By Smt.Rajani.P.S., Member
The complainant’s case is as follows: The husband of 1st complainant and father of 2nd and 3rd complainants, late Mr.Raveendranathan had taken a moneyback insurance policy bearing No.000144453 on 3/12/03 from 1st respondent through an application dated 31/10/2003 to the 2nd respondent. The policy coverage was Rs.1,50,000/- with an annual coverage premium of Rs.14,880/-. The said policy will be matured on 3/12/2018. As per the terms of the said policy, in the event of death of the insured during pendency of the scheme, the respondents will pay the entire coverage amount of Rs.1,50,000/- to the legal heirs of the deceased. The said Mr.Raveendranathan was admitted in the Mother Hospital due to some discomforts coupled with vomiting. After diagnosis the doctor informed that the patient was having some liver problem. He died on 10/4/06 while undergoing treatment at Mother hospital. As per the terms and conditions of the above said policy, the complainants are entitled for the entire amount of Rs.1,50,000/-. The 3rd complainant being the nominee of the said policy, filed a claim petition before the respondents. But the respondents repudiated the claim as per letter dated 16th October 2006 stating that the death of the deceased was due to liver cirrhosis and he was suffering from liver cirrhosis even prior to his application for insurance and hence not entitled for the amount. The respondents also forfeited the paid premiums of the policy. The application for the insurance of the deceased was approved after detailed medical check-up and detailed verification of the application and the Medical Examination report and the respondents had issued the policy to the deceased. Hence the allegation of the 1st respondent that the deceased had suppressed material facts in the matter of pre-existing diseases is totally baseless and denied also. The deceased was never having any complaints of liver cirrhosis or any kind of liver complaints at the time of joining in the medical scheme. The respondents have no right to reject the claim or to forfeit the paid premiums of the policy. The act of the respondents show deficiency in service and unfair trade practice. The complainants are adversely affected by the acts of the respondents for no fault of theirs for which they are to be compensated. Hence the complaint.
2. The version filed by the respondents 1 and 2 : The complaint is not maintainable and liable to be dismissed as against complainants 1 and 2 as they are not the claimants under the policy bearing number 0001444453. The deceased had made 3rd complainant as the ‘nominee’ with respect to the said policy and therefore liable to be dismissed for misjoinder of parties. The life assured had suppressed material facts as regards his health in his medical examination report dated 26/1/03. The repudiation was intimated to 3rd complainant vide letter dated 16/10/06. The life assured had approached one of the corporate agents of the respondents at Thrissur and he was explained that the contract of insurance is based on utmost good faith and that he should correctly, honestly and fairly disclose all the facts with his knowledge and belief in his application form and relying upon the information provided in the said application form and the subsequent MER and trusting the same to be true and correct issued the insurance. These respondents were intimated about the demise of the life assured by the 3rd complainant on 23rd August 2006. In the last attended physician’s certificate submitted the said doctor has stated that the immediate cause of death of the life assured as ‘Massive Gastro intestinal bleeding’ and the primary cause of death as ‘Cirrhosis Liver’. He has also stated that the life assured was a patient of cirrhosis and intestinal tract. The said doctor has also mentioned that he had seen the life assured in the year 2001 when he was admitted for vomiting of blood for the period from September 10, 2001 to September 18, 2001 and was suffering from ‘Cirrhosis Liver’. The said doctor also stated that he has not taken ethanol for nearly 4-5 years. Abuse earlier could cause such a disease. The life assured had stated in the MER that he was admitted to Mother Hospital in 2001 with Duodenal Ulcer Bleeding in 2001. However in the said MER, the life assured knowingly and with malafide intent to deceive the respondents did not disclose that he was suffering from cirrhosis liver then. Further he replied to question 4(e) of the MER that ‘Have you ever had or sought advice for (e) ulcer, colitis, chronic diarrhea, hepatitis or jaundice or other liver or digestive disorder as ‘No’. Therefore the respondents rightfully repudiated the claim in view of suppression of material facts. These respondents have acted fairly and in good faith and there is no deficiency in service on the part of the respondents and hence dismiss the complaint. It has been held in (1(1994)CPJ 425) Bam Dev Vs. United India Insurance Co. Ltd. that where the repudiation of any claim is ordered after due application of mind and on relevant reasons it does not amount to deficiency of service. As per the judgement the Hon’ble Supreme Court reported in AIR 1962 SC 814, there is no obligation on the part of the respondents to refund the premium paid under a policy were in under the claim has been repudiated by the insurer. These respondents are not liable to compensate the complainants in any manner. Hence dismiss.
3. Points for consideration are :
1) Was there any deficiency in service on the part of the respondents ?
2) If so reliefs and costs ?
4. The evidence consists of the oral testimony of PW1, Exhibit P1, Exhibit X1 and Exhibit R1 which was marked as Exhibit R2 by mistake. Respondents produced some other documents but it is not seen marked.
5. Points : The complaint was filed by the legal heirs of the deceased to get the insured amount. The deceased was a policy holder of the respondents vide Policy No.000144453 on 3/12/03 through an application dated 31/10/03 to the 2nd respondent. The application was approved after detailed medical check-up and detailed verification of the application and the Medical Examination Report. The said insured was admitted in hospital and died on 10/4/06 at hospital. The said policy will mature on 3/12/2018. As per the terms and conditions of the policy the complainants are entitled for an amount of Rs.1,50,000/-. But the respondents repudiated the claim by stating that the deceased had suppressed material facts i.e. the matter of pre-existing disease. The deceased was never having any complaints of liver cirrhosis or any kind of liver complaints at the time of joining in the medical scheme.
6. The respondents in their version stated that they repudiated the claim in view of suppression of material facts He had treated in 2001 for vomiting of blood and the treated doctor’s certificate shows that the insured was a patient of cirrhosis and earlier had bleeding from gastro intestinal tract. The life assured had stated in the MER that he was admitted in 2001 with Duodenal Ulcer bleeding in 2001. However in the said MER he did not disclose that he was suffering from cirrhosis liver then.
7. Exhibit R1 is the Medical Examiner’s report of the insured and it shows that the deceased had stated that he had admitted with D.U. bleeding in 2001 While he answered to the question 4(e) i.e. Ulcer, colitis, chronic diarrhea, hepatitis or jaundice or other liver or digestive disorder as ‘no’. But Exhibit X1 case sheet shows that the diagnosis of the disease of the insured in 2001 as cirrhosis of liver, portal hypertension Oesophageal varices. But PW1 deposed that the treated doctor had not told about liver problem to the deceased. Exhibit X1 case sheet was marked without any objection and no steps has been taken to examine the treated doctor by the complainants to prove their case. So it is to be understood that the deceased had undergone treatment for liver cirrhosis before taking the policy and he has not disclosed the same in the Medical Examination Report. So there is suppression of material facts and hence the complainants are not entitled for the policy coverage amount.
8. In the result the complaint stands dismissed.
Dictated to the Confdl. Asst., transcribed by her, corrected by me and pronounced in the open Forum this the 17th day of February 2012.
