SMT. RAVI SUSHA : PRESIDENT
Complainant filed this complaint under sec.12 of the Consumer Protection Act 1986 for getting an order directing opposite parties to pay an amount of Rs.10,00,000/-being the policy amount of policy No.798885161 to 798885165 and Rs.2,20,000/- being the interest from 3/8/2015 to 2/6/2017 and Rs.2,00,000/- as damages for mental agony and pain and Rs.50,000/- towards cost of the proceedings of this case.
The case of the complainant is briefly as follows, the complainant is the window of Mr.Ranish Ravindran, who met with an untimely death on 3/8/2015. The deceased Mr.Ranish Ravindran, H/o complainant was having 10 LIC policies in the 1st OP. After the unexpected death of complainant’s husband she had approached 1st OP to get the benefits under the policy in the name of the deceased being the legal heir and nominee. But unfortunately the claim made by the complainant under the policies were rejected by the 3rd OP stating that they have decided to repudiate all liabilities under the policies alleging that the deceased has withheld material information regarding his health at the time of effecting the policies with LIC. Complainant submits that her husband was a healthy person at the time of effecting the policies with the LIC and there is no suppression of material facts or information. Further the statement made by the 3rd OP that the Ranish Ravindran had undergone treatment for tuberculosis in 2010 and he was an asthma patient, the above said allegations are false, It is submitted that the complainant’s husband died on account of cardiac arrest. It is to be noted that cardiac arrest is not at all the result of disease of tuberculosis or asthma and hence the rejection of the claim of the complainant is highly arbitrary and unsustainable. Aggrieved by the rejection order of the 3rd OP the complainant approached the 2nd OP and the 2nd OP also rejected the claim and directed to refund only the premium amount paid by the deceased to the tune of Rs.78,185/-. Against the claim rejection orders of OPs, the complainant filed this complaint.
The complaint has been contested by the OPs. OPs have pleaded that the deceased Ranish Ravindran was the policy holder under 10 policies bearing Nos .798885161 to 798885170. Out of the above policies 5 policies bearing Nos 798885161 to 798885165 were taken exercising multiple option submitting a single proposal form on 8/10/2014. The date of commencement is 10/10/2014 and all the policies are having a sum assured of Rs.2,00,000/-. In all policies the complainant is the nominee. The claim under the above policies were rejected as the policy holder has suppressed material facts regarding his illness. The deceased was having asthma from childhood and he has undergone treatment for pulmonary tuberculosis from 9/3/2010 to 8/9/2010 but the same was not disclosed the same while taking the policy in the year 2014. The query in the proposal regarding the consultation of medical practitioner for the last five years and regarding admission in hospital were answered in negative. The allegation that Ranish Raveednran was healthy person at the time of effecting policy is not only false but also suppression of true facts. The OPs submitted that the life assured had taken 10 policies at a single stretch by two proposals. Out of the same 9 policies are for 2 lakh each and one policy is Rs.1,90,000/- making a total sum assured at Rs.19,90,000/-. The sme is purposefully done to keep the total sum assured below 20 lakhs, as in case the total sum assured touches the 20 lakhs, medical examination by the third party administrator is mandatory. The primary cause of insured’s death was Acute massive pulmonary embolism and secondary cause is deep vein Thrombosis. These are not deceases coming overnight and are developed on the back ground of prolonged bronchial asthma from child hood. The cause of death has direct nexus with the ailment, he suppressed at the time of taking policy. He was admitted in Manipal Hospital on 28/7/2015 with a history of cough and wheezing. The diagnosis shows acute massive pulmonary embolism and he was transferred to ICU for further management. The allegation that Ranish Ravindran died due to cardiac arrest is not correct. The non disclosure of disease and admission to hospital is a fraud committed on OPs and therefore the 5 policies bearing Nos 798885161 to 798885165 are void. The rejection of claim of complainant by the first OP is on valid legal ground. The complainant is not entitled for any amount from the OPs. There is no deficiency of service on the part of OPs, hence prayed for the dismissal of the complaint.
While the case is pending , additional OP.NO.4 , the mother of the deceased insured was impleaded as per IA.NO. 31/2019 and after receiving notice additional 4th OP filed version stating that there is deficiency in service on the part of OPs 1 to 3 and she is also entitled to get half of the share of the policy amount.
The question for examination is as to whether in the present case , the insured had suppressed any material facts which would have been relevant for the insurance company in order to decide whether to issue an insurance policy to the deceased?
It is a well settled position of law that a contract of insurance is based on the principle of utmost good faith applicable to both the parties. The insured knows all the facts, the insurer is un aware of anything which may be material to the risk. The insurer may not even have the means to find out facts which would materially affect the risk. The law, therefore enjoins on the insured an absolute duty to disclose correctly all material facts which are within his personal knowledge. A contract of insurance, therefore, can be repudiated for non disclosure of material facts. Any fact, which goes to the root of the contract of insurance and has a bearing on the risk involved would be “material” and if the proposer has knowledge of such fact, he is obliged to disclose it, particularly while answering questions in the proposal form. Any inaccurate answer will entitled the insurer to repudiate their liability because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering into a contract of insurance. Hence an assured is under obligation to make a true and full disclosure of the information on the subject which is within his knowledge.
Here the complainant’s case is that her husband was a healthy person at the time of effecting policy and he died due to heart attack and there is no nexus between the cause of death and alleged ailment he had not mentioned in the proposal form. According to complainant, hence there was no material suppression and she is entitled for the policy amount.
On the other hand OPs submissions are that the insured was an asthmatic patient from childhood and the primary cause of his death is Acute massive pulmonary embolism and secondary cause is deep vein Thrombosis. These are not deceases coming overnight and are developed on the back ground of prolonged bronchial asthma from child hood. Further stated that he was treated for tuberculosis from 9/3/2010 to 8/9/2010 and these material were suppressed while taking policy and therefore the policies are null and void and hence OPs are not liable to pay the policy amount. OPs another contention is that the life assured had taken 10 policies at a single stretch by two proposals. Out of the same 9 policies are for 2 lakh each and one policy is for Rs.1,90,000/- making a total sum assured at Rs.19,90,000/-. The sme is purposefully done to keep the total sum assured below 20 lakhs, as in case the total sum assured touches the 20 lakhs, medical examination by the third party administrator is mandatory.
On verifying the documents available, Ext.B1 is the proposal form submitted by the insured on 9/10/2014. On perusal of Ext.B1, personal history portion , the answers given by the insured against questions Nos.a, b,d,e. the information sought for these questions were (a) During the last five years did you consult a medical practitioner for any ailment requiring treatment for more than a week? No, (b) Have you ever been admitted to any hospital or nursing home for general check up , observation, treatment or operation? No. (d) Are you suffering from or have you ever suffered from ailment pertaining to liver, stomach, heart, lungs, kidney, brain, or nervous system ? No (e) Are you suffering from or have you ever suffered from diabetes, tuberculosis, High BP, Low BP, cancer, epilepsy, Hernia, hydrocele, leprosy, or any other disease? No. All the questions were answered in the negative. Further in question No(ii) he had given answer that his state of health was good and he had stated that he had never suffered or was suffering or was hospitalized or requiring medical treatment for more than a week and admitted in any hospital for treatment.
Here it is an admitted fact through medical records that the insured undergone treatment for pulmonary tuberculosis from 9/3/2010 to 8/9/2010 in Manipal hospital under the treatment in the Department of Respiratory medicine under Dr.Isacc Mathew (DW2) specialized in medicine and Respiratory medicine. DW2 doctor deposed that later the insured consulted him on 24/7/2015 for the complaint of Bronchial Asthma. From Ext.X1 the insured had taken continuous treatment for tuberculosis from 8/3/2010 to 10/12/2010 ie for more than 6 months. Further Ext.X1 shows that he was taken treatment from Dr.Vasan.S.S on 22/11/2012 , 24/11/2012 and 31/1/2013 . Further Ext.X1(f) shows that the treating doctor Dr.Isacc Mathew reported on 28/7/2015, about chief complaint that cough on and off. Breathlessness. Since October 2014. It is to be pertinent to note that the insured had taken 10 policies in October 2014. Moreover another point to be noted is that out of 10 policies, 9 policies are for Rupees 2 lakhs each and one policy is for Rs.1,90,000/- making a total sum assured below Rs. 20 lakhs. The OPs learned counsel submitted that in case the total sum assured touches Rs.20 lakhs, medical examination by the third party administrator is mandatory.
On 28/7/2015 the provisional diagnosis was Acute Bronchial Asthma. Further in death summary, the cause of death mentioned as Hyponic Encephaopathy, status post cardiac arrest, acute massive pulmonary embolism, deep venous thrombosis. DW2 Doctor deposed that the cardiac arrest is secondary to the pulmonary embolism. In death summary, the discussion portion states that Mr.Ranish Ravindran, a 33 year old gentleman, with background of asthma was admitted with a history of cough and wheezing to the wards on 28/7/15. He was managed for an acute infective exacerbation with antibiotics/ nebulisations and steroids. On the morning of 30//7/2015, he suddenly became very breathless and collapsed. Code blue was activated and CPR was commenced as per ACLS protocol. He had intermittent brief returns of spontaneous circulation which would rapidly degenerate into bradyasystoly. Intra –resuscitation echocardiography was done which showed grossly dilated RA and RV. A diagnosis of acute massive pulmonary embolism was considered and IV tenecteplase was administered during resuscitation. CPR was continued as per ACLS protocol. Return of spontaneopus circulation was achieved after about 90 minutes. He was transferred to the ICU for further management. He continued to be hemodynamically unstable and required high doses of noradrenaline and adrenaline infusion. Targeted temperature management and neuro protective measures were commenced. Therapeutic anticoagulation was commenced. He became anuric and acidotic and required renal
replacement therapy in the form of slow extended dialysis(SLED). His pupils were fixed and dilated with no Dolly’s eye movements nor is there a response to tracheal suctioning . Formal brain stem testing was done on 2/8/15. There were no brain stem reflexes demonstrated, however an apnea test could not be completed as patient became hypoxic. On 3/8/15, a nuclear perfusion scan of the brain was done which revealed no intracranial blood flow consistent with brain death. He succumbed to his illness at 7.45 pm on 3/8/2015.
Thus through Exts.X1,and X1(a) to X1(h) and from the evidence of DW2 Dr.Isacc Mathew , a senior doctor specialized in pulmonary diseases who treated the insured in Manipal Hospital proves that the patient Ranish Ravindran was having childhood asthma which was developed into tuberculosis in the year 2010 and he was having Anti Tuberculosis treatment ATT for six months. He was having continuous treatment thereafter in 2011,2012.2013 and again he had breathing difficulties in 2014,2015 which resulted in his death. The prolonged illness of asthma has considerable damaged his lungs and the death summary Ext.X1(h) confirms that the cause of death is acute massive pulmonary embolism deep venous thrombosis hypoxic encephalopathy which meaning scarring of lung tissues. In re-examination has stated that the pulmonary embolism stops blood supply to all organs including heart. Doctor has also explained that the patient had deep vein thrombosis which cause massive pulmonary embolism leading to cardiac arrest and the death of the patient.
Undoubtedly, these were material facts and being within the knowledge of the insured, he was obliged to disclose the correctly in the questionnaire issued to him for the purpose of obtaining the policy n question. Having suppressed the said facts while answering the questionnaire, we are of the opinion that the Insurance company was within its rights to repudiate the claim of the complainant. It is also raise some doubt that he had affected the disease again in October 2014 and in the same month itself the insured had taken 10 policies and the total sum assured arranged is less than Rs.20,00,000/- in order to avoid medical examination.
Hence from the said fact it is evident that the insured intentionally suppressed his pre-existing disease. It is also evident that the policies taken prior to this disputed policies, were prior to the diagnosis of disease which were given to the legal heir of the life assured. The OPs already refunded the premium amount paid by the deceased in this disputed policies for Rs.78,185/- to the complainant. In that view of the matter, there was no question of any deficiency of service on the part of OPs.
In the result, complaint fails and hence the same is dismissed. No order as to cost.
Exts:
A1to A6- letter issued by OPs to the complainant dtd.3/12/15,13/2/2016,2/7/16,9/7/16,24/4/17
A7- Copy of complaint issued by complainant to 2nd OP dtd.25/2/2016
B1- proposal form
B2(series) – Policies ( 5 in Nos)
B3(series)- Policies ( 5 in Nos)
B4- attested copy of death certificate
X1(series)- Manipal Hospital records (subject to proof)
PW1-Reshmya.P- complainant
DW1-Beena.K- OP
DW2-Dr.Isaac Mathew- witness of OPs
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
eva
/Forwarded by Order/
ASSISTANT REGISTRAR
