An insurance company must provide evidence to substantiate the repudiation of a claim based on pre-existing diseases; claims of policy lapse raised for the first time at the appellate stage, which were not part of the initial defense, will not be considered.

COMMON ORDER

ORDER:(HON’BLE SMT. R.S. RAJESHREE, MEMBER, NON-JUDICIAL)

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01. FA No.581/2021 & FA 721/2021 are filed by the opposite parties No.1 & 2, u/s 41 of Consumer Protection Act, 2019, being aggrieved by the order of District Consumer Commission, Karimnagar, dated 02.02.2021 passed in CC 506/2015 and prays this Commission to allow the appeal and to set aside the orders of the District Commission and may be pleased to pass such other order or orders which may deem fit and proper in the interest of justice.

For the sake of convenience, the parties are described as complainant and opposite parties as arrayed in the original complaint.

As both these appeals have arisen out of the same CC both the appeals are being disposed of by way of common order.

02. The case of the complainant is that her deceased brother, Thumma Kankaiah during his life time has taken membership with the opposite party No.2. Opposite party No.2 had provided a unique Super Saver plan to its members by collecting the membership fee which included the insurance coverage issued by opposite party No.1. The Opposite party No.1 had issued a policy bearing No.505020220, after collecting requisite premium amount towards insurance. That her brother died on 17.10.2013, that after the death of her brother, she being a nominee had made a claim with the opposite parties. But the opposite parties have repudiated the claim on the following ground “As per the investigation and clam evaluation member have pre-existing disease when he was entered into the plan.” That the opposite parties have specifically informed that there is no need for any medical examination prior to taking the policy. Despite the same the opposite parties have repudiated the claim on the ground of pre existing disease. That as the opposite parties have rejected a genuine claim, she got issued a legal notice on 03.08.2015 to which opposite party No.1 had given a reply on 10.08.2015 on lame excuses. That this act of repudiating the claim on false grounds amounts to deficiency of service. As such, a complaint was filed before the district Commission seeking insurance amount apart from compensation and cost.

03. Written Version of Opposite Party No.1: The opposite party No.1 filed written version denying all the allegations made in the complaint and had contended that there is no privity of contract between the complainant and this opposite party. However, admitted that they have issued a group insurance policy in favor of Opposite party No.2. The opposite party further pleads that they have not received any death claim from the complainant. That they have received only a legal notice issued by the complainant to which a suitable reply was given and only on receiving the legal notice, they got to know that the complainant is one of the beneficiaries to the group insurance policy issued in favor of opposite party No.2. Further informed the complainant to provide other details and documents in order to process the claim. That the present complainant is filed on false and baseless allegation. Hence prayed to dismiss the complaint.

04. The opposite party No.2 filed its written version denying the allegation made by the complainant and had pleaded that late Thumma Kankaiah, had surrendered the policy on pre-mature basis on 05.03.2015 and the pre-mature benefit amount of Rs.9,250/- was paid to the complainant. That as per the investigation the member/DLA was a suffering from Asthma at the time of taking the Membership and according to the Membership report he was suffering from COPD(TB). Further that the present complaint is filed with a mala fide intention only to harass the opposite party. Based on the above contentions prayed to dismiss the complaint.

05. Before the District Commission, complainant