BEFORE A.P STATE CONSUMER DISPUTES REDRESSAL COMMISSION AT HYDERABAD
F.A.No.661 of 2012 AGAINST C.C.No.NO.27 OF 2012 DISTRICT FORUM KARIMNAGAR
Between
M/s ICICI Prudential Life Insurance co.Ltd.,
ICICI Pru Life Tower, 1089, Appa Saheb
Maratha Marg, Prabha Devi, Mumbai-025
Also at:
The Branch Manager
M/s ICICI Prudential Life Insurance Co.Ltd.,
Plot No.3-1-580, Ground Floor, Kyas Towers
Amedkar Road, Karimnagar
Appellant/opposite party
A N D
Farath Unisa @ Faruthunnisa Begum
W/o late Mohd. Abdul Qayyam
R/o 2-2-100/A (2-2-98), Barkatpura
Metpally Village and Mandal of
Karimnagar District
Respondent/complainant
Counsel for the Appellant M/s C.Sai Kumar
Counsel for the Respondents M/s V.Gourisankara Rao
QUORUM: SRI R.LAKSHMINARSIMHA RAO, HON’BLE MEMBER
&
SRI THOTA ASHOK KUMAR, HON’BLE MEMBER
MONDAY THE TWENTY THIRD DAY OF SEPTEMBER
TWO THOUSAND THIRTEEN
Oral Order ( As per R.Lakshminarsimha Rao, Member)
***
1. The opposite party insurance company is the appellant. The appeal is challenge to the order of the District Forum whereby the appellant is directed to pay an amount `1,25,000/- towards the sum assured under insurance policy bearing No.09132410 with interest at 9% per annum and `1,000/- towards costs.
2. The husband of the respondent namely, Mohd Abdul Qayyam obtained life insurance policy from the appellant insurance company on 09.6.2008 for a period of 10 years for a sum of `1,25,000/-. The respondent was appointed as the nominee of the insured and he died on 16.2.2010 due to cardiac arrest. The respondent submitted claim to the appellant on 24.10.2010 and as the appellant did not pay the amount i.e., assured sum of `1,25,000/-, the respondent got issued notice on 30.04.2011. The appellant had sent repudiation letter dated 19.8.2008 informing the respondent that her claim was repudiated on the ground that her husband suppressed his illness at the time of submitting the proposal.
3. The respondent submitted that her husband did not suppress any material information regarding his health while submitting the proposal form to the appellant insurance company. She has submitted that the appellant having issued the insurance policy in favour of her husband, is liable to pay the sum assured as her husband died due to heart failure.
4. The appellant resisted the case on the premise that the complaint is not maintainable as there was no deficiency in service or negligence on its part and that on 9.6.2008 the husband of the respondent submitted proposal form by paying a sum of `25,000/- towards yearly premium and on receiving the proposal form and the premium, the appellant issued insurance policy bearing No.09132410 on 13.6.2008. After the death of the insured, the appellant caused claim enquiry and came to know that the policyholder suppressed material information about his illness at the time of submitting the proposal. The deceased was suffering from diabetes for a period of 10 years and he was on treatment and therefore the claim for payment of sum assured was repudiated.
5. The respondent in support of her claim filed her affidavit and the documents, Exs.A1 to A11. The appellant had not filed any documents.
6. The District Forum allowed the complaint on the premise that the appellant did not produce medical record to show that the deceased policy holder was under treatment prior to the date of submitting the proposal form and the appellant failed to make enquiry with regard to information furnished by the policy holder while submitting the proposal form. The District Forum observed that the appellant did not obtain medical record from the hospital to prove the illness of the policy holder.
7. Aggrieved by the order of the District Forum the opposite party has filed appeal contending that the order of the District Forum failed is erroneous, perverse and contrary to law. It is contended that the husband of the respondent obtained the insurance policy fraudulently and dishonestly and that he was suffering from diabetes mellitus for 10 years and he was hospitalized on 28.3.2007 in intensive care unit for uncontrolled diabetes mellitus prior to submission of the proposal form. It is contended that the husband of the respondent was an alcoholic and used to consume tobacco and non-disclosure of the material fact goes to root of the matter vitiating the insurance policy.
8. The appellant has contended that the District forum failed to appreciate the document dated 28.3.2007 issued by Apollo Emergency Hospital, Hyderabad and that the fact of hospitalization of the insured had gone unchallenged. It is contended that the insured made false declaration regarding his past medical history and the District Forum failed to appreciate the reply given by the appellant to the notice of the respondent.
9. The point for consideration is whether the order of the District Forum suffers from misappreciation of facts or law?
10. The respondent’s husband Mohd Qayyam submitted proposal form on 09.06.2008 to the appellant insurance company. In the order of the District Forum the date of proposal form is mentioned as 6.6.2008. To the questions No.20(E) the husband of the respondent had given the answer as ‘No’. The relevant questions regarding his health and the answers given by him are shown below in tabular form.
| Q. No. | Question | Answer |
| 20(E) | Do you consumer or have ever consumed Tobacco, Alcohol or any narcotic? If yes please give the following details: | Substance | Yes | No | Consumed | Quantity | | Tobacco | | ü | Cigar/Cigarette/Beedi/Gutkha | | | Alcohol | | ü | Beer/Wine/Hard Liquor | Glasses/Pegs |
| No For No.of years |
| 20(a) | Are you presently in good health? Please submit previous medical reports (if any) as receipt of these reports helps us in faster assessment of the health of the life to be assured. | Yes |
| 23(c) | Have you ever consulted any doctor or are you currently undergoing/have undergone any tests, investigations, awaiting results of any tests or investigations or have you ever been advised to undergo any tests, investigations or surgery or been hospitalized for general check-up observation treatment or surgery? | No |
| 23(f) | Did you have any ailment/injury/accident requiring treatment/medication for more than a week/ | No |
| 23(h) | Have you suffered from or are suffering from any of the following: i) Diabetes/High Blood Sugar | No |
11. The respondent got issued notice through her advocate to the appellant on 30.4.2011 and the appellant through its reply intimated the respondent that on 20.4.2010 i.e., approximately 20 months from the date of issuance of insurance policy, they received death claim intimation of Qayyam Abdul that he was expired on 16.2.2010 due to congestive cardiac failure, coronary artery disease, left ventricular dysfunction with hypertension and diabetes mellitus.
12. The peculiar circumstances where the appellant is deprived of opportunity to lead evidence by the District forum are manifest as on 17.4.2012 the District Forum dismissed the application filed by the appellant to set aside the exparte order passed against it. Thereafter the case was adjourned to 19.4.2012 for filing of affidavit of the respondent who filed her affidavit on 19.4.2012 and the matter was reserved for orders. On 26.4.2012 the appellant filed petition, I.A.No.114 of 2012 to reopen the matter to receive its written version. Interestingly, the District Forum received the written version and reserved the matter for orders and on 2.5.2012 it had suomotu reopened for further hearing and reserved the matter for pronouncement of order which was pronounced on 7.5.2012.
13. The petition I.A.No.79 of 2012 filed to set aside the exparte order was dismissed by the District Forum observing that it had no power to set aside the exparte order. Interestingly, the District Forum has received the written version of the appellant subsequently by allowing I.A.No.114 of 2012. The District Forum cannot adopt different procedure on different dates of hearing and it is unbecoming of the District Forum to receive the written version even after dismissing the petition filed for setting aside the exparte order. Even after receiving the written version, in a very hasty manner the District Forum proceeded to pronounce the order by not giving opportunity to the appellant to file affidavit or the documents.
14. The District Forum cannot be expected to be ignorant of the law which was applied by it while dismissing the petition, I.A.No.79 of 2012 filed for setting aside the exparte order passed against appellant insurance company. The District Forum dismissed the application and peculiarly allowed the application subsequently filed, I.A.No.114 of 2012 and received the written version of the appellant insurance company. The District Forum by applying the law laid by the Hon’ble Supreme Court dismissed the earlier application and in-contravention of the very same law, the District Forum has proceeded to allow the petition No.114 of 2012 which is against the spirit of law laid by the Hon’ble Supreme Court as also that the District Forum ought not to have receive the written version of the appellant.
15. Thus, for the foregoing reasons this Commission is inclined to receive the documents mentioned in the reply notice and filed before this Commission in the appeal. The medical record of the deceased insured issued by Apollo Emergency Hospital, Hyderabad indicates that he suffered from uncontrolled diabetes mellitus and was admitted in the hospital in ICU on 28.3.2007 and he concealed the factum of treatment while filling of the proposal form and gave reply in negative to the question regarding treatment or consultation prior to the date of submitting the proposal form. The husband of the respondent, thus obtained the life insurance policy by concealing material facts of his ill health and in the circumstances repudiation of the claim can be held justified.
16. The Hon’ble Supreme Court in “P.C.Chacko vs Life Insurance Corporation of India “ 2008(1)SCC 321 wherein the Supreme Court held
“The purpose for taking a policy of insurance is not, in our opinion, very material. It may serve the purpose of social security but then the same should not be obtained with a fraudulent act by the insured. Proposal can be repudiated if a fraudulent act is discovered. The proposer must show that his intention was bona fide. It must appear from the face of the record. In a case of this nature it was not necessary for the insurer to establish that the suppression was fraudulently made by the policy holder or that he must have been aware at the time of making the statement that the same was false or that the fact was suppressed which was material to disclose. A deliberate wrong answer which has a great bearing on the contract of insurance, if discovered may lead to the policy being vitiated in law.”
17. In ‘Satwant Kaur Sandhu vs New India Assurance Company Ltd ‘ IV(2009)CPJ 8(SC), the Apex Court considered the contract of insurance based on the principle of utmost good faith on the part of the assured to hold
“Thus it needs little emphasis that when an information on a specific aspect is asked for in the proposal form, an assured is under a solemn obligation to make a true and full disclosure of the information on the subject which is within his knowledge. It is not for proposer to determine whether the information is sought for is material for the purpose of the policy or not”.
18. In the aforementioned decisions the repudiation of the claim for non-disclosure of the material facts was held valid and sustainable. The facts of the aforementioned case and those of the present case are similar and as such the ratio laid down therein is applicable to the facts of the case on hand. In the case on hand the insured was suffering from uncontrolled diabetes mellitus and despite undergoing treatment therefor he had not revealed the disease he was suffering from and the treatment he had undergone therefor at the time of obtaining the insurance policy.
19. In the result, the appeal is allowed setting aside the order of the District Forum. Consequently, the complaint is dismissed. No order as to costs.
MEMBER
MEMBER
Dt.23.09.2013
కె.ఎం.కె*
