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Branch Manager, Max New York Life Insurance Co. Ltd., Situated at Hero Honda Show room Near District Court, Kadapa & Another v/s C. Ramalakhumma

    FA.No.905 of 2010 against C.C.No.119/2009 District Forum, Kadapa

    Decided On, 05 October 2012

    At, Andhra Pradesh State Consumer Disputes Redressal Commission Hyderabad


    For the Appellants : D.V. Ramakrishna Sarma, Advocate. For the Respondent : M/s. K.R.R. Associates, Advocates.

Judgment Text

Oral Order: (Hon’ble Sri Justice D.Appa Rao, President)

The opposite party, insurance company, preferred the appeal against the order of the District Forum directing it to pay Rs.3,91,791/- covered under the policy.

The case of the complainant in brief is that her husband, C.Mallela Bali Reddy, took life insurance policy for a sum of Rs.3,91,790/- commencing from 30-7-2008. While so he died on 20-12-2008 due to brain Haemorrhage. The said fact was informed to the insurance company and the required documents were submitted. However, it was repudiated on the ground that the assured was suffering from hypertension from 16-1-2008 and it was suppressed and therefore she was not entitled to the amount and refunded an amount of Rs.9,271.76 ps. paid towards premium amount. Assailing the said repudiation, she filed the complaint to pay the maturity value of Rs.3,91,791/- i.e. together with interest at 18%, compensation of Rs.50,000/- and costs.

The insurance company resisted the case. It alleged that the claim was repudiated on the ground that the deceased had mis-represented and suppressed his ailment, hypertension. After receipt of the claim, it was found that he had suppressed that he had taken treatment at Primary health Centre, Mylavaram for hypertension for the past one year. Therefore, it prayed for dismissal of the complaint.

The complainant in proof of her case filed her affidavit evidence and got marked Exs.A1 to A4 while the opposite parties marked Exs.B1 to B7.

The District Forum after considering the evidence placed on record opined that the insurance company had deliberately tampered Ex.B5 and that the assured did not suppress the ailment and therefore directed the insurance company to pay the amount of Rs.3,91,791/- within two months from the date of order, it did not award interest, compensation or costs.

Aggrieved by the said order, the insurance company preferred this appeal contending that the District Forum did not consider either facts or law in correct perspective. The conclusion made basing on Ex.B5 is not correctly made. In the proposal, he had suppressed the fact that he has taken treatment with the Medical Officer, Primary Health Centre, Mylavaram where there was a categorical mention that he was under treatment from 16-1-2008. Therefore, the claim was rightly repudiated and prayed that the complaint be dismissed.

The point that arises for consideration is whether the order of the District Forum is vitiated by any mis-appreciation of fact or law in that regard?

During the course of hearing, the appellant filed an application to receive original form ‘C’ i.e. original of Ex.B5 to show that it did not tamper the document and on the other hand the complainant had tampered and filed Ex.A2. The said petition was allowed and the original of Ex.B5 is marked as Ex.B8. It is an undisputed fact that the complainant is the wife and nominee of one Mr.M.Bali Reddy. During his life time, he had taken a policy from the insurance company with a maturity value of Rs.3,91,790/- commencing from 30-7-2008. It is also not in dispute that he died on 20-12-2008 due to brain haemorrhage. The complainant in order to establish that it was sudden and he was not having any pre-existing ailment, filed Ex.A2, certificate to show that he was not having pre-existing ailment. The insurance company in order to prove that the deceased insured had pre-existing ailment filed Ex.B5, the attending physicians statement. The District Forum basing on the discrepancies in Ex.A2 and that of Ex.B5 observed as follows:

‘The date of first consultation as per Ex.A2 was 16-12-2008 but it was mentioned as 16-1-2008 as per Ex.B5. The date of admission was 16-12-2008 as per both Ex.A2 and Ex.B5. In Ex.A2 the age of the deceased was shown as 54 years. In Ex.B5 the age of the deceased was shown as 53 years. There was a little difference of letters and writings in both Ex.A2 and Ex.B5. In Ex.A2, the date of admission and first consultation was clearly shown as 16-12-2008. In Ex.B5 under the date of first consultation in the month column '2' was missed purposefully by the side of numerical '1'. It was very clear that '2' was removed. On perusal of the numerical '1' in '12' at the column history of present illness and the numerical '1' in '12' in the date of first consultation it was similar. So the numerical '2' at the column the date of first consultation has been removed to show that the deceased was suffering from hypertension since 16-1-2008. Thus Ex.B5 was created document subsequent to Ex.A2 to avoid the payment of the claim'.

In order to demonstrate that the District Forum has erroneously upheld Ex.A2, filed the originals of Ex.A2 and B5 they being photocopies in the appeal and received as additional evidence marked as Ex.B8 which we have earlier adverted to.

A perusal of the certificate would undoubtedly show that the complainant had tampered the document in order to show, under the column of ‘General Information’ in column 1, the age was corrected to 54 and column 6, ‘Duration of ailment’ one year was blocked. Equally under ‘INFORMATION ABOUT THE ILLNESS/ACCIDENT’ against the date of first consultation was shown as 16-1-2008 was corrected as 16-12-2008 under Ex.A2. These corrections were made obvious to the naked eye in order to show that the ailment was not pre-existing. Ex.B8 the original would undoubtedly show that the ailment was existing by the date when the policy was taken. He was suffering from hypertension prior to the date of his death. This was issued by Primary Health Centre, Mylavaram. When the very document filed by the complainant discloses pre-existing ailment, it can be said that this was manipulated in order to claim the amount. The complainant had made mis-representation by correcting the original certificate and took a photo copy and had submitted it to the insurance company in order to collect the amount under the policy. This is intentional. The very record discloses that the insured himself had history of hypertension. We do not mulct the judgement with various decisions. Suffice it to say, if the very document filed by the complainant discloses that there was suppression of ailment, necessarily the complainant would not be entitled to the amount.

We do not intend to reiterate that the contract of insurance is ‘uberrimae fides’ where observance of utmost good faith is enjoined on the parties to the contract i.e. they must disclose all material facts in respect of the risk to be covered by the insurance. The insured is obliged to give full and correct information on all matters which would influence the judgement of a prudent insurer in determining whether he will accept the risk, and if he would, at what rate of premium and subject to what conditions. The material facts having a bearing on the risk in life insurance contracts viz., the state of health or illness (present and past) occupation and habits, particulars of previous insurance etc and only within the knowledge of the proposer. The insurer, therefore, has to rely entirely on the information, which the proposer gives at the time of proposal. If a material fact is suppressed, the insurer will be mis-led about the risk covered and hence the same will vitiate the contract. The

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insurer will then be well within its right to treat the contract as void as per the terms and conditions of the policy document. When the insured had suppressed the ailment, in fact, intended to misled the insurance company as well as the Forum to pass favourable orders, we have no other go than to hold that the complainant was guilty of suppression of the ailment. She will not be entitled to the amount. The entire case of the complainant is falsified by Ex.B8, therefore, we are of the opinion that the District Forum was not right in awarding the amount. We do not agree with the opinion expressed by the District Forum in this regard. In the result this appeal is allowed and the order of the District Forum is set aside. Consequently the complaint is dismissed. However in the circumstances no costs.