PBEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 21st day of December 2013
Filed on : 10/10/2011
Present :
Shri. A Rajesh, President.
Shri. Sheen Jose, Member.
Smt. Beena Kumari V.K. Member.
C.C. No. 544/2011
Between
Ligi Deepan, : Complainant
Mannulli house, (By Adv. Saji Isaac K.J.
Flat No. 42, Mayura Apartment, 311 H.B. Flats, Panampilly Nagar,
Kadavanthara, Ernakulam. Cochin-36)
And
I C I C I Prudential Life Insurance : Opposite parties
Co. Ltd., Vinod Silk Mills (party-in-person)
Compound Chakravarthy
Ashok Nagar, Ashok Road,
Kamndivali (E)
Mumbai-400 101.
I C I C I Prudential Life
Insurance Co. Ltd.,
Thomson Towers,
3rd Floor, M.G. Road,
North End, Cochin-682 035.
O R D E R
A Rajesh, President.
The facts of the complainant’s case are as follows:
The complainant is the widow of the deceased Joseph Deepan. They have one girl child. The deceased had taken a Smart kid-new unit linked regular premium policy from the opposite parties on 14-07-2007 for the child Dilna Deepan. The sum assured was Rs. 1,25,000/- and the yearly premium payable was Rs. 25,000/-. The policy was issued by the opposite party after their regular check up. The 3rd premium fell due on 14-07-2009 and the premium could not be paid in time. At that juncture the opposite party sent a notice stating that the benefits of the policy can be availed only if he remits the premium. Believing the notice the life assured (deceased) remitted the premium of Rs. 25,000/-. At the request of the opposite party the life assured submitted a health declaration form. The complainant’s husband died on 20-08-2010. The insurance claim of the complainant was repudiated by the opposite party stating that the deceased had suppressed material facts. There has been no suppression of material facts and the complainant is entitled to get the benefits of the policy together with a compensation of Rs. 1,00,000/- and costs of the proceedings. This complaint hence.
2. The version of the opposite parties is as follows:
The life assured had concealed the material facts regarding his health which was necessary to disclose at the time of revival of the insurance policy. The life assured deliberately concealed the facts thereby rendered the contract of insurance void - ab- initio and in operative. The life assured within 3 months from the date of revival of the policy was under treatment for De compensated Cirrhosis of liver, Portal Hypertension, Upper Gastro intestinal Bleed, Grade III Esophageal Avarices. On the basis of the information and declaration made in the personal health declaration form and the medical report submitted along with it, the opposite parties revived the policy on 12-05-2010. The repudiation of the insurance claim of the complainant was made on justified grounds of concealment of material facts at the time of revival of the policy which is justified and legal. There is no deficiency in service or unfair trade practice on the part of the opposite parties. The complaint is devoid of any merit and deserves dismissal.
3. The complainant was examined as PW1 and Exts. A1 to A5 were marked. The witness for the opposite parties was examined as DW1 and Exts. B1 to B6 were marked. Heard the learned counsel for the parties.
4. The points that arose for consideration are as follows:
i. Whether the complainant is entitled to get insurance claim
from the opposite parties?
ii. Whether the opposite parties are liable to pay compensation
and costs of the proceedings to the complainant?
5. Point No. i. Admittedly the complainant’s husband, the deceased Joseph Deepan availed himself of Ext. A1 smart kid – New Unit Linked RP Policy of the opposite party with effect from 14-07-2007 with a sum assured of Rs. 1,25,000/-. Their child Dilna Deepan is the nominee in the policy and the complainant is the appointee of the policy. The life assured paid 2 yearly premiums to the tune of
Rs. 25,000/- each to the opposite party. The 3rd premium fell due on
14-07-2009. The life assured remitted the 3rd premium belatedly on 10-05-2010 and the opposite party revived the policy. In the meantime the life assured breathed his last on 20-08-2010 and accordingly the complainant submitted the insurance claim application to the opposite parties. The opposite parties repudiated the insurance claim vide Ext. A4 letter dated 29-12-2010 which reads as under.
“On careful evaluation of medical records, received by us, during the claim processing, it is noted that the Life Assured was hospitalized on September 17,2009 wherein he was diagnosed of “Decompensate Cirrhosis of Liver, Portal Hypertension, Upper Gastro Intestinal bleed, Grade III Esophageal Varices, and underwent Endoscopic Variceal Ligation”. Further, it is also noted that the Life Assured was suffering from Diabetes Mellitus and Systemic Hypertension.
This medical history, which was prior to the reinstatement, was not disclosed in the Personal Health Declaration Form, Had the true history of his health been disclosed, the company would not have reinstated the policy.
We state that the Company has been led to reinstate the Policy by suppressing material facts. We are therefore constrained to repudiate your claim for the above policy and all monies that have been paid there under belong to us”.
6. The learned counsel for the complainant submitted that in a revival what is required to be performed is the performance of the original contract and not the new contract. The learned counsel relied on the decisions rendered by the Hon’ble High Court of Kerala in LIC of India Vs. Sosamma Punnan AIR 1991 Ker 230 and the Hon’ble Apex Court in Mithoolal Nayak Vs. LIC of India AIR 1962 SC 814.
7. Admittedly the life assured issued a personal health declaration form before revising the policy and on the basis of the same alone have they revived the same in which the life assured did not disclose any ailment. Ext. B5 discharge summary of the deceased goes to show that he had been undergoing treatment at Lakeshore Hospital, Ernakulam from 17-09-2009 to 22-09-2009 for the following ailments
“Decompensated Cirrhosis of Liver - meld Score 23
Portal hypertension
Upper Gl bleed
Grade III Esophyageal Avarices
Endoscopic Variceal Ligation Done
Type 2 Diabetes Mellitus
Systemic Hypertension
8. The non disclosure of the above ailments in the declaration form is fatal to the complainant’s case. The complainant contented that in the payment notice the opposite party stated that the benefits will not be lost and believing the statements in the notice the deceased remitted the subsequent instalment. But nothing is on record to substantiate the above contention of the complainant.
9. The Hon’ble Apex Court in Satwant Kauar Vs. New India Assurance Co. Ltd., 2009 CTJ (SC) 956 held as follows:
“Answers given by the proposer to the two questions were “sound Health” and “Nil” respectively. It would be beyond anybody's comprehension that the insured was not aware of the state of his health and the fact that he was suffering from Diabetes as also chronic Renal Failure, more so when he was stated to be on regular haemodialysis. There can hardly be any scope for doubt that the information required in the afore-extracted questions was on material facts and answers given to those questions were definitely factors which would have influenced and guided the respondent – Insurance Company to enter into the Contract of Mediclaim Insurance with the insured. It is also pertinent to note that in the claim form the appellant had stated that the deceased was suffering from Chronic Renal Failure and Diabetic Nephropathy from 1st June, 1990, ie. within three weeks of taking the policy. Judged from any angle, we have no hesitation in coming to the conclusion that the statement made by the insured in the proposal form as to the state of his health was palpably untrue to his knowledge. There was clear suppression of material facts in regard to the health of the insured and, therefore, the respondent – insurer was fully justified in repudiating the insurance contract. We do not find any substance in the contention of learned counsel for the appellant that reliance could not be placed on the certificate obtained by the respondent form the hospital, where the insured was treated. Apart from the fact that at no stage the appellant had pleaded that the insured was not treated at Vijaya Health Centre at Chennai, where he ultimately died. It is more than clear from the said certificate that information about the medical history of the deceased must have been supplied by his family members at the time of admission in the hospital, a normal practice in any hospital. Significantly, even the declaration in the proposal form by the proposer authorizes the insurer to seek information from any hospital he had attended or may attend concerning any decease or illness which may affect his health.”
10. In the above circumstances we are only to hold that there was material suppression on the part of the life assured while reviving the policy and the repudiation of the insurance claim is sustained here. For the same reason we are not to rely on the decision cited by the learned counsel for the complainant.
Therefore the proceedings in this complaint stands closed.
Pronounced in the open Forum on this the 21st day of December 2013.
Sd/-A. Rajesh, President.
Sd/- Sheen Jose, Member.
Sd/-Beena Kumari V.K., Member.
Forwarded/By Order,
Senior Superintendent.
Appendix
Complainant’s exhibits :
Ext. A1 : Copy of policy
A2 : Copy of premium notice dt.
A3 : Copy of renewal receipt
A4 : Copy of letter of repudiation
29-12-2010
A5 : Copy of certificate
Opposite party’s Exhibits : :
Ext. B1 : Copy of proposal
dt. 30-05-2007
B2 : Copy of policy
dt. 15-07-2007
B3 : Copy of claim intimation
B4 : Copy of letter dt. 16-10-2010
B5 : Copy of discharge summary
dt. 22-09-2009
B6 : Copy of letter dt.29-12-2010
Depositions:
PW1 : Liji Deepan
DW1 : Amar Balagopal
