Haryana

StateCommission

CC/83/2014

Purshottam - Complainant(s)

Versus

Aviva Life Ins. Co. - Opp.Party(s)

27 Feb 2017

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

                                                         Complaint No.83 of 2014

Date of Institution: 22.08.2014

                                                               Date of Decision: 27.02.2017

 

Mrs. Parshotam widow of Shri Devender Singh, r/o H.No.665, Sector 11, Near Chaman Lal DAV School, Panchkula (Haryana).

                                      …..Complainant

Versus

Aviva Life Insurance company ltd., Aviva Tower Sector Road, Opposite DLF Golf course, DLF Phase-V, Sector 43, Gurgaon through its Branch Manager/Authorized person.

…..Opposite party

 

CORAM:             Mr. R.K.Bishnoi, Judicial Member.

                             Mrs. Urvashi Agnihotri, Member.                                                                                                                                        

Present:              None for complainant.

                             Shri Nitin Gupta, Advocate counsel for the opposite party.

 

                                                   O R D E R

R.K.BISHNOI, JUDICIAL MEMBER:

It was alleged by the complainant that her husband opted to take insurance policy for a sum of Rs.60/- lacs and applied online with the opposite party (O.P.).  He received e-mail on 15.10.2011 to appear before medical Board on 18.10.2011 at 09.00 A.M. in pursuance of that policy.  On 16.10.2011 he filled proposal form having number NUP75028626.  On 18.10.2011 he was medically examined at DR.Sandhu Pathology & Imaging Centre, Chandigarh and was recommended for insurance.  After payment of premium insurance policy was issued on 22.10.2011. When it was found that insurance policy was incomplete an information was immediately given to O.P. Thereafter an other policy was received.  Second installment of premium was paid on 20.10.2012.  On 16.01.2011 Devender Singh (since deceased) fell ill and was taken to Alchemist Hospital, Panchkula where he was diagnosed with  Chronic Right subdural Hematoma with Right hemisphere cerebral edema? Second impact syndrome.  He was having vomiting,  heaviness of head and mild photophobia etc.  On 16.02.2013 he again fell ill and taken to Alchemist Hospital, Panchkula. He was diagnosed with F/U/C Pulmonary Embolism, Subdural Hemorrhage Deep Vein Thrombosis.  On 02.04.2013 he again fell ill and was taken to Alchemist Hospital, Panchkula from where he was referred at PGI on 04.04.2013 for expert opinion. He was admitted in PGI on 04.04.2013 and remained there upto 23.04.2013 when he breathed his last.  Medical certificate issued by PGI toll the cause of death as  “CATASTROPHIC ANTIPHOSPHOLIPID ANTIBODY SYNDROME, MULTI ORGAN FAILURE WITH ACUTE LIVER FAILURE, ACUTE RENAL FAILURE TYPE 1 RESPIRATORY FAILURE, HOSPITAL ACQUIRED PNEUMONIA, SEPSIS, SECPTIC SHOCK DEEP VEIN THROMBOSIS, INFERIOR VENA THROMBOSIS, SEIZURES? COPTICAL VEIN THROMBOSIS WITH ANEMIA, THROMBOCYTOPENIA, COAGULOPATHY.”  Information about death was immediately given to O.P. As being nominee and wife of deceased claim was submitted with the O.P., but, the same was repudiated vide letter dated 23.10.2013 without any reasonable cause.

2.      O.P. filed reply controverting her averments and alleged that there was no deficiency in service on it’s part.  Actually he concealed the fact of previous ailment at the time of obtaining insurance cover and was not entitled for compensation.  He was diagnosed  as a case of ‘recurrent deep vein thrombosis with pulmonary thromboembolism since 2004’ and for that he was admitted in PGI, Chandigarh in 2004 i.e. for pulmonary embolism which occurred due to deep vein thrombosis. After that he was on anticoagulant therapy warfarin.  His thrombosis time was markedly deranged more than 50 (Normal 8.8-12.5), which resulted in chronic subdural hematoma diagnosed in January 2013 at Alchemist Hospital, Panchkula.It is well settled that contract of insurance is  a contract of “Uberrimae Fidae” and non-disclosure of previous ailment disentitle complainant from any compensation, so his claim was rightly rejected.

3.      Both the parties have led their evidence.

4.      None has appeared on behalf of the complainant. Complaint pertains to the year 2014. So there is no necessity to wait any more.

5.      Learned counsel for the opposite party vehemently argued that as per documents available on the file it is clear that DLA was suffering from so many ailments before obtaining insurance policy which were concealed by him. So complainant was not entitled for compensation.

6.      From the perusal of Discharge summary Ex.C-6 and C-7 it is clear that complainant was suffering from this problem since long. For ready reference the relevant portion of Ex.C-6 is reproduced as under:-

                   “Brief History of present illness:

Patient presented with chief complaints of vomiting 2 episodes, heaviness of head and mild photophobia, severe headache refractory to pain killers. History of pulmonary embolism in 2004 and patient on warfarin, since then.

Relevant portion of Ex.C-7 is also reproduced as under:-

                   “Final diagnosis

F/U/C Pulmonary Embolism, Subdural Haemorrhage Deep Vein Thrombosis”

These documents clearly shows that the complainant was having this problem since 2004 but when he submitted proposal form Ex.R-2 he did not disclose about any ailment which is clear from the perusal of clause-6 of the proposal form.  In this way he concealed the fact of previous ailment.

7.      When complainant has concealed the true facts from the opposite party he was not entitled for any relief as per opinion of Hon’ble National Commission expressed in revision petition No.3114 of 2014 titled as Amzad Khan Vs. Aviva Life Insuance Co. Ltd. decided on 30.01.2015, relevant portion of which is as under:-

“It is submitted that the contract of insurance including the contract of life assurance are contracts uberrima fides and every material fact must be disclosed otherwise there is good ground for rescission of the contract.  The Apex Court Judgement of Satwat Kaur Sandu Vs. New India Assurance Co. Ltd. IV (2009) CPJ 8 (SC) has referred the term “proposal Form” as defined under the Insurance Regulatory and Development Authority, 2002 as a “Form” to be filled in by the proposer for insurance, for furnishing all material information required by the insurer to decide whether to accept or decline, to undertake the risk and in the event of  acceptance of the risk, to determine the rates, terms and conditions of a cover to be granted and observed that in a contract of insurance, any fact which would influence the mind of a prudent insurer in deciding whether to accept or not to accept the risk is “material fact”.  If the  proposer has knowledge of such fact, he is obliged to disclose it particularly while answering questions in the proposal form.  It is submitted that the complainant has no “locus standi” to claim any alleged sum assured, as the insurance policy was obtained by the DLI by mis-representation of material facts in order to defraud the opposite party.  The contract of insurance is void, and not tenable in the eyes of law as it is entered by DLI to defraud the opposite party.  In these circumstances, the complaint is liable to be dismissed in limine.”

It is opined in this case that if such like fact is not disclosed at the time of obtaining insurance policy the same is fatal.  He was suffering from Pulmonary Embolism (PE), which is a serious problem and not a routine illness, which is defined as under:-

“Pulmonary embolism (PE) is a blockage of an artery in  the lungs by a substance that has traveled from elsewhere in the body through the bloodstream (embolism). (1) Symptoms of a PE may include shortness of breath, chest pain particularly upon breathing in, and coughing up blood. (2) Symptoms of a blood clot in the leg may also be present such as a red, warm, swollen, and painful leg.  (2) Signs of a PE include low blood oxygen levels, rapid breathing and rapid heart rate, and sometimes a mild fever. Severe cases can lead to passing out, abnormally low blood pressure, and sudden death.”

8.      In such a situation complaint is liable to be dismissed as opined by Hon’ble Supreme Court in  Satwant Kaur Sandhu Vs. New India Assurance company ltd. 2009 (IV) CPJ 8 (SC) and Hon’ble National Commission in  Tata AIG Life Insurance co. Ltd. Vs. Orissan State Cooperative Bank & anr. 2012 (IV) CPJ 310 (NC).  Resultantly the complainant is not entitled for any compensation and the complaint is hereby dismissed.

 

February 27th, 2017   Urvashi Agnihotri                                R.K.Bishnoi,                                                               Member                                              Judicial Member                                                         Addl. Bench                                        Addl.Bench                

S.K.