Jharkhand

Bokaro

CC/18/60

Sunita Ritoliya - Complainant(s)

Versus

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

B N Sharma

08 Jul 2022

ORDER

District Consumer Commission, Bokaro.

Case No. 60/2018

  Date of Filing-07-05-2018

 Date of Order-08-07-2022

Sunita Ritoliya S/o Late Ajay Kumar Ritoliya

 R/o Gujarat Colony, Chas, District- Bokaro    

Permanent R/o Near Shiv Mandir ratanji road,

Purana Bazar, District- Dhanbad Pin -826001

Vr.

 

1. Aviva Life Insrance Co. Aviva Tower, Sector Road, Opp. Golf Course, DlF- Phase V, Sector V, Sector43, Gurgaon, Haryana
2.  Aviva Life Insurance Co.  HA-20, City Centre, Sector-4, Bokaro Steel City

Present:-

          Shri Jai Prakash Narayan Pandey, President

           Smt. Baby Kumari, Member

1. Complainant has filed this case with prayer for direction to O.P. for payment of Rs. 17,60,000/- with interest @ 12% per annum  and to pay Rs. 1,20,000/- as compensation for various type of harassment.
2. Complainant’s case in brief is that late Ajay Kumar Ratolia was her husband who obtained Life Insurance policy No. 10217174 on 28.03.2015  from O.P. Aviva Life Insurance Co. for Rs. 19,20,000/- on payment of annual premium Rs. 82,472/-. Further case is that the complainant is nominee in that very policy and her husband has paid two regular premiums but on 10.01.2017 at 11:15 P.M. her husband got pain in stomach who was admitted in PMCH, Dhanbad and died on 11.01.2017 at 12:20 A.M. for which death certificate was issued by the Doctor. Further case is that complainant applied for payment of insurance claim and submitted all documents to the O.P. but only Rs. 1,50,000/- was paid as full and final payment under the policy stating that deceased was suffering from pre-existing disease which was not disclosed in claim form. Inspite of issuance of legal notice no payment was made hence case has been filed.

3     O.P. has filed W.S. mentioning therein that insurance policy was obtained fraudulently, dishonestly and by misrepresentation and suppressing the past medical history of Alcoholic Liver Disease with Portal Hypertension for which the life assured was taken treatment since 2010 i.e. prior to submitting the proposal of the subject policy as he was suffering from Chronic Liver Disease, Alcoholic Cirrhosis superimposed alcoholic Hepatitis and admitted in the institute of Liver & Biliary Sciences at New Delhi from 08.05.2010 to 04.06.2010.   Further reply is that it has been decided by the Hon’ble Supreme Court and Hon’ble N.C.D.R.C. in several cases that in such cases claim is liable to be rejected. Further reply is that since insured died within 2 years of the insurance policy hence matter was inquired by the O.P. and it was found that policy was obtained by suppression of material facts related to vital disease of the deceased.  Further reply is that earlier at New Delhi deceased was diagnosed about  Acute on chronic liver disease

Alcoholic cirrhosis with superimposed alcoholic hepatitis Portel

Hypertension-nonbleeder small ESO Vx, Decompensated with ascites no SBP/HE/HRS, CTP-9/158 MELD-20, MELDna 24, DF-38, Esophageal Condidiasis After taking treatment for the above ailment the Life Assured was discharged on 04.06.2010. The discharge summary is annexed as Annexure-R-6. The Clinical progress note, reports and other indoor case papers are annexed as Annexure-R7 Collectively. Further reply is that the assured in the Proposal form by replying the Health related Question in the Proposal form in Negative. The relevant extract of the proposal for is as follow:-

Section 6.2 (Health and Activity Section)

1. Are you currently receiving any medical treatment or are you awaiting medical or Surgical consultation, test or investigation? (You need not disclose matters relating to uncomplicated pregnancy, common colds, influenza, hay-fever or any minor ailment required a single consultation): ”No”

Have you ever had any medical or surgical treatment, including investigations, tests, scans or X- rays for any of the following illnesses or medical conditions?  Iv Diabetes, Kidney or Liver problem ? “No”. Further reply is that since the death of the Life Assured was within two years from the date of issuance of the subject policy, the same falls under the category of an early claim and hence as per Sec 45 of the Insurance Act, the said claim was duly investigated by the Opposite Party to determine the bonafied of the claim. During the said investigation, it was brought to attention of the answering Opposite party that the Life Assured had Knowingly, willfully and fraudulently suppressed his past Medical History of Alcoholic Liver Disease and Portal Hypertension and was under treatment since 2010. However, the said medical history was intentionally suppressed by the Life Assured and the health related Question was replied in negative. The Life Assured was admitted in Institute of Liver and biliary Science, Vasant Kunj, New Delhi on 08-05-2010 with Complains of Jaundice since 45 days and abdominal distention since 1 month. The Final Diagnosis in the discharge summary was recorded as Acute on chronic liver disease:-

Alcoholic cirrhosis with superimposed alcoholic hepatitis Portel,Hypertension-nonbleeder small ESO Vx, Decompensated with ascites no SBP/HE/HRS, CTP-9/158 MELD-20, MELDna 24, DF-38, Esophageal Condidiasis. Further reply is that if the answering Opposite Party would have been apprised about the medical history, the subject policy would not have been issued to the Life Assured. Therefore, it is prayed to dismiss the case.

3.  In light of above pleadings of the parties following point is to be decided that whether complainant is entitled to get relief as prayed or not?
4.  Following facts are admitted facts :-

i). That Ajay Kumar Ritolia was husband of the complainant.

ii) That complainant is wife of said Ajay Kumar Ritolia and she is nominee of his insurance policy.

iii) That Ajay Kumar Ritolia obtained insurance policy No. 10217174 on 28.03.2015 for the period of 12 years.

iv) That husband of the complainant died on 11.01.2017.

6.    From perusal of the papers submitted by the complainant it appears that as per complaint petition insured was admitted in PMCH Dhanbad where he died but from photo copy of the death certificate it appears that it was issued on 11.01.2017 from Patliputra Nursing Home, Jora Phatak Road, Dhanbad. Therefore, death certificate of the hospital is contradictory to the facts mentioned at para 5 of the complaint petition. However complainant has suppressed the papers of PMCH and purposely has not filed it before this commission this act creates lot of confusion doubt about fairness of the complainant.  Other papers are photo copy of the death certificate issued by Municipal Corporation, photo copy of the policy cover letter, photo copy of the repudiation letter, photo copy of the policy paper which are not in dispute.

7.   On the other hand O.P. has filed photo copy of proposal form (Annexure R-1) which shows that at column 6.2 Health & Activity section there is no disclosure of any previous illness of the deceased. Annexure R-4 is death certificate of the nursing home in which it has been mentioned that death was due to cardiac Respiratory failure caused by CLD Jaundice. CLD is known as Cirrhosis of liver disease.  Annexure R-6 is the discharge summary issued by INSTITUTE OF LIVER & BILIARY SCIENCES, New Delhi. According to this paper insured was admitted in that very hospital on 08.05.2010 and discharged on 04.06.2010 with acute chronic liver disease, Alcoholic Cirrhosis with superimposed Alcoholic Hepatitis  DIAGNOSIS: Acute on Chronic Liver Disease Alcoholic cirrhosis with superimposed alcoholic hepatitis Portel hypertension- nonbleeder small Eso Vx Decompensated with ascites no SBP/HE/HRS CTP-9/15 MELD -20, MELDna 24, DF-38 Esophageal condidiasis PRESENTING SYMPTOMS: Jaundice since 45 days, Abdominal distention since 1 month. HISTORY Mr. Ajay Ritolia 37 yr male was presented with above mentioned complaints. On evaluation patient was found to have ascites, cougalopathy, jaundice with hypoalbuminemia. Asciteic fluid examination showed normal study. Patient was treated with i.v albumin & diuretics. Patient was underwent UGI endoscopy which showed small Eso Vx with esophageal candidlasis, was put on oral fluconazole. Patient HVPG was 15 mg, started on B- blocker, Patient is gradually improving. Patient being discharged in stable condition.  Annexure R-7 are photo copy of clinical progress notes of that very hospital which are supportive to the discharge summary. Annexure R-9 is claim investigation report in which it is mentioned that on contact with local people namely Sandip Sachdeva & others it was disclosed that insured was having liver disease for which he was taking treatment from Hyderabad and Delhi. In conclusive remarks it is mentioned that Conclusive Remarks: It is a case of Pre-existing liver disease as information received from the local people, neighbors and local Shop owners. The underwriters are advised to institute a check at Asian Institute of gastroenterology at Hyderabad and also at institute of liver and Biliary Science at Vasant Kunj, New Delhi prior to settle the claim as these are not in our area of coverage. 

8.         On perusal of above documents and pleadings of the parties it is apparent that the cause of death of the insured is direct result of his previous ailment related to Liver Cirrhosis and other complications causing jaundice. Therefore, we are of the opinion that insured has obtained insurance policy by suppression of material facts. Hence repudiation of claim by O.P. insurance company is correct. Accordingly complainant is not entitled to get any relief hence this point is being decided against the complainant.

9.         Hence case is dismissed on merit and parties shall bear their own costs.