BEFORE THE A.P.STATE CONSUMER DISPUTES REDRESSAL COMMISSION : HYDERABAD.
F.A.No. 624/2011 against C.C.No.59/2009, Dist. Forum,Nizamabad.
Between:
Smt. U.Jayalaxmi, W/o.Gangakishan,
Aged about 45 years, Occ: Govt. Servant,
R/o.H.No. 1-125-7/9,
Near Gnana Jyothi School,
Kotarmoor, Perkit , Armoor Mandal,
Nizamabad Dist. …Appellant/
Complainant
And
1.SBI Life Insurance Co. Ltd.,
Central Processing Unit,
Kapas Bhavan, Plot No.3-A,
Sector – 10, CBD Belapur,
Navi, Mumbai – 400 614.
2. The Branch Manager,
State Bank of Hyderabad,
Dichpally Branch,
Dichpally, Nizamabad District. … Respondents/
Opp.parties
Counsel for the Appellant : M/s. V.Gowrisankar Rao
Counsel for the respondents : Mr.Srinivas Karra –R1
QUORUM: SMT.M.SHREESHA, HON’BLE MEMBER
AND
SRI S.BHUJANGA RAO, HON’BLE MEMBER.
WEDNESDAY, THE FOURTEENTH DAY OF NOVEMBER,
TWO THOUSAND TWELVE.
Oral Order : (Per Sri S.Bhujanga Rao, Hon’ble Member).
***
The unsuccessful complainant filed the appeal against the order dt.20.6.2011 of the District Forum, Nizamabad made in C.C.No.59/2009 filed by the complainant seeking direction to opposite party no.1 to pay Rs.5,67,000/- along with interest chargeable by opposite party no.2, on the house loan account of the deceased and to grant compensation of Rs.1 lakh.
The brief case of the complainant is that one Sri U.Gangakishan, husband of the complainant obtained house loan from opposite party no.2 and has obtained SBI Life-Super Suraksha. Under this insurance, the SBI Life will pay the remaining house loan, as on the date of the death of the insured. The said U.Gangakishan paid an amount of Rs.28,178/- towards the premium of SBI-Life Super Suraksha and certificate was issued on 24.8.2007.
While so, the insured U.Gangakishan died on 3.7.2008, due to heart attack. After his death, the complainant made an application to opposite party no.2 requesting to liquidate the house loan as per the ‘SBI Life Super Suraksha’. Opposite party no.2 forwarded the claim of the complainant to opposite party no.1 SBI Life Insurance Co.Ltd. and opposite party no.1 addressed a letter to opposite party no.2 dt. 31.10.2008, marking a copy to the complainant, stating that the claim cannot be paid as the husband of the complainant had given a false good health declaration, at the time of entry into the scheme and that the insured was suffering from Ischemic heart disease prior to the enrolment into the scheme. The Insurance Ombudsman dismissed the complaint filed by the complainant questioning the repudiation of the claim by opposite party no.1. Hence the complaint.
Resisting the claim, opposite party no.1 filed written version denying the material allegations made in the complaint and contended that the deceased life assured committed breach of principle of utmost good faith by suppression of material facts of his pre existing illness of Ischemic Heart Disease, Diabetes Mellitus and Chronic Pulmonary Disease. The life assured being a patient of Ischemic Heart Disease, Diabetes Mellitus and Chronic Pulmonary disease since 2003, should not have signed on the proposal forms and enrolled for the insurance cover. Only the persons, who are in sound health and do not suffer from any disease mentioned in the DGH form are eligible to be enrolled to the insurance cover. Thus the repudiation of the claim by opposite party is justified and legal. Hence the complaint is not maintainable and deserves to be dismissed.
During the course of enquiry, both parties filed their affidavit evidence and got marked Exs. A1 and A2 and B1 to B14 respectively in support of their respective cases.
Upon hearing the counsel for both parties and on consideration of the material on record, the District Forum came to the conclusion that there is no deficiency in service on the part of opposite party no.1 and consequently dismissed the complaint.
Aggrieved by the said order, the complainant preferred the above appeal contending that the District Forum erred in believing that the opposite party no.1 repudiated the claim on 31.10.2008 vide Ex.A2 on the ground that the insured suppressed his pre existing illness i.e. ischemic heart disease prior to the enrolment of the policy on 1.8.2007 and the insured gave a false declaration as to his health condition. The District Forum failed to see that the husband of the complainant never underwent ECG, TMT, 2D Echo, Angiogram and other tests for confirmation of Ischemic Heart Disease in any hospital nor did he admitted in any hospital and got treatment for Ischemic Heart Disease. That the District Forum failed to see that opposite party no.1 failed to clinchingly establish that the Ischemic Heart Disease was confirmed and treated by any cardiologist/hospital by producing contemporaneous evidence. The District Forum failed to see that Ex.B2 i.e. the Housing Loan Insurance Consent-cum-Authorisation-cum-Good Health Declaration does not whisper about diabetes as one of the clinical illness and Pulmonary Tuberculosis(P.T.). The District Forum ought to have held that the repudiation of the claim on the ground of alleged suppression of Ischemic Heart Disease is without any basis and ought to have held that the same amounts to deficiency in service. That the District Forum failed to see that the insured got general checkup at Dhanvanthari Health Camp on 10.8.2003, whereas he died in his house on 3.7.2008. The insured never took any treatment for Ischemic Heart Disease. The appeal may be allowed setting aside the impugned order of the District Forum and the complaint filed by her may be allowed.
We heard both sides.
Now the point for consideration is whether the impugned order of the District Forum is vitiated for misappreciation of fact or law?
It is an admitted fact that the deceased life insured late U.Gangakishan obtained house loan from opposite party no.2 and has also obtained SBI Life-Super Suraksha. Under this policy, the SBI Life will pay the remaining house loan as on the date of death of the insured. The certificate was issued on 24.8.2007. It is also an admitted fact the insured died on 3.7.2008 due to heart attack and after his death the complainant made an application to opposite party no.2 requesting to liquidate housing loan under SBI Life–Super Suraksha policy and that the claim of the complainant was forwarded to opposite party no.1, who repudiated the claim by its letter dt. 31.10.2008 on the ground that the life assured U.Gangakishan has given a false good health declaration, at the time of entry into the scheme as the insured was suffering from ischemic heart disease prior to enrolling into the scheme. These facts are also proved by Ex.A1, photocopy of certificate of insurance in the name of deceased U.Gangakishan and other documents on record filed by the opposite parties.
The contention of the complainant is that the deceased did not suffer from any heart ailment at the time of taking the policy and at the time of giving declaration and that the deceased did not undergo any treatment for heart ailment, at any time, and that the good health declaration given by the deceased is true and correct, as such, the rejection of the claim by opposite party no.1 is illegal and arbitrary. On the other hand, the contention of the opposite party is that the deceased life assured was suffering from Ischemic Heart
Disease, Diabetes Mellitus and Chronic Pulmonary Disease before signing the good heal declaration form, suppressing his pre existing ill health, the life assured gave false good health declaration, as such , the repudiation of the claim by opposite party no.1 is valid under law and that there is no deficiency in service on the part of opposite party. In support of their contention, opposite party no.1 filed Exs.B1 to B14.
Ex.B1 is the SBI Life general conditions. Ex.B2 is the SBI Life -Home Loan Insurance for Borrowers of State Bank Group whereunder, the life assured gave good health declaration to the effect that he is in sound health, does not have any physical defect/deformity, performs his routine activities independently and that he never suffered or have been suffering or have hospitalized for any critical illness or condition requiring medical treatment for critical illness, as on the date.
The critical illness is defined as follows: The life to be insured should not:
i). have suffered or be suffering from cancer,
ii). be taking treatment for heart disease,
iii). have undergone/or have been advised medically to undergo chest and/or heart surgery within the following six months.
iv). have irreversible kidney and/or irreversible live failure.
v). have suffered or be suffering from paralysis.
vi). Have undergone or been advised to undergo a major organ transplantation such as heart, lung, liver or kidney.
vii). Have suffered or be suffering from AIDS or venereal diseases.
Basing on Ex.B3, Investigation Report of the investigator Zubair & Co., Secunderabad and Exs.B4, B6 to B8, B10 and B12, consultation cum prescription chits, the claim of the complainant was repudiated on the ground that the deceased gave false good health declaration as he was suffering from Ischemic Heart Disease prior to enrolment into the policy on 1.8.2007.
As seen from Ex.B5 Registration Data Card of Dhanvanthari Health Camp conducted on 10.8.2003 at Son Village of Adilabad Dist., it was not a conclusive of the doctors, of any heart ailment, it was only suspected along with other ailments koch’s lung and NIDDM, the doctors in the Camp advised for Echo, TMT and other tests. The contention of the complainant is that life assured did not undergo Echo , TMT and other tests as advised by the doctors at the Camp. Without undergoing test, one cannot come to conclusion that a person is suffering from Ischemic heart disease. There is no material on record to show that the life assured underwent treatment for heart ailment at any point of time and hospitalized during the period from 10.8.2003 till the enrolment into the above policy on 1.8.2007. There is no evidence on record to show that the life assured underwent Echo, TMT and other tests as advised by the doctors in Dhanvanthari Health Camp. Admittedly, on 10.8.2003, E.C. and ECG were not taken. Therefore the diagnosis as per the Exs.B4 to B8 , B10 and B12, prescriptions is not a confirmative one and it is only a clinical diagnosis. The life assured got general check up at Dhanvanthari Health Camp on 10.8.2003 whereas he died at home on 03.7.2008. The insured never took treatment for Ischemic Heart Disease.
Except attending the health camp on 10.8.2003 at Son Village of Adilabad dist., the complainant has disputed the medical consultation cum prescriptions filed by the opposite party. The opposite party insurance company has not adduced any evidence in proof of the same. Even if Exs.B4 to B8 , B10 and B12 are accepted as genuine documents, they do not establish that the deceased life assured had taken treatment for heart disease and that the life assured was suffering from critical illness on the date of good health declaration given by the life assured at the time of admission into the Group Insurance Scheme to SBI Life. Admittedly, the life assured was not hospitalized for the heart disease or any other disease at any time. Therefore, the disease if any, with which, the life assured was suffering by the date of admission into the Group Insurance Scheme to SBI Life does not fall within the definition of “critical illness” as mentioned in Good Health Declaration contained in Ex.B2. As seen from Ex.A2 letter of repudiation of the claim of the complainant sent to the complainant, the claim was repudiated on the ground that the complainant suppressed pre existing illness i.e. Ischemic Heart Disease prior to the enrolment of the policy on 1.8.2007 . As stated above, admittedly, the life assured died due to heart attack and not on account of diabetes or any other disease. Ex.B2 does not whisper about diabetes and pulmonary tuberculosis (PT) as some of the clinical illnesses. In view of the above facts and circumstances, there is no material suppression of any ailment on the part of the life assured.
In view of the above facts and circumstances, we are of the firm view that the repudiation of the claim of the complainant under Ex.A2 letter is without any basis and is not valid under law. The opposite party insurance company has not considered the material on record properly before sending Ex.A2 letter of repudiation to the complainant, which act of the opposite party insurance company amounts to deficiency in service. Undoubtedly, the complainant suffered mental agony on account of repudiation of the claim by the opposite party insurance company. Therefore, we hold that the complainant is entitled to get the amount claimed in the complaint, besides compensation for causing mental agony.
Having regard to the above facts and circumstances, we are of the view that the impugned order of the District Forum is not sustainable under law and is liable to be set aside.
In the result, the appeal is allowed. The impugned order of the District Forum is set aside. The complaint is allowed, in part, directing the opposite party no.1 to pay to the complainant a sum of Rs.5,67,000/- along with interest chargeable by opposite party no.2 on the housing loan account of the deceased. The opposite parties are directed to pay a sum of Rs.25,000/- towards compensation and Rs.5000/- towards costs of the complaint and this appeal, to the complainant. Opposite parties 1 and 2 are directed to comply with the order within 4 weeks from the date of this order.
MEMBER
MEMBER
Pm* Dt.14.11.2012
