance claim is sought to be repudiated on the ground of suppression of material fact, the same should have a direct bearing with the cause viz., there should be nexus in between the cause of death and the disease with which the deceased life assured was suífering and which is said to have been suppressed.
20) The Complainant has failed to show by any cogent evidence as to what is the cause of death of the deceased life assured. Except for producing Ex.A13 which is the certificate issued by Revenue Authorities, Even in what was the c a u s e of death.
1othing i8 produced to show as to 05.07.2014 alter deceased died on Ex.A13 it is mentioned that the of the As already stated in Ex.A13, the age suflering with fever for 3 days. to and even according person who was cremated is shown a s 58 years therelore, it the Complainant, her husband was aged only 45 years, deceascd life assurcd in cannot be said that Ex.A13 is in respect of the insofar as the age of the person buried View of the material discrepancy is also placed upon concerned. The other reliance under Ex.A13 is Confidential Report Ex.A14 which is the confidential report by the agent.
information is based
as conclusive
since the
of the agent cannot be taken
of Ex.X1.
which the Complainant
alleges in respect
upon the hear-say will be
of what is informed to
the agent by the people
Only on the basis mentioned that a s per
the
the agent had clearly
made note of. In Ex.A14,
fever. There
the cause of death
was
information that is obtained by him, to show a s to the part of the Complainant is no clinching evidence on death.
what was the cause of
Ex.X1
behalf of the Insurance Company,
21) As against the above, on
summoned from the hospital wherein
has been
is the medical record that As
deceased w a s suffering with Hypoblesemia.
it is mentioned that the
medical record, the deceased was suffering with Haemorrogic per the The medical record further shows that the stroke CVA Right Hemiplegia.
there and was on medication a known case of hypertension patient was What is evident from with the above ailment.
diagnosed for and was life assured had a Haemorrogic Stroke for Ex.X1 is that the deceased evident that the which he underwent treatment in the said hospital. It is such serious ailment just few months deceased life assured suffered revived by suppressing the same. prior to getting the lapsed policy Respondent/Complainant relied upon
22) The learned counsel for the of which shows that the facts the following judgments, the perusal therein are quite distinct.
In the matter of Parvathapu Mangamma versus The Aviva Life
(a) Insurance Company of India in CC No.58/2019, decided on 17.01.2022 passed by Telangana State Consumer Disputes Redressal Commission, Hyderabad, wherein, it is observed as under:
10has taken the policy by it is shown that the life assured " material ailment which w a s well within suppressing existence of succumbs and obtaining the policy and ultimately nowledge sto that he will be held to be ailment after the policy is issued, from responsible for having suppressed the material information the insurance company thereby making the insurance company the proposal. If no satisfactory evidence is produced to to accept to the and issuance of the policy, the Snow that prior proposal within his was well ye assured had any ailment which did not disclose the knowledge, underwent treatment therefor, Same and subsequently resulting the death and if there is a nexus between all these three, only then the insurance company is liable to can be heard saying that the claim of the life assured be repudiated on the ground of suppression varie."
In the matter of India First Life Insurance Company Limited versus
(b) Botla Yakantha @ Srikala in FA No.13/2019 decided on 14.07.2022 passed by Telangana State Consumer Disputes Redressal Commission, Hyderabad, wherein, it is observed as under:
"..in the absence of there being any nexus or close proximity in between the cause of death and the facts suppressed, the insurance company cannot repudiate the claim solely on that ground. May be if there are other grounds on which the repudiation is made, this may be one of the factors to be weighed but in the instant case, the entire claim is repudiated solely on the ground that the life assured has suppressed the fact he was admitted in hospital in January 2010 when he taken the policy in March 2014 and died on 28.05.2015. Absolutely, no evidence is produced to show about any treatment or hospitalisation in between 2010 and 2015. The Forum below has appreciated the material on record in correct perspective and granted the relief. We see no reason to interfere with the said findings and the impugned order is liable to be corfirmed byy dismissing the appeal."
(c) In the matter of SBI Life Insurance Company Limited versus Katkam Padma, in FA No.328/2017 decided on 12.07.2022 passed by Telangana State Consumer Disputes Redressal Commission, Hyderabad, wherein, it is observed as under:
When the insurance company seeks to repudiate the claim on the ground of suppression of material fact, onus lies upon them to convincingly and cogently establish that the life assured has suppressed the existing ailment. The burden is upon them to prove but in the instant case, though an attempt has been made but the insurance company could not succeed in establishing that the Bhoomanna who has undergone treatment during April/ May 2009 is the same Katkam Bhumaiah who has obtained the 11 housing loan and the insurance from the Appellant insurance company."
(d) In the matter of Indla First Life Insurance Company Limited versus Ajmeera Sammaiah, in FA No.74/2017 decided on 18.03.2021 passed Disputes Redressal by Telangana State Consumer Commission, Hyderabad, wherein, it is observed as under:
the insurance company seeks to repudiate the claim on When the ground of suppression of material fact, onus lies upon them that the life assured has o convincingly and cogently establish is upon them to Suppressed the existing ailment. The burden has been made prove but in the instant case, though an attempt but the insurance company could not succeed in establishing9 that the Bhoomanna who has undergone treatment during Aprl/ Bhumaiah who has obtained the May 2009 is the s a m e Katkam the Appellant insurance housing loan and the insurance from company."
Indla and others
(e) In the matter of Life Insurance Corporation of
No.464/2017 decided on
versus Munugunurl Vanitha, in FA
State Consumer Disputes
24.09.2021 by Telangana
passed
Redressal Commission, Hyderabad.
"In the instant case, admittedly, the insurance company except of Institute Medical Sciences, for producing the record of Nizam's admitted on where the insured w a s Hyderabad hospital no other 12.05.2011 and died on 28.05.2011, absolutely to show that evidence w a s produced by the insurance company the insured w a s suffering prior to taking the insurance policies, chronic alcoholic which from any ailment or that he w a s a We have resulted in the insured being affected with jaundice.
that has been produced by carefully perused the medical record is nothing in the said the insurance company. Absolutely there the deceased record to show that prior to his hospitalization, The medical evidence w a s suffering from any serious ailment.
that 20 days prior to his placed on record which shows The medical admission, he w a s complaining of stomach-pain. record produced by the insurance company do not in any way alcoholic or that the show that the deceased insured w a s an c a u s e of the ailment of the deceased w a s consumption of alcohol."
that when Ex.B2, the request to
23) It is manifest from the above deceased life assured was aware about revive the policy was made, the thereto a s is evident from Ex.X1. his hospitalisation just few days prior affect the insurability of the life assured. This is a material fact which will said to be in any way Therefore, the insurance company cannot be the said grounds. The District deficient in repudiating the claim on 12 these aspects in proper perspective Forum has not properly appreciated and the said the insurance company ana nas erroneously held against the s a m e is liable to nndings cannot be sustained. In view of the above, be set aside and the appeal to be allowed.
order of the District
24) n the result, the appeal is allowed and the
own costs in this
Forum is set aside, however, the parties to bear their
appeal. The statutory deposit, if any, made by the Appellants/Opposite
with
parties shall be returned to the insurance company together
accrued interest.