1. The brief facts of the case of the complainant are that her husband late Siba Narayan Behera was working as OS-1 under OP.5 and died a natural death on 14.3.12. During his life time he had obtained 2 policies from the Ops 1 & 3 in the year 2003 and also during 2011. It is submitted that the Ops 1 & 3 after death of her husband settled insurance claim against the Group Policy of 2003 but in case of Swarna Ganga Group Insurance Policy bearing No.84000002406 dt.01.8.2011, the Ops did not settle the death benefit of her husband. It is submitted that a monthly premium of Rs.1200/- was deducted from the salary of the deceased by the Ops 4 & 5 and was deposited with Ops 1 to 3 every month and while the policy was in force, the insured died but the Ops repudiated the claim of the complainant on 22.6.12 with reason that the life assured had pre-existing diseases while taking the said policy. The complainant submitted that the Ops have not taken any medical test during proposal and the deceased was not suffering any chronic disease at the time of taking policy. Stating the repudiation as illegal and alleging deficiency in service on the part of the Ops, she filed this case praying the Forum to direct the Ops to settle the death claim of Rs.6.00 lacs towards policy benefits with interest @ 18% p.a. and to pay Rs.30, 000/- towards compensation and costs to the complainant.
2. The Ops 1 to 3 filed counter in joint denying the allegations of the complainant but contended that the Deceased Life Assured (DLA), Mr. Siba Narayan Behera was a staff of UGB and has applied for Swarna Ganga Group Insurance Scheme under Master Policy No.84000002406 issued to UGB through membership Form bearing P.F. No.OR-1560-1305 dt.29.6.2011 with risk commenced from 01.8.2011 for a sum assured of Rs.6.00 lacs and the DLA was issued certificate of insurance. The DLA reported to have died on 14.3.2012. As the policy resulted in claim in just 7 months and 13 days, the Ops enquired into the matter and found that DLA was suffering from Diabetes Mellitus, Hypertension and Coronary Artery Disease, Nephropathy, Diabetes retinopathy prior to the date of enrollment into insurance cover. It is also contended that the DLA was a known case of Diabetes Mellitus since 8 years, HTN since 2 years and Ischemic Heart Disease(IHD) since 2 years and he was in regular treatment. The Ops contended that the DLA deliberately suppressed the material facts and obtained the insurance cover fraudulently and hence the claim was repudiated on legal and valid grounds and the same was informed to the complainant vide letter dt.22.6.2012. With these and other contentions along with number citations in support of their case, the Ops denying any deficiency in service on their part, prayed to dismiss the case of the complainant.
3. The OP No.4 remained ex-parte in the entire proceeding. The OP No.5 filed counter contending that he being the employer has been added as formal party. The OP was regularly paying the premiums to the insurer after deducting the same from the salary of the DLA and as such they have no liability. Thus denying any fault on their part, the OP also prayed to dismiss the case against them.
4. The complainant and Ops 1 to 3 have filed certain documents along with affidavits in support of their cases. Heard from the parties through their respective A/Rs and perused the materials available on record.
5. In this case, issuance of insurance policy vide Master Policy No.84000002406 dt.01.8.2011 in favor of Deceased Life Assured (DLA) with monthly premium of Rs.1200/- for a sum assured of Rs.6.00 lacs by the Ops is an admitted fact. The DLA died a normal death on 14.3.12 Jeypore for which the present complainant being the nominee has advanced the death claim of her husband with compliance of all formalities but the Ops on 22.6.2012 repudiated the claim inter alia on the ground of suppression of material information at the time of proposal by the LA to which the complainant objected and has filed the present case.
6. From the rival contentions of both the parties the following issues emerge importance for consideration. (1) Whether the LA was suffering from Diabetes Mellitus, Hypertension, Retinopathy and disclosure of the same during proposal was mandatory, (2) whether the death of LA was due to Coronary Artery Disease, (3) whether the repudiation of the claim by the Ops was genuine, (4) whether the Ops committed any deficiency in service by not settling the claim of the complainant and (5) if so, as to what relief?
7. While deciding Issue No.1, it is seen that according to the Ops 1 to 3 their claims investigation report reveals that the LA was a patient of Diabetes for last 8 years, Hypertension since 2 years and Ischemic Heart Disease (IHD) since 2 years. It is further stated that the DLA was in regular treatment for Diabetes and as per report dt.19.7.2011, the DLA was under treatment for Diabetes Mellitus with nephropathy and retinopathy. The contention of the Ops is that the DLA had concealed the material fact while availing the insurance cover and suppressed his past medical history of Diabetes Mellitus, Hypertension and Coronary Artery Disease, nephropathy, retinopathy and hence they repudiated the claim on legal and valid grounds on 22.6.12.
8. Perused the copy of prescription of treating doctors as well as the report of investigating team of Ops and found that that the DLA was a patient of diabetes since last few years. He was taking Glynase as per advice of doctor from the year 2002 and Cardace for hypertension from 9/2006 to 4/2008. The DLA was also consulting the Ophthalmologist for his eye treatment. Hence the DLA was suffering from Diabetes and hypertension since last few years and during proposal the DLA has not disclosed the said fact at the time of proposal for insurance.
9. It has been severally held by the higher Forums that in the present day to day human life there are lot of problems and they lead a very stressful life. Due to said reasons, diabetes and hypertension like problems have become a common phenomenon as noticed in the human body and the percentage is very high. People are to maintain those ailments. So Diabetes and hypertension are not the diseases but the normal wear and tear of human life. It is seen from the hospital record filed by the Ops that the DLA has never hospitalized for the Diabetes Mellitus and hypertension. It is a settled principle of law that until a person is hospitalized or undergoes operation in the near proximity of obtaining policy or so year or two before, it is not supposed to disclose any day to day problem or normal wear and tear of human life particularly in modern times where person lives stressful life. Patient of diabetes since last few years would not mean that he suppressed material facts about his health justifying repudiation of claim.
10. Issue No.2 is whether the cause of death of LA was Coronary Artery Disease. While deciding this issue it is seen that heart attack is said to be the cause of death. Investigation report of the Ops reveals that the DLA had no bad habit and he was actively at work as they ascertained from the office and neighbors of the DLA. It is seen that the DLA after a brief illness was taken to the local hospital where he was declared dead. He was not admitted in the hospital prior to his death. No report of local doctors is available on record. The DLA has not availed leave before his death. Therefore, it was a normal death. Burden to prove that death of the insured occurred due to the disease that existed at the time of filling of proposal form and that too to the knowledge of the person filling in the form, lay heavily on the insurer. It is to be stated here that no document is filed by the Ops in support of their contentions that the DLA was under treatment of IHD and taking CARDACE for heart disease. No document is available that the DLA was receiving treatment in any Cardiac Centre or any ECG has been conducted at any point of time. CARDACE is a medicine for hypertension and controls Blood Pressure. That medicine can also be used to keep the function of the heart intact as per medical literature but due to want of ECG report and prescription of Cardiac doctor, we can safely concluded that the medicine has been used to control hypertension/BP. Further the DLA was not treated at any point of time for any heart ailment. No direct nexus could be established between diabetes, hypertension and the deceased’s heart failure. Hence the DLA had died a natural death as ascertained from the above discussions.
11. Issue No.3: Whether the repudiation of the claim by the insurer is genuine. In this case it is seen that the Ops have tried to create evidence in order to repudiate the claim of the complainant on some flimsy grounds, simply because insured died after a short time of acceptance of the insurance proposal. Admittedly, the DLA was suffering from diabetes, hypertension and was also examined by Ophthalmologist for his eyes before acceptance of proposal and also found that DLA was not suffering from any serious disease. He was active and no bad habit was seen with him as discussed supra. DLA was not examined by any doctor at the time of his death, so at best; it can be presumed that it was a natural death. Nobody has control over death. In view of above facts and circumstances, it is not prima facie proved that the DLA had committed any fraud or had misstated the facts at the time of filling of proposal form.
12. In view of the aforesaid discussions, we hold that the repudiation made by the Insurance Co. was totally arbitrary, unjustified and without proper application of mind. By not settling the death claim of the complainant, the Ops 1 to 3 committed deficiency in service. Hence the complainant is entitled for the sum assured of Rs.6.00 lacs under the policy with interest @ 9% p.a. from the date of repudiation i.e. 22.6.12. We are not inclined to award any compensation in favour of the complainant as prayed for except a sum of Rs.2000/- towards cost of this litigation.
13. Hence ordered that the complaint petition is allowed in part and the Ops 1 to 3 being jointly and severally liable are directed to pay Rs.6, 00,000/- towards sum assured besides other benefits if any with interest @ 9% p.a. from 22.6.2012 and to pay Rs.2000/- towards costs to the complainant within 30 days from the date of communication of this order. No orders against other Ops.
(to dict.)
