BEFORE THE KARNATAKA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BANGALORE. (ADDL. BENCH)
DATED THIS THE 10th DAY OF JANUARY, 2023
CONSUMER COMPLAINT NO.19/2012
PRESENT
SRI RAVI SHANKAR, JUDICIAL MEMBER
SMT. SUNITA C.BAGEWADI, LADY MEMBER
Ms.Deepali Vikas Ahirao,
W/o Late Vikas Ahirao,
Aged about years,
Residing at #15, 80 ft Road, ...Complainant
Bengaluru – 560 095
(By Mrs.Geetha Raj, Advocate)
V/s
Birla Sun Life Insurance Company Ltd,
4th Floor, Vaman Centre,
Makhwana Road, …Opposite Party/s
Near Marol Naka,
Off-Andheri-Kurla Road,
Andheri (East)
Mumbai- 400 059
(By Sri.R.Jayagopalan, Advocate)
O R D E R
BY SRI.RAVISHANKAR, JUDICIAL MEMBER
The complainant files this complaint against the Opposite Party alleging deficiency of service in not settling the claim towards death of her husband, hence prays for settlement of the claim to the tune of Rs.30,40,575/- along with @18% interest per annum and Rs.1,00,000/- compensation for deficiency in service with cost and grant such other reliefs.
2. The brief facts of the complaint are as under;
The husband of the complainant during his life time had obtained life insurance policy from the Opposite Party Company by sending a proposal form on 3-10-2008 and he had paid premium of Rs.10,950/-. After obtaining the premium amount, the Opposite Party has issued a policy bearing No.002103389 with an annual premium of Rs.10,950/- and risk commenced from 28-10-2008. The said policy was issued after various medical examination of the husband of the complainant by authorized diagnostic center. Such being the case, on 3-12-2009, he was admitted to Green View Medical Centre with a complaint of chest pain despite of good treatment the husband of the complainant expired on the same day at the hospital due to severe cardiac arrest and after the death of the husband of the complainant, the hospital superintendent has issued medical certificate and shown the cause of death as “Acute Myocardial Infarction”. After the death of the husband of complainant being nominated the policy, the complainant approached the Opposite Party for compensation by virtue of the policy on 16-1-2010. After received the claim form, the Opposite Party has not settled the claim and repudiated through their letter dated 4-3-2010 for the reasons that the husband of the complainant was suffering from Hypertension, Left Ventricular Hypertrophy as well as Hyperthyroidism and suppressed the said facts at the time proposal, hence not settled the claim under the ground of suppression of material facts.
The complainant further alleged that, the husband of the complainant has not suffered any ailment as stated by the Opposite Party due to sudden chest pain the complainant’s husband was admitted to the hospital on 3-12-2009 and on the same day he was died. The complainant’s husband was not taken any treatment prior to taking the policy, hence filed a complaint alleging deficiency in service and prayed for settlement of the claim.
3. After service of the notice, the Opposite Party has appeared through his counsel and filed version and contended that, the risk of the policy commenced on 28-10-2008, the basic sum assured under the policy was Rs.30,40,575/- with annual premium of Rs.10,950/-. The policy was issued based on the application/proposal submitted by Vikas Daulatrao Ahirao the husband of the complainant, though he was submitted to medical test, this Opposite Party totally relied on the statements furnished by life assured, in his application the specific questions were given as “NO” and he has shown that did he underwent any medical test like ECG, X-ray, Blood test and other test, the said life assured had answered in the negative. Similarly the questions whether he had ever sought for advice for chest pain, high blood pressure, stroke, heart attack, heart murmur or other heart disorders or for cancer, tumor, thyroid disorder, enlarged glands or enlarged lumph nodes, and he answers as negative. This Opposite Party has utmost faith relied on the statements made by the husband of the complainant issued the insurance policy. Subsequently, they have received an information on 16.1.2010 from the complainant, on 3-12-2009 the life assured was died, the Opposite Party sent necessary claim forms, without admitting the liability. After receipt of the said they investigated the matter and report was submitted on 26-2-2010, whereas we noticed that the life assured was diagnosed to have border line LVH and that he had hyperthyroidism diagnosed one month before death and that he was a known case of HTN since two years on Telma. Basing on the said report, they have decided to repudiate the claim and accordingly sent a repudiation letter dated 4-3-2010. The complainant is not entitled to get any relief as the husband of the complainant has suppressed his health conditions at the time of taking proposal. Therefore, they have refunded an amount of Rs.2,844/- being the cash surrender value of the premium. Hence submits that there is no deficiency in service and prays to dismissal of the complaint.
4. The complainant has filed affidavit evidence and marked documents as Exs.C1 to C6. The Opposite Party has also filed affidavit evidence and marked documents as Exs.R1 to R7.
5. Heard arguments from both sides.
6. On perusal, the following points will arise for our consideration;
(1) Whether the complainant proved deficiency in service on the part of Opposite Party?
(2) Whether the complainant is entitled to the reliefs as sought?
(3) What Order?
7. The findings to the above points are;
(1) In the affirmative
(2) In the affirmative
(3) As per final Order.
R E A S O N S
Point Nos. (1) to (3):-
8. On going through the pleadings, documents and affidavits produced by both parties, we noticed that, the complainant had obtained Birla Sun Life Insurance Dream Plan from the Opposite Party by paying premium amount of Rs.5,475/- after receipt of the said premium the Opposite Party have issued a policy by covering the risk of the life of the husband of the complainant and assured amount is Rs.30,40,575/-. It is not in dispute that on 3-12-2009 the husband of the complainant was died due to cardiac arrest at hospital. After the death of the husband of the complainant being nominated to the policy, the complainant claimed for compensation by virtue of the policy, but the Opposite Party instead of settling the claim have repudiated the claim, for believing that the complainant was suffering from hypertension, hyperthyroidism and shown their inability to settle the claim aggrieved by the said, the complainant preferred this complaint.
9. We noticed that, the complainant had produced a medical certificate issued by Green View Medical Centre wherein the doctor has categorically mentioned that the husband of the complainant (Vikas Daulat Rao Ahirrao) died due to Acute Myocardial Infarction with Ventricular Fibrillation and also noted that in the column of pre history he was suffering from hyperthyroidism and also hypertension under Telma medication. Except that medical certificate does not discloses that he was suffering from any heart diseases. We noticed that, the husband of complainant on 3-12-2009 visited Green View Medical Center with a history of instant chest pain. On the same day he died due to cardiac arrest. According to us, the death of life assured is natural and unfortunately at the early age he died due to heart attack. The Opposite Party has not produced any relevant materials to show he was suffering serious health problems which aggravated to the death of life assured. He was only under the medication for hypertension. Hypertension according to us is not a life threatening disease. It is only a disorder which can be regularized. Merely having border line of LV Hypertrophy does not mean that he was suffering from ill health. The Opposite Party has repudiated the claim of the complainant only on flimsy ground. We found there is negligence on the part of Opposite Party in repudiating the claim of the complainant. Instead of settlement of the claim, the Opposite Party has paid meager amount of Rs.2,844/- towards the cash surrender value of the premium amount paid which is clear deficiency of service. Apart from that the Opposite Party has not established that the complainant is not entitled to get any relief as claimed. On the other hand, the complainant has produced the documents to show that the husband of the complainant was hale and health during his life time. As such we consider the Opposite Party is liable to pay the assured amount under the policy to the complainant. Accordingly, the complaint is allowed with costs and we proceed to pass the following:
O R D E R
The complaint is allowed in part with cost of Rs.5,000/- payable to the complainant.
The Opposite Party is directed to pay an assured amount of Rs.30,40,575/- after deducting the amount already paid.
Further the Opposite Party is directed to pay compensation of Rs.1,00,000-00 towards deficiency of service to the complainant.
Further the Opposite Party is directed to comply the above order within 30 days from the date of receipt of this order. Failing which, the payable amount shall carry interest @9% p.a. from the date of default till realization.
Send a copy of this order to both parties.
Member Judicial Member
