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known smoker since 17 years and was suffering from Extra Pulmonary

Tuberculosis in 2002 (Lung Cancer) which led to Non small Cell Carsinoma of right

Lung with Multiple Bone Meastasis Hypertension and Diabetes Mellitus Type II.

The insured was admitted in Yashoda Hospital for treatment on 28-2-2008 and

consulted Dr. Babaiah, Senior Oncologist. But he died on 01-4-2008. The cause

of death was Cancer suffered by the insured even prior to the commencement of

the policy and hence, taking policy was a fraud for unlawful gain. Had the

deceased revealed the true facts of his ill health, the risk would not have been

entertained and policy would have been rejected. The death occurred due to

previous complications.

5. The insured as a doctor and the case history issued by Yashoda

Cancer Institute, Hyderabad revealed that the insured was a known Lung Cancer

patient with low back pain since one year. The first diagnosis was not mentioned.

The low back pain was due to bone Meastasis. He was a known diabetic and

hypertension. The question of hypertension and cancer was willfully concealed by

the insured and they were not disclosed by the complainant in the statement, and

hence an adverse inference may be drawn against the complainant for non

disclosure of the first treatment details of cancer.

6. The policy was not issued at Kadapa and death was not occurred at

Kadapa at the time of taking policy. The insured was a resident of Hyderabad and

policy was issued at Hyderabad. For the sake of jurisdiction the R3 was

unnecessarily impleaded. The R3 was an unnecessary party and claim may be

dismissed against R3. Thus the Forum had no jurisdiction.

7. Under Section 45 of Insurance Act the company would repudiate the

claim within two years of commencement of the policy. If it is found that the

insured had suppressed the facts of his health and obtained a policy, the policy

could not be cancelled. Thus there were no merits and the complaint may be

dismissed with costs.

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8. On the basis of the above pleadings the following points are settled for

determination.

i. Whether there is any negligence and deficiency of service on the

part of the respondents?

ii. Whether the complainant is entitled to the relief as prayed for?

iii. To what relief?

9. On behalf of the complainant Ex. A1 to A3 were marked and on behalf

of the respondent Ex. B1 to B5 were marked. No written arguments were filed by

both parties.

10. Point No. 1 & 2 The complainant was the wife of Late Dr. V. Mohan

Rao, who worked as Joint Director of Health Department, Govt. of A.P. Hyderabad.

Late Dr. Mohan Rao, took one life insurance policy with unit linked plan on his life

for Rs. 5,00,000/- with policy No. 0051429015 commenced from 28-4-2007 from

R1. The complainant was the nominee under the policy. The insured Mohan Rao

paid Rs. 50,000/- towards annual premium to the policy. While so the insured

died on 01-4-2008 at Yashoda Hospital, Hyderabad due to ill health. After the

death of Mohan Rao his wife as nominee submitted all the documents as required

to the respondents to settle the claim under the policy. But the respondents

repudiated the claim under Ex. A1, dt. 19-6-2008 a Xerox copy of the letter on the

ground that the insured late Dr. V. Mohan Rao had history of Extra pulmonary

tuberculosis in 2002 (Lymph Glands) and a known smoker for the past 17 years

and the details were not disclosed in the proposal form, dt. 28-4-2007. Since the

material facts have not been disclosed in the proposal form, the respondents

repudiated the claim. The complainant addressed a letter to the Claims Review

Committee to reconsider the claim under the policy and arrange payment of claim

amount with her change of address at Kadapa. It was Ex. A2. The Claims

Review Committee confirmed the repudiation of the claim by way of letter under

Ex. A3, dt. 18-8-2008 to the complainant to her Kadapa address. Except Ex. A1

to A3 the complainant had not filed any other documentary proof to prove her

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claim. It is unfortunate that either of the parties in the complaint have not

submitted the copy of the policy with terms and conditions. Even though the

Forum returned at the first instance the complaint with an objection to file the

copy of the policy as prima-facie proof, it was represented that the complainant

lost her Photostat copy of the policy and it would be submitted after getting the

same. The complainant had atleast not filed first premium payment receipt also.

11. On the other hand the respondents filed a Xerox copy of proposal form

of Late Dr. Mohan Rao under Ex. B1, dt. 28-4-2007 which disclosed the sum

assured as Rs. 5,00,000/- and the annual premium was Rs. 50,000/- and the

nominee was the complainant. The policy was taken by the deceased at

Hyderabad as Joint Director of Health (Leprosy) Hyderabad. In Ex. B1 under

question No. 14, regarding the history of the health of the insured it was noted that

the deceased was in good health. It was the duty of the complainant to file death

extract, discharge summary from the hospital and case record of the deceased

from Yashoda Hospital, Hyderabad. The Xerox copy of case record under Ex. B2

and Xerox copy of death summary issued by Yashoda Hospital, Hyderabad under

Ex. B3 and Xerox copy of certificate issued by Dr. M. Babaiah, Yashoda Cancer

Institute, Hyderabad under Ex. B4, the Xerox copy of burial ground report of Dr.

Mohan Rao issued by Grater Hyderabad Municipal Corporation, Hyderabad under

Ex. B5 were filed by the respondents.

12. A Super Speciality Hospital or Corporate Hospital like Yashoda

Hospital, Hyderabad should not give a case record with untrue facts or false

information regarding the health condition of a patient. In Ex. B2, Yashoda

Hospital, Hyderabad mentioned that Dr. Mohan Rao was known case of Lung

Cancer with Bone Meastasis with low back pain since one year which was

aggravated since one month and had past history of Extra pulmonary tuberculosis

in 2002 (Lymph Glands) and known smoker since 17 years and occasional alcohol

consumption. The daughter of the deceased gave consent form for admission,

investigation and treatment of the patient on 28-2-2008 and the same was

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enclosed in Ex. B2. The insured had hypertension and diabetes mellitus. The

entire history of present illness and the past history of the deceased have been

mentioned in the death summary Ex. B3. The cause of death on 01-4-2008 was

Non Small Cell Carcinoma of Right Lung With Multiple Bone Meastasis

Hypertension and Diabetes Mellitus Type II. The particulars of the patient in the

case record of the hospital Ex. B2 have been furnished either by the patient or his

relatives.

13. The complainant contended that the insured did not suppress the

material facts regarding his health in the proposal form Ex. B1. At the time of

giving proposal form, the insured was hale and health. But it was denied by the

respondents. When the respondents denied that the complainant suppressed the

material facts it was their duty to prove the same. The respondents filed Ex. B2

and E x . B3 to prove that the insured had a past history of Extra pulmonary

tuberculosis in 2002 (Lymph Glands) and occasionally consumption of alcohol and

a known smoker since 17 years. In Ex. B1 under question No. 14 (c) regarding

tuberculosis, the proposer i.e. the deceased gave a negative answer. Yashoda

Hospital, Hyderabad had no necessity to mention tuberculosis since 2002 in their

case record Ex. B2. Knowing fully well regarding tuberculosis in 2002 (Lymph

Glands) the proposer did not reveal the facts under question No. 14 (c) in Ex. B1.

The deceased suppressed the material facts of his health in the proposal form i.e.

Ex. B1. As discussed earlier it was also noted in Ex. B3 death summary also.

Being a doctor the deceased had known much regarding changes in the body after

he had an attack of Lung Cancer.

14. It was mentioned under Ex. B1 that the premium was annual

premium of Rs. 50,000/- i.e. first premium was paid along with proposal form on

28-4-2007 and the next immediate premium should be on 28-4-2008. But before

the payment of premium on 28-4-2008 the insured died on 01-4-2008 and

therefore, the contract was not a concluded contract. In these circumstances the

complainant is entitled only to the first premium amount of Rs. 50,000/- from

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respondents 1 & 2 jointly and severally. Regarding the jurisdiction of the

complaint the complainant impleaded the branch office of the company at Kadapa

a s 3

jurisdiction to entertain the complaint. Thus there is deficiency of service on the

part of the respondents in non refund of first premium amount of Rs. 50,000/-

while repudiating the claim. Hence, the points are answered accordingly.

15. Point No. 3 In the result, the complaint is allowed, directing the

respondents 1 & 2 jointly and severally liable to pay Rs. 50,000/- (Rupees Fifty

Thousand Only) without interest, compensation and costs, payable within 45 days

from the date of receipt of this order. The rest of the claim and the case against

R3 is dismissed without costs.

Dictated to the Stenographer, transcribed by him, corrected and pronounced

by us in the open forum, this the 22nd June 2009

MEMBER MEMBER PRESIDENT

APPENDIX OF EVIDENCE

Witnesses examined.

For Complainant : NIL For Respondent : NIL

Exhibits marked for Complainant : -

Ex. A1 X/c of repudiation letter from respondents to complainant, dt. 19-6-08

Ex. A2 Copy of letter from complainant to R2, dt. 19-7-2007.

Ex. A3 Letter from respondents to complainant, dt. 18-8-2008.

Exhibits marked for Respondents: -

Ex. B1 X/c of proposal form No. 0051429015, dt. 28-4-2007.

Ex. B2 X/c of care record issued by Yashoda Hospital, Secunderabad.

Ex. B3 X/c of death summary issued by Yashoda Hospital, Secunderabad.

Ex. B4 X/c of certificate issued by Yashoda Hospital, Secunderabad

Ex. B5 X/c of burial ground report issued by Greater Hyderabad Municipal

Corporation, dt. 2-4-2008.

MEMBER MEMBER PRESIDENT

Copy to :-

1) Sri G. Trivikram Singh, Advocate.

2) Sri D.V.S. Prasad, Advocate.

1) Copy was made ready on :

2) Copy was dispatched on :

3) Copy of delivered to parties :

B.V.P. - - -