Per:- Mr. Deshpande, President Place : BANDRA JUDGMENT Smt. Sangita Manish Ruia – the Complainant herein; is the wife of deceased Mr. Manish Ruia, who had taken an insurance policy of double benefit from the Opposite Party – HDFC Standard Life Insurance Company Ltd., through a proposal dtd.23/3/2004 for sum assured Rs.4,00,000/-. Mr. Manish Ruia (hereinafter referred to as the ‘Deceased Life Assured’) was diagnosed for the first time with brain tumor and was operated at Bombay Hospital on 15/1/2005 and was discharged on 21/1/2005. However, he did not recover and passed away on 3/1/2006. [2] On the death of the Deceased Life Assured, the Complainant in her capacity as an appointee of the said policy submitted death claim with the Opposite Party No.1 through its officer – the Opposite Party No.2. However, vide a letter dtd.15/2/2006, the Opposite Party No.2 informed the Complainant that the Opposite Party No.1 – Insurance Company; has repudiated the claim on the ground that while taking the insurance policy, the Deceased Life Assured was suffering from ‘Abdominal Koch’s Disease’ and this fact was suppressed by the Deceased Life Assured while submitting the proposal form for taking the insurance policy. The Complainant preferred an appeal before the Grievance Redressal Officer of the Opposite Party No.1 – Insurance Company; but she met with failure. Thereafter, the Complainant preferred an appeal before the Insurance Ombudsman, but met with the same fate. Ultimately, the Complainant filed present complaint, seeking direction as against the Opposite Parties to pay the insured sum of Rs.4,00,000/- together with interest thereon as well as compensation in sum of Rs.5,00,000/-. [4] The Opposite Party – Insurance Company; resisted the complaint by filing its written version and took stand that the Deceased Life Assured had submitted a proposal form on 23/3/2004 and had made a declaration to the effect that he had not taken treatment for any illness and was not suffering from any disease. However, the Deceased Life Assured was suffering from ‘Abdominal Koch’s Disease’ in the month of Feb-2004 and had taken treatment for the same and this fact was suppressed by the deceased while submitting the proposal for taking the insurance policy. Thus, the Deceased Life Assured had suppressed the material fact while submitting the proposal and the contract of insurance was vitiated. Thus, the Opposite Party – Insurance Company; justified its action of repudiating the Complainant’s claim. [5] The Complainant filed her affidavit in support of the complaint. She also produced the discharge card as well as doctor’s certificate regarding the treatment given to the Deceased Life Assured for brain tumor. As against this the Opposite Party – Insurance Company; produced copies of proposal form as well as certificate issued by a doctor having entries therein regarding treatment given to the Deceased Life Assured for ‘Abdominal Koch’s Disease’. The Opposite Party – Insurance Company; also filed written notes of arguments in support of its contention raised in the written version. [6] We have gone through the pleadings, affidavits, and documents as well as written notes of arguments. [7] We take the points that arise for our consideration and record our findings there-against as below:- Sr. No. | Points for consideration | Findings | 1. | Whether the Complainant has proved that there has been deficiency in service on the part of the Opposite Party – Insurance Company; by repudiating her claim? | NO | 2. | What order? | The complaint stands dismissed. |
REASONS FOR FINDINGS [8] There is no dispute between the parties to the complaint proceeding as regards the fact that the Deceased Life Assured – Mr. Manish Ruia; had taken ‘HDFC CHILREN’S DOUBLE BENEFIT PLAN’ policy from the Opposite Party – Insurance Company; for sum assured Rs.4,00,000/- and the proposal to that effect was submitted by the Deceased Life Assured on 23/3/2004. The policy was in force when death occurred. [9] According to the Complainant, few days before 14/1/2005, the Deceased Life Assured was feeling giddiness & drowsiness and certain tests were conducted and he was diagnosed as suffering from brain tumor. The Deceased Life Assured was admitted at Bombay Hospital on 14/1/2005. C. T. Scan, M. R. I. were taken and the Deceased Life Assured was operated on the next day i.e. 15/1/2005. The Complainant has produced on the record a copy of Hospital Certificate issued by Dr. C. E. Deopujari – Consultant Neurosurgeon to the Bombay Hospital. The record shows that the Deceased Life Assured expired on 3/1/2006 i.e. almost about one year after the discharge from the hospital. On death of the Deceased Life Assured, the Complainant being his wife and appointee under the policy, submitted a claim to the Opposite Party – Insurance Company; and the Opposite Party – Insurance Company; vide its letter dtd.15/2/2006, a copy of which is produced on the record at page (10) of the compilation of the complaint as Annexure-‘D’, repudiated the claim. While repudiating the claim under that letter, the Opposite Party – Insurance Company; reproduced questions & answers in the proposal form submitted by the Deceased Life Assured to the Opposite Party – Insurance Company; while taking the insurance policy. The letter contains a statement to the effect that the Deceased Life Assured was diagnosed of ‘Abdominal Koch’s Disease’ in the month of Feb-2004 and he had received treatment of ‘Anti Koch Treatment (AKT)’ and this fact was not disclosed in the proposal form dtd.23/3/2004. A copy of entire set of the proposal form has been produced by the Opposite Party – Insurance Company; as Annexure-‘A’ with its written version. At Exhibit-B, there is a copy of certificate issued by Dr. Vijaykar, who was a consulting doctor of the Deceased Life Assured and the contents of the certificate in the prescribed form show that the patient (Deceased Life Assured) had taken treatment for ‘Abdominal Koch’s Disease’ from the month of Feb-2004 and the treatment given was ‘Anti Koch Treatment (AKT)’. In the certificate issued by Dr. Deopujari, there is a mention that the Deceased Life Assured had taken ‘Anti Koch Treatment (AKT)’ for ‘Abdominal Koch Disease’ for a period of 10 months. It was from the month of Feb-2004 onwards. Thus, even in the certificate issued by Dr. Deopujari, on death of Deceased Life Assured, there is mention of Deceased Life Assured having taken treatment of ‘Anti Koch Treatment (AKT)’. At Exhibit-D there is a copy of discharge summary issued by Bombay Hospital, when the Deceased Life Assured was again admitted for brain tumor on 29/9/2005 and discharged on 7/10/2005. In this discharge summary also, the first statement reads as follows:- “Mr. Manish is a known case of Abdominal Koch’s for which he took AKT for 10 months 2 years back.” [10] This Discharge Summary was signed by Dr. C. E. Deopujari and Dr. Rajiv Kumar. Thus, the entries in the discharge summary also corroborate certificate issued by Dr. Deopujari as well as certificate issued by Dr. Pradip Vijaykar. It was during the period Feb-2004 onwards and as the entries reveal the treatment was taken by the Deceased Life Assured for AKT for 10 months commencing from the month of Feb-2004. The proposal form for the policy in question was submitted on 23/3/2004. Thus, when the Deceased Life Assured had submitted the proposal form for taking this particular policy, he was already diagnosed of ‘Abdominal Koch’s Disease’ and the treatment was in progress. However, answers given by the Deceased Life Assured to the questions in the proposal form reveal that the Deceased Life Assured replied in the negative to the question as to whether he had ever suffered from any disease, which were mentioned in the proposal form. Be it noted that ‘Abdominal Koch’s Disease’ is tuberculosis and was not negligible disease like common fever, head-ache or hypertension. [11] It was submitted by the Learned Advocate for the Complainant that the Deceased Life Assured did not die of ‘Abdominal Koch’s Disease’, but he died of brain tumor and the claim has not been repudiated by the Opposite Party – Insurance Company; on the ground of suppression of fact that the Deceased Life Assured was suffering from the said disease. This could not be because the Deceased Life Assured was diagnosed of brain tumor in the month of Jan-2005 whereas the policy was taken in the month of March-2004. However, when the insurance policy was taken, he was diagnosed of ‘Abdominal Koch’s Disease’ and had taken treatment for the same. The fact that the deceased did not die of the said disease does not make any difference in the context of furnishing details and particulars in the proposal form. In this context, the Opposite Party – Insurance Company; has relied upon the decision of the Hon’ble National Consumer Disputes Redressal Commission in Revision Petition No.1072 of 1997 (In the matters of V. Radhamma Vs. Regional Manager, LIC of India) decided on 30/4/2004; whereunder it is held that it is not the cause of death, but existence of pre-existing disease of the policy-holder, which is material for deciding the liability for payment of the same insured. [12] While submitting the proposal form, the Deceased Life Assured had the knowledge of the disease, which fact was suppressed while submitting the proposal. Section-45 of the Insurance Act, which is always invoked in such cases has been considered by the Hon’ble Supreme Court in number of cases and the often quoted decision is Mithoolal Nayak Vs. Life Insurance Corporation of India ~ 1962-Suppl.-(2)-SCR-571; where-under the Hon’ble Supreme Court held that the statement must be on a material matter and the suppression must be fraudulently made by the policy-holder while having knowledge that it was false. [13] On analyzing the evidence available on the record, we find that there was suppression of material fact on the part of the Deceased Life Assured, and therefore, the Opposite Party – Insurance Company; was justified in repudiating the Complainant’s claim. Needless it to say that the contract of insurance is ‘uberima-fides’ and every material fact must be disclosed otherwise there is good ground for recession of the contract. [14] In view of the above stated reasons, we hold that there was no deficiency in service on the part of the Opposite Party – Insurance Company; in repudiating the claim submitted by the Complainant. Hence, we proceed to pass the following order:- ORDER The complaint stands dismissed. No order as to costs.
| | [HONABLE MRS. Mrs.DEEPA BIDNURKAR] Member[HONABLE MR. Mr. J. L. Deshpande] PRESIDENT[HONABLE MR. MR.V.G.JOSHI] Member | | 
