BEFORE THE A.P STATE CONSUMER DISPUTES REDRESSAL COMMISSION CIRCUIT BENCH AT VISAKAPATNAM

FA 388 of 2012 against CC 9/2009, Dist. Forum, Srikakulam

Between:

1) Bajaj Allianz Life Insurance Co. Ltd.

Rep. by its Branch Manager

Palasa, Srikakulam

2) Bajaj Allianz Life Insurance Co. Ltd.

Rep. by its Managing Director

4th & 5th Floor, Ashoka Plaza

Corporate Software Park

Survey 32/3, Nagar Road

Viman Nagar, Pune-411 014. *** Appellants/

O.Ps

And

Bellana Dasaradha Gupta

S/o. Late Chandramouli

Main Road, Opp. SBI

Baruva (V&P). Sompeta Mandal

Srikakulam Dist.

*** Respondent/

Complainant

Counsel for the Appellant : M/s. G. Anand Kumar

Counsel for the Respondent : M/s. T.B.B. Krishna Mohan

CORAM:

SMT. M. SHREESHA, PRESIDING MEMBER

&

SRI S. BHUJANGA RAO, MEMBER

MONDAY, THE TENTH DAY OF JUNE TWO THOUSAND THIRTEEN

ORAL ORDER: (Per Smt. M. Shreesha, Member)

***

1) Aggrieved by the order in CC 9/2009 on the file of Dist. Forum, Srikakulam, the opposite parties preferred this appeal.

2) The brief facts as stated in the complaint are that the complainant’s wife Smt. E. Ramanamma had taken a policy in her name from the Op for the period from 11.1.2007 to 10.1.2027 for which Ops issued a bond after receipt of first instalment. While so, on 23.6.2007 the life assured died of fever which was intimated to the Ops and a claim was made but the Ops repudiated it on the ground that the life assured suffered from diabetes and hypertension and also renal problems prior to the issuance of the policy which was suppressed in the proposal form.

3) The complainant submits that the Op conducted the medical examination by their panel doctor prior to issuance of the policy but there after repudiated it on false allegation of suppression. The complainant also got issued a legal notice on 20.10.2008 but there was no response. Hence this complaint seeking directions to Ops to pay the policy bond amount of Rs. 1 lakh with interest, compensation and costs.

4) Op1 filed counter admitting to the issuance of the policy commencing from 11.1.2007 for a sum assured of Rs. 1 lakh after receipt of premium amount of Rs. 10,000/- and also admits that the complainant intimated them about the death of the life assured on 23.6.2007. Op1 submits that the life assured has been suffering from diabetes mellitus since 6 years, hypertension since 10 years and renal problem since 1 year which was suppressed prior to taking of the policy and this was stated by their investigator M/s. C.R.P. Tech India Pvt. Ltd. The investigating agency obtained a report from their family doctor Sri A. V. Rama Krishna, MBBS and submitted a detailed report with respect to this suppression. Hence Op1 submits that their repudiation is justified and that there was no deficiency of service on their behalf.

5) The Dist. Forum based on the evidence adduced i.e., Ex. A1 to A5 and Ex. B1 to B4 allowed the complaint directing the Ops to pay Rs. 1 lakh with interest @ 9% p.a., from the date of compliant till the date of realization together with costs of Rs. 3,000/-.

6) Aggrieved by the said order the opposite parties preferred this appeal.

7) Both sides filed their written arguments.

8) The facts not in dispute are the issuance of the policy by the Ops to the complainant’s wife for a sum assured of Rs. 1 lakh issued on 11.1.2007 evidenced under Ex. A4 for a period of 20 years. It is also an admitted fact that the life assured died on 23.6.2007 and it is the complainant’s case that in spite of making the claim along with the necessary documents, the Ops repudiated it on the ground of suppression of ailments which are totally false. Ex. A5 which is the repudiation letter dt. 14.12.2007 states that the life assured had history of diabetes mellitus since 6 years, hypertension since 10 years and renal problem since 1 year prior to the proposal dt. 6.1.2007. Ex. A1 is the legal notice got issued by the complainant on 20.10.2008 and Exs. A2 and A3 are the postal receipts.

9) It is the appellant/Ops’ case that the life assured had suppressed the above ailments and relied on Exs. B3 dt. 23.6.2007 which is the case sheet issued by Sagara Durga Hospital. The history of the patient in the case sheet reads as follows :

History of : DM (6 years) (On insulin and OHA)

HTN (10 years) on treatment

Renal problem 1 year.

Hysterectomy etc.

In the diagnosis also it is stated that the patient is suffering from DM, HTN, CAD, CRF, incisional hernia and she finally died of septicaemia which is the primary cause and the secondary cause is the DM, HTN, CAD, CRF & AC on CR. It is pertinent to note that the proposal form which is Ex. B1 is dt. 6.1.2007 and is signed by the life assured wherein the life assured did not disclose that he had DM or HTN which is posed in 14(d) & 14(g) of the proposal form. The life assured had clearly answered ‘No’ to these questions. Ex. B3 which is the case sheet states that the patient was on insulin for the last six years which establishes that the life assured was clearly a diabetic and that she had renal problem since one year which was not declared in the proposal form. As per Section 45 of the Insurance Act the insured had to prove that the life assured had suppressed the material facts which in the instant case the Op has established vide Ex. B3 and that the complainant in his affidavit or written arguments never disputed the treatment taken by the life assured in Sagar Durga Hospital. The complainant in his written arguments relied on the following decisions of the Supreme Court.

LIC of India Vs. Smt. Asha Goel reported in JT 2011 (1) SC 10

Mithoolal Nayak Vs. LIC of India reported in AIR 1962 SC 814.

Athayee & Others Vs. LIC of India reported in AIR 2003, MAD 382.

10) In the instant case Ex. B3 case sheet clearly states the patient’s history and the respondent/complainant’s contention that the life assured took treatment only on 22.6.2007 at Sagar Durga Hospital and she passed away in the hospital on the very next day. The patient’s history clearly shows that the patient was on insulin and had renal problem and it is pertinent to note that whether the patient is in the hospital for one day or for two days is immaterial as the repudiation was on the basis of suppression of her health condition which Ex. B3 hospital record reveals the patient’s history. To reiterate, even if the patient is in the hospital for one day or one week, the patient’s history cannot change. Therefore the contention of the complainant that the patient was only treated for one day and died on the very next day and therefore Ex. B4 cannot be taken into consideration, cannot be sustained.

11) We also rely on the decision of Apex Court in Satwant Kaur Sandhu Vs. New India Assurance Company Ltd. wherein the Apex Court held that the hospital reports recording the past history of illness should be relied upon even though the hospital giving the report has not treated the patient in the past and that the non-examination of doctors on an affidavit does not invalidate the documentary evidence on record.

12) Keeping in view the aforementioned reasons and judgements we are of the opinion that the Ops rightly repudiated the claim and therefore this appeal is allowed and the order of the Dist. Forum is set-aside. Consequently, the complaint is dismissed. No costs.

1) _______________________________

PRESIDING MEMBER

2) ________________________________

MEMBER

10/06/2013

*pnr

UP LOAD – O.K.

BEFORE THE A.P STATE CONSUMER DISPUTES REDRESSAL COMMISSION CIRCUIT BENCH AT VISAKAPATNAM

FA 388 of 2012 against CC 9/2009, Dist. Forum, Srikakulam

Between:

1) Bajaj Allianz Life Insurance Co. Ltd.

Rep. by its Branch Manager

Palasa, Srikakulam

2) Bajaj Allianz Life Insurance Co. Ltd.

Rep. by its Managing Director

4th & 5th Floor, Ashoka Plaza

Corporate Software Park

Survey 32/3, Nagar Road

Viman Nagar, Pune-411 014. *** Appellants/

O.Ps

And

Bellana Dasaradha Gupta

S/o. Late Chandramouli

Main Road, Opp. SBI

Baruva (V&P). Sompeta Mandal

Srikakulam Dist.

*** Respondent/

Complainant

Counsel for the Appellant : M/s. G. Anand Kumar

Counsel for the Respondent : M/s. T.B.B. Krishna Mohan

CORAM:

SMT. M. SHREESHA, PRESIDING MEMBER

&

SRI S. BHUJANGA RAO, MEMBER

MONDAY, THE TENTH DAY OF JUNE TWO THOUSAND THIRTEEN

ORAL ORDER: (Per Smt. M. Shreesha, Member)

***

1) Aggrieved by the order in CC 9/2009 on the file of Dist. Forum, Srikakulam, the opposite parties preferred this appeal.

2) The brief facts as stated in the complaint are that the complainant’s wife Smt. E. Ramanamma had taken a policy in her name from the Op for the period from 11.1.2007 to 10.1.2027 for which Ops issued a bond after receipt of first instalment. While so, on 23.6.2007 the life assured died of fever which was intimated to the Ops and a claim was made but the Ops repudiated it on the ground that the life assured suffered from diabetes and hypertension and also renal problems prior to the issuance of the policy which was suppressed in the proposal form.

3) The complainant submits that the Op conducted the medical examination by their panel doctor prior to issuance of the policy but there after repudiated it on false allegation of suppression. The complainant also got issued a legal notice on 20.10.2008 but there was no response. Hence this complaint seeking directions to Ops to pay the policy bond amount of Rs. 1 lakh with interest, compensation and costs.

4) Op1 filed counter admitting to the issuance of the policy commencing from 11.1.2007 for a sum assured of Rs. 1 lakh after receipt of premium amount of Rs. 10,000/- and also admits that the complainant intimated them about the death of the life assured on 23.6.2007. Op1 submits that the life assured has been suffering from diabetes mellitus since 6 years, hypertension since 10 years and renal problem since 1 year which was suppressed prior to taking of the policy and this was stated by their investigator M/s. C.R.P. Tech India Pvt. Ltd. The investigating agency obtained a report from their family doctor Sri A. V. Rama Krishna, MBBS and submitted a detailed report with respect to this suppression. Hence Op1 submits that their repudiation is justified and that there was no deficiency of service on their behalf.

5) The Dist. Forum based on the evidence adduced i.e., Ex. A1 to A5 and Ex. B1 to B4 allowed the complaint directing the Ops to pay Rs. 1 lakh with interest @ 9% p.a., from the date of compliant till the date of realization together with costs of Rs. 3,000/-.

6) Aggrieved by the said order the opposite parties preferred this appeal.

7) Both sides filed their written arguments.

8) The facts not in dispute are the issuance of the policy by the Ops to the complainant’s wife for a sum assured of Rs. 1 lakh issued on 11.1.2007 evidenced under Ex. A4 for a period of 20 years. It is also an admitted fact that the life assured died on 23.6.2007 and it is the complainant’s case that in spite of making the claim along with the necessary documents, the Ops repudiated it on the ground of suppression of ailments which are totally false. Ex. A5 which is the repudiation letter dt. 14.12.2007 states that the life assured had history of diabetes mellitus since 6 years, hypertension since 10 years and renal problem since 1 year prior to the proposal dt. 6.1.2007. Ex. A1 is the legal notice got issued by the complainant on 20.10.2008 and Exs. A2 and A3 are the postal receipts.

9) It is the appellant/Ops’ case that the life assured had suppressed the above ailments and relied on Exs. B3 dt. 23.6.2007 which is the case sheet issued by Sagara Durga Hospital. The history of the patient in the case sheet reads as follows :

History of : DM (6 years) (On insulin and OHA)

HTN (10 years) on treatment

Renal problem 1 year.

Hysterectomy etc.

In the diagnosis also it is stated that the patient is suffering from DM, HTN, CAD, CRF, incisional hernia and she finally died of septicaemia which is the primary cause and the secondary cause is the DM, HTN, CAD, CRF & AC on CR. It is pertinent to note that the proposal form which is Ex. B1 is dt. 6.1.2007 and is signed by the life assured wherein the life assured did not disclose that he had DM or HTN which is posed in 14(d) & 14(g) of the proposal form. The life assured had clearly answered ‘No’ to these questions. Ex. B3 which is the case sheet states that the patient was on insulin for the last six years which establishes that the life assured was clearly a diabetic and that she had renal problem since one year which was not declared in the proposal form. As per Section 45 of the Insurance Act the insured had to prove that the life assured had suppressed the material facts which in the instant case the Op has established vide Ex. B3 and that the complainant in his affidavit or written arguments never disputed the treatment taken by the life assured in Sagar Durga Hospital. The complainant in his written arguments relied on the following decisions of the Supreme Court.

LIC of India Vs. Smt. Asha Goel reported in JT 2011 (1) SC 10

Mithoolal Nayak Vs. LIC of India reported in AIR 1962 SC 814.

Athayee & Others Vs. LIC of India reported in AIR 2003, MAD 382.

10) In the instant case Ex. B3 case sheet clearly states the patient’s history and the respondent/complainant’s contention that the life assured took treatment only on 22.6.2007 at Sagar Durga Hospital and she passed away in the hospital on the very next day. The patient’s history clearly shows that the patient was on insulin and had renal problem and it is pertinent to note that whether the patient is in the hospital for one day or for two days is immaterial as the repudiation was on the basis of suppression of her health condition which Ex. B3 hospital record reveals the patient’s history. To reiterate, even if the patient is in the hospital for one day or one week, the patient’s history cannot change. Therefore the contention of the complainant that the patient was only treated for one day and died on the very next day and therefore Ex. B4 cannot be taken into consideration, cannot be sustained.

11) We also rely on the decision of Apex Court in Satwant Kaur Sandhu Vs. New India Assurance Company Ltd. wherein the Apex Court held that the hospital reports recording the past history of illness should be relied upon even though the hospital giving the report has not treated the patient in the past and that the non-examination of doctors on an affidavit does not invalidate the documentary evidence on record.

12) Keeping in view the aforementioned reasons and judgements we are of the opinion that the Ops rightly repudiated the claim and therefore this appeal is allowed and the order of the Dist. Forum is set-aside. Consequently, the complaint is dismissed. No costs.

1) _______________________________

PRESIDING MEMBER

2) ________________________________

MEMBER

10/06/2013

*pnr

UP LOAD – O.K.