SMT. RAVI SUSHA: PRESIDENT

Complainant has filed this complaint U/s 12 of Consumer Protecetion Act 1986,  for getting an order against opposite party to pay Insurance sum assured Rs.50,000/- together with death claim Rs.3,00,000/- and cost of the proceedings Rs.25,000/-.

The facts of the case according to the complainant that his father late Mr. Ramachandran K had taken life Insurance policy from Bharati AXA through Blue chipTaliparamba on 18/05/2017.  The policy number is 501-5837155.  On 09/11/2018 he was admitted to Pariyaram Medical College Hospital due to stroke & later shifted to MIMS Kozhikkode due to shortage of ventilation of Pariyaram Medical college where he expired on 10/11/2018 and the claim was submitted but the company rejected the same. In the claim repudiation letter sent by Bharati AXA it was informed that the complainant’s father Mr. Ramachandran K had given false & misleading information to the company. The company said that it has been established by the medical documents produced at the claim stage that the life insured was known case of  cerebrovascular accident, multi infract state since 2016.  But to the best of our knowledge and belief, life assured was diagnosed with stroke only after taking the policy, in July 2017, from Pariyaram Medical College.  Complainant has sent letter to reconsider the policy claim.  But the company didn’t send any proof & simply sent another letter rejecting the same.  Hence this complaint.

            OP Insurance company have denied the contentions of the complainant and stated that the subject policy has been obtained by the life assured fraudulently, dishonestly and by misrepresentation  and suppressing his medical history of cerebrovascular Accident, Multi Infract state since 2016 diagnosed and treated prior to issuance of  the policy.  Thus the present complaint is liable to be dismissed on this ground.  In the present case, the claim of the complainant was repudiated on the basis of intentional non-disclosure of past medical history of Cerbrovascular Accident, Multi Infract state diagnosed and treated prior to issuance of the policy and untrue statement made in the proposal from coupled with other material facts.  The life Assured was diagnosed and was under treatment for cerebrovascular, Multi Infract State since 2016 ie prior to issuance of the policy which was deliberately no disclosed by him in the proposal form; with an intent to induce the OP to issue the policy which otherwise would not have been issued if the above said medical history would have been disclosed by the Life assured in the proposal form.  The life assured deliberately concealed the fact regarding his past medical history in the proposal form by replying the health related questions in negative.  Therefore the claim of the complainant was rejected by the OP.  Thus there is no deficiency in services on the part of the OP.

            Both parties have not adduced oral evidence.  Complainant has produced two documents.  Death certificate of the Life Assured (Ext.A1).  From the side of OP, terms and conditions of the policy (Ext.B1),  copy of claim form submitted by the complainant (Ext.B2), Copy of medical record from Pariyarm Medical college hospital (ext.B3), Copy of claim repudiation letter (Ext.B4), copy of Reply (Ext.B5).  The medical record of the Insured from Aster Mims Hospital was summoned and marked as Ext.X1.

            After that both learned counsels of parties filed written argument notes.  Learned counsel for complainant submitted that in the absence of any medical records to show that the father of complainant late Mr. Ramachandran K (LA) had a complaint of cerebro vascular accident, Multi infract state since 2016, the insurance company repudiated the claim of the complainant.  Complainant has stated that there was no material suppression on the part of the life assured in the proposal form submitted before the Insurance Company.  So the repudiation of the claim by the Insurance Company is unjustifiable and the action of OP amounts to deficiency of service.

            On the other hand OP’s learned counsel submitted that since the policy was obtained by the life Assured by concealing his past history of cerebrovascular Accident, multi Infract state since 2016, the insurance contract is invalid void-ab- initio, in operative and unenforceable.  It is stated that the medical record dated 09/11/2018 from Pariyaram Medical college hospital states  past history of Multi Infract state, CUA about 2 years back ie prior to issuance of policy, so there is non-disclosure of this material fact, and hence LA is not entitled to get sum assured and other benefits. In the instant case, there is evidence from Pariyaram Medical College hospital (Ext.B3) that the deceased had availed treatment from 20/07/2017 onwards.  In Ext.B3 page 14.  Final diagnosis on 20/07/2017 Recurrent CUAT but period is not specified.  Further in Ext.X1 the medical record of the deceased from Aster MIMS Hospital, from where the LA was admitted on 10/11/2018 at 11.19 AM and Death happened at 11.20 AM.  In which history and physical Examination Findings : History of Sudden loss of consciousness at around 10 PM on 09/11/2018.  He is a known case of diabetes mellitus and small vessel disease of brain on medications including antiplatelits.

            In Ext.X1 also period from which he had disease has not been stated.  Further in Ext.B4, it is seen that OP had made investigations to find out the history of the life assured and material suppression.  In the assessment enquiry dated 28/12/2018, stated that Life insured was admitted in MIMS for brain disease in November 17 and later admitted in November 2018 in Pariyaram Medical college hospital.  Life insured died on 10/11/2018 in MIMS Hospital due to reversible brain stem Dysfunction.  Also suffering from DM but duration not known and no records found.  During investigation with neighbours – they informed that life insured died on 10/11/2018 due to brain disease in MIMs Hospital and nothing adverse was found.  Further the investigator reported that Discharge summary from Aster Mims Hospital – Life insured was admitted on 25/11/2017 and discharged on 05/12/2017 Final Diagnosis – Recent Acute infract.

            Here the fact that an insurance policy was obtained by the deceased from the OP  Insurance company and his death as a result of irreversible brain stem Dysfunction is not in dispute.  The policy was repudiated by the OP Insurance company on ground of suppression  of material facts that life insured  had a history of cerebrovascular accident since 2016.

            On perusal of the said medical records, no such history can be seen, more over the investigator reported that the patient did not have such a history.  Further and more importantly there is no affidavit of the treated doctor nor of any officer of the insurance company to prove the authenticity of the medical treatment records.  Insurance company did not adduce an evidence of the medical officer to prove their contention.   Insurance company took no steps to prove the same.

            In view of the above we are of the view that the insured died as a result of irreversible brain stem dysfunction.  OP failed to prove the material suppression of the insured in the proposal form of the policy.  So our view is that the repudiation made by the OP is not justifiable. 

The action of the OP amounts to deficiency of service on their part.  Hence the complainant is entitled to get sum assured with bonus as per the policy.  Here neither of the parties submitted policy certificate.  Hence we cannot specify the amount in the order.

In the result complaint is allowed in part.  Opposite party Insurance company is directed to pay the sum assured with bonus as stated in the policy of the deceased Ramachandren K in policy No.501-5837155 to the complainant.  Opposite party is also directed to give Rs.10,000/- as cost of the proceedings.  Opposite party shall comply the order within one month from the date of receipt of the order, failing which the awarded amount entitled to get to the complainant carries interest @ 9%  per annum from the date of order till realization.  Complainant is liberty to file execution application against opposite party for realization of the amount as stated in Consumer Protection Act 2019.

Exts.

A1- Death certificate of  life assured

B1- Terms and conditions of the policy

B2- Copy of claim form

B3-Copy of Medical record from Pariyaram Medical college

B4- Copy of copy of claim repudiation letter

B5- Copy of reply

X1- Medical record of the Insured from Aster MIMS Hospital

      Sd/                                                                          Sd/                                                     Sd/

PRESIDENT                                                                   MEMBER                                                   MEMBER

Ravi Susha                                                               Molykutty Mathew                                     Sajeesh K.P

(mnp)

/Forward by order/

Assistant Registrar