T. Sunil Chowdary, President
1. This appeal is filed, under Section 15 of the Consumer Protection Act, 1986, assailing the Order, dated 08.08.2016 passed in C.C.No.110 of 2015, on the file of the District Consumer Disputes Redressal Forum, Kurnool, wherein the complaint filed by the complainant was allowed in part.
2. The parties hereinafter will be referred to as they were arrayed before the District Forum for the sake of convenience.
3. The facts leading to filing of the appeal in nutshell are as follows: The complainant is the wife of Golla Ramajaneyulu, herein after referred to as life assured. The life assured has obtained a Policy, bearing No.005689452, for a sum assured of Rs.20,00,000/-, from the 2nd opposite party. Unfortunately, the life assured died on 10.07.2013. The complainant submitted the claim application to the opposite parties for settlement of insurance claim. The opposite parties repudiated the claim of the complainant, vide its letter, dated 31.12.2014. The complainant once again submitted the application to the 2nd opposite party to re-consider her claim application. However, the opposite parties once again rejected the claim of the complainant on 10.09.2015. Having no other alternative, the complainant approached the District Forum for Redressal.
4. The 1st opposite party filed memo, adopting the written version of the 2nd opposite party.
5. The 2nd opposite party filed counter, inter alia contending that the life assured had obtained the policy from the opposite parties by suppressing the material facts i.e., his age and health condition. In the proposal form, the life assured mentioned his date of birth as 05.05.1975 basing on the fake school certificate. The life assured did not disclose in the proposal form that he has been suffering with the kidney problem much prior to the submission of the proposal forum. The opposite parties repudiated the claim of the complainant as the life assured suppressed the material facts in the proposal form. The complaint is not maintainable either on facts or in law. Hence, the complaint may be dismissed.
6. Before the District Forum both parties filed evidence affidavits. On behalf of the complainant, Exs.A-1 to Ex.A-3 were marked. On behalf of the opposite parties, Exs.B-1 to B-4 were marked.
7. Basing on the pleadings, evidence affidavits, documentary evidence and other material available on record, the District Forum arrived at a conclusion that there was deficiency in service on the part of opposite parties, accordingly, allowed the complaint, directing the opposite parties jointly and severally to pay the assured sum of Rs.20,00,000/- to the complainant.
8. Feeling aggrieved by the impugned order, dated 08.08.2016 passed in C.C.No.l 10 of 2015, the opposite parties preferred this appeal.
9. The learned counsel for the opposite parties (appellants) submitted that the impugned order is not sustainable on the following grounds:
1. The District Forum misconstrued the recitals of Ex.B-2 and discarded the same on untenable grounds;
2. The District Forum failed to consider the suppression of the material facts in the proposal form that itself is a valid ground to repudiate the claim of the complainant;
3. The findings recorded by the District Forum are contrary to the pleadings as well as the settled principles of law and
4. If the order of the District Forum is allowed to stand, certainly, it would amount to miscarriage of justice, therefore, it is a fit case to allow the appeal.
10. For contra, the learned counsel for the complainant (respondent) submitted that the District Forum rightly discarded Ex.B-2, by assigning reasons. He submitted that the opposite parties failed to establish that the life assured suppressed the material facts in the proposal form. He further submitted that the findings recorded by the District Forum are based on material much less legally admissible material, therefore, it is a fit case to dismiss the appeal.
11. Basing on the rival contentions, the points that arise for consideration are:
1. Whether the opposite parties are justified in repudiating the insurance claim of the complainant and
2. Whether there are any grounds to set aside the impugned order.
12. The complainant is the wife of late Golla Ramajaneyulu. Late Golla Ramajaneyulu submitted a proposal form Ex.B-1 to the opposite parties for issuance of the policy. Basing on Ex.B-1 proposal form, the opposite parties issued Ex.A-1 Policy, bearing No.005689452 for a sum assured of Rs.20,00,000/-, on 28.07.2012 in favour of life assured. Unfortunately, the life assured died on 10.07.2013. Ex.A-2 is the death certificate issued by the Kurnool Municipal Corporation. Immediately after the death of life assured, the complainant submitted the claim form to the opposite parties with a request to settle the insurance claim as early as possible. After receipt of the claim form, the opposite parties appointed an investigator, who in turn, submitted his report Ex.B-2. Basing on the material available on record, the opposite parties repudiated the claim, vide its letter, dated 31.12.2014 Ex.B-3. The complainant once again submitted a letter to the opposite parties to re-consider her insurance claim. The opposite parties second time also rejected the claim of the complainant, vide its letter, dated 10.09.2015 Ex.A-3/B-4. A perusal of the record reveals that the Insurance Company repudiated the claim of the complainant on the following two grounds:
1. The life assured mentioned his date of birth in the proposal form basing on the fake school certificate and
2. By the time of taking of the policy, the life assure was suffering from kidney problem.
13. Suffice it to say, the initial burden lies on the opposite parties (Insurance Company) to establish the stand taken by it in the repudiation letter. Once the opposite parties discharge the burden lies on it, the onus of proof shifts on the complainant to substantiate her stand. In Ex.B-1 proposal form, the life assured mentioned his date of birth as 05.05.1975. As rightly pointed out by the learned counsel for the opposite parties, the life assured mentioned his qualification as SSC, in the proposal form. We have clearly scanned Ex.B-1 proposal form in order to ascertain on what basis the life assured mentioned his date of birth i.e., basing on the school certificate or any other relevant document. The proposal form is conspicuously silent with regard to the basis for mentioning the date of birth of life assured in the proposal form. The learned counsel for the opposite parties submitted that the life assured produced fake school certificate, wherein his date of birth was mentioned as 05.05.1975. There is no mention in the proposal form that the life assured submitted his SSC certificate in order to prove his date of birth. A perusal of the proposal form clearly reveals that the life assured submitted his Voter Identity Card. It is not the case of the opposite parties that the date of birth as mentioned in the proposal form, is not tallying with the date of birth in the Voter Identity Card. Along with the investigation report Ex.B-2, the opposite parties produced the photo copy of school certificate with the alleged endorsement of the Head Master. The opposite parties did not choose to obtain the affidavit of the Head Master, who alleged to have made endorsement on the SSC certificate. There is no mention in the investigation report on which date the investigator obtained the endorsement on the school certificate and from where he obtained the alleged SSC certificate. It is a known fact that the Insurance Company has to obtain declaration from the proposer in the proposal form. If the language in which proposal form is printed is not known to the proposer, then one of the employees or agent of the Insurance Company has to read over and explain the contents of the proposal form and obtain the signature of the proposer. If the proposer subscribes his signature on declaration form, the recitals mentioned in the proposal form are binding on him. In the instant case, the opposite parties did not obtain the signature of the life assured on the declaration. A perusal of Ex.B-1 clearly demonstrates, the declaration column was kept unfilled. It is needless to say, as per the IRDA Guidelines, a duty is cast on the agent of the opposite parties to explain the contents of the proposal form, thereafter obtain his/her signature on the declaration. The material placed on record clinchingly establishes while taking the Ex.B-1 proposal form, the opposite parties did not follow the procedure contemplated by the IRDA. Edifice of any proceedings based on pleadings of the parties. No party to the proceedings is entitled to advance arguments without pleadings so far as factual aspect is concerned. For one reason or another, there is no pleading in the written version of the 2nd opposite party that the life assured has obtained the policy by suppressing the material fact i.e., age of the life assured.Ex.B-2 is no way helpful to the opposite parties. Viewed from any angle, the opposite parties are not justified to repudiate the claim on the ground that the life assured mentioned his date of birth basing on the fake school certificate.
14. The next question that falls for consideration is whether the life assured has suppressed his pre-existing disease as on the date of taking of the policy. The gist of the complainant is that the life assured was suffering with kidney problem much prior to the taking of the policy. One of the grounds for the repudiation of the claim of the complainant is the suppression of the pre-existing disease by the life assured. The opposite parties did not produce single scrap of paper to establish that the life assured was suffering with kidney problem much prior to 28.07.2012. In the investigation report Ex.B-2, it is clearly mentioned that the investigator could not get the medical record of the life assured. In the absence of the medical record, it is not possible to arrive at a conclusion that the diseased was suffering from kidney problem much prior to the taking of the policy. We are unable to understand as to how the Insurance Company came to a conclusion that the life assured was suffering with kidney problem prior to 28.07.2012. It is needless to say, any conclusion arrived at by the Judicial or the Quasi Judicial Authority, without any basis, is not sustainable in the eye of law. There is no material much less convincing material to establish that the life assured was suffering with kidney problem much prior to 28.07.2012. The Insurance Company repudiated the claim of the complainant without any basis. As observed supra, the Insurance Company has not followed the guidelines issued by the IRDA while accepting the proposal form. Viewed from any angle, there is no justification on the part of the opposite parties in repudiating the claim of the complainant. Repudiation of the claim without any basis would amounts to deficiency
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of service as contemplated under Section 2(1 )(g) of the Consumer Protection Act, 1986. If the complainant establishes the deficiency in service on the part of the opposite parties, the complainant is entitled for the reliefs sought for. Hence, Point No. l is answered in favour of the complainant against the opposite parties. Point No .2: 15. An appeal is a continuation of the original proceedings. While deciding the appeal, this Commission can reconsider and re-appreciate the material available on record. If the findings recorded by the District Forum are not based on any material, certainly, this Commission can set aside the same. In the instant case, the District Forum considered the various documents filed by both parties in the backdrop of the pleadings of both parties. The District Forum has assigned reasons much less cogent and valid reasons to its findings. We are fully endorsing with the findings recorded by the District Forum. There is no irregularity or illegality in the impugned order which warrants interference of this Commission. Viewed from any angle, the appeal is liable to be dismissed. 16. In the result, the appeal is dismissed without costs. Appeal dismissed.