BEFORE A.P STATE CONSUMER DISPUTES REDRESSAL COMMISSION AT HYDERABAD
F.A.No129 OF 2011 AGAINST C.C.NO.71 OF 2009 DISTRICT FORUM WARANGAL
Between:
D.Satyalaxmi W/o late DVA Satyanarayana
Aged about 44 yrs, Occ: Housewife
R/o A.P.Residential School, Near KITS College
K.C.Colony, Hasanparthy Village & Mandal
District Warangal
Appellant/complainant
A N D
1. The Asst.General Manager
Policy Servicing Claims (D)
Shriram Life Insurance Co.Ltd.,
Regd.Off:No.3-6-478, III Floor
Anand Estate, Near Liberty Theatre
Himayatnagar, Hyderabad
2. The Divisional Manager
Shriram Life Insurance Co.Ltd.,
Divisional Office, Tarnaka
Secunderabad
3. The Branch Manager
Shriram Life Insurance Co.Ltd.,
Hanamkonda, Warangal
Respondents/opposite parties
Counsel for the Appellants M/s V.Gourisankara Rao
Counsel for the Respondent M/s KRR Associates
QUORUM: SRI R.LAKSHMINARASIMHA RAO, HON’BLE MEMBER
AND
SRI THOTA ASHOK KUMAR, HON’BLE MEMBER
THURSDAY THE EIGHTEENTH DAY OF OCTOBER
TWO THOUSAND TWELVE
Oral Order (As per Sri R.Lakshminarasimha Rao, Hon’ble Member)
***
1. The appellant’s husband during his lifetime obtained “Shri Plus (SP)” insurance policy bearing No.LNO 70700039101 for the sum assured `5,00,000/-. The premium was payable at `50,000/- per annum. The appellant’s husband died on- 16.05.2008 due to failure of kidneys and after the death of her husband she lodged claim with the respondent -insurance company. The respondent-insurance company repudiated the claim on 13.09.2008 whereon the appellant got issued notice on 6.05.2009 and filed the complaint before the District Forum.
2. The version of the respondent-insurance company is that it had accepted the proposal on the basis of information furnished by the appellant’s husband and issued the insurance policy in his favour and the investigation conducted after receiving the claim revealed that the insured was suffering chronic kidney disease which he suppressed at the time of submitting the proposal and he died while undergoing treatment at hospital. It is contended that respondent-insurance company through its letter dated 25.07.2008 requested the appellant to submit the medical record of her husband and on her failure to submit the medical record, the respondent-insurance company issued reminder on 13.08.2008.
3. It is submitted that the investigator of the respondent-insurance company obtained the medical record of the insured from Gandhi Hospital, NIMS and Shroff Hospitals, Hyderabad. The medical record of the insured show that he was suffering from Diabetes Mellitus, Diabetes Nephropathy and Chronic Kidney Disease. Diabetes Mellitus takes years to develop into diabetic nephropathy. For non-disclosure of the material facts about his ill-health by the insured, the respondent-insurance company repudiated the claim.
4. The appellant filed her affidavit and the documents Exs.A1 to A11. On behalf of the respondent insurance company, its Assistant General Manager filed his affidavit and the documents, ExB1 to B22.
5. The District Forum dismissed the complaint on the premise that the appellant’s husband suppressed the fact of his suffering from kidney disease at the time of taking the insurance policy.
6. Feeling aggrieved by the order of the Distirct Forum, the complainant has filed appeal contending that the respondent-insurance company failed to establish that her husband was treated for diabetic nephropathy and chronic kidney disease and that the respondent-insurance company has not filed case sheet, discharge summary, prescriptions, medical bills or affidavit of any doctor who treated him
7. The point for consideration is whether the respondent is entitled to the benefits conferred by the insurance policy?
8. The facts which have been admitted and which do not require elaborate discussion are that on 28.03.2007 the respondent insurance company had issued Life Insurance Policy for a sum assured of `5,00,000/- in favour of the appellant’s husband and the insured died on 16.05.2008 due to kidney disease. The appellant had lodged claim for payment of the sum assured under the policy.
9. The appellant insurance company repudiated the claim on the premise that it had arisen within one year from the date of issuing of the insurance policy and the insured suppressed the fact that he was suffering from kidney disease. The appellant’s husband submitted proposal that he was not suffering from any disease much less kidney disease. The contention of the appellant is that her husband was hale and healthy at the time of taking the insurance policy.
10. The Medical Record of the Gandhi Hospital establishes the insured was treated for kidney disease on 19.01.2008 and he was on dialysis in the same hospital on 27.01.2008. He was admitted in NIMS on 16.05.2008 and he died on the same day while undergoing treatment.
11. The District Forum observed that diabetic nephropathy would not develop overnight and it takes years to for diabetes mellitus to develop into diabetic nephropathy. The learned counsel for the respondent-insurance company has contended that the appellant had not submitted medical record of her husband to enable the respondent process the claim and the respondent-insurance company had issued reminder to her on 13.05.2008 which had failed to draw any response from the appellant.
12. The investigator appointed by the respondent-insurance company collected the medical records from Gandhi Hospital, NIMS and Shroff Hospital, Hyderabad which suggest the kidney disease and diabetic nephropathy that the insured suffered from and is the cause of his death. No one can deny that Diabetic Nephropathy is the aggravated form of chronic kidney disease for which the insured had to undergo dialysis. Thus, once we come to conclusion that the insured suffered from a chronic kidney disease, it need be addressed as to for how long the insured was suffering from the disease and whether he had knowledge of the disease.
13. The learned counsel for the respondent-insurance company has referred to medical literature on chronic kidney disease which is extracted herein below:
“Chronic Kidney Disease causes”
‘Although chronic kidney disease ---------certain cancer’
14. The learned counsel for the respondent-insurance company has relied upon the decision of the Hon’ble National Commission in “LIC of India vs Nagarathna” 2012(2) CPR 214 and “M/s United India Insurance Co.Ltd., vs Milap Telecom” 2012(1)CPR 114 to contend that the insured should not suppress any material facts while obtaining insurance policy.
15. There is no quarrel with the proposition that the insured is under obligation to furnish information in any aspect asked for in the proposal form. However, the insurance company has to discharge onus cast on it to establish that the appellant’s husband suffered from diabetic nephropathy or diabetes mellitus and was treated therefor. Added to the inability of the respondent-insurance company to prove suppression of kidney disease by the insured, in the case sheet issued by Gandhi Hospital, it is recorded that he has no past history of diabetes mellitus and hypertension etc., as under:
History of illness : Loss of appetite, vomitings
Previous illness: No H/O OL dysuria
No H/O C.disease
No past H/O HTN
No past H/O DM
No past H/o renal disease
No H/O herbal medication
No H/O NISADC intake
No H/O chest heart palpitation.
16. In view of failure of the respondent-insurance company to establish that the appellant’s husband suffered from diabetic nephropathy or diabetes mellitus or chronic kidney disease by examining the doctor who treated him or producing the medical record prior to taking the insurance policy, this Commission holds that the findings returned by the District Forum as regards to the suppression of ill-health by the insured at the time of submitting the proposal is liable to be set aside.
17. In the result, the appeal is allowed setting aside the order of the District Forum. The respondent-insurance company is directed to pay a sum of `5 lakh with interest @9% p.a. from the dated of filing of the complaint till payment together with costs of `3,000/-. Time for compliance four weeks.
MEMBER
MEMBER
Dt.18.10.2012
W/KMK*
