(Passed this on 17^th February,  2018)

Shri. S.P. Muley, President –

1.      This complaint is regarding non settlement of insurance claim by the Opposite Parties.

2.      The complainant is a widow of Anil Ukey who expired on 13/9/2010. The O.P.1 provides loan and insurance policies and the O.P.2 is a bank and works under the guidance of the O.P.1. The husband of the complainant had taken loan of Rs. 12 lakh from the O.P.1 and an insurance policy from the O.P.2 for a period of 12 years in June 2010. The policy was assigned to the O.P.2. After the death of her husband she was in dire need of money and hence she applied with documents to the OPs for getting insurance amount Rs. 12,62,244/-. However her claim was rejected on the ground that her husband was suffering with Sickle Cell and this fact was concealed by him while giving proposal to ger the policy. However, it is stated he was never suffering from Sickle Cell problem and he died of cardiac arrest. He did not hide any fact. Thus, it is alleged rejection of her claim by the OPs is nothing but deficiency in service and unfair trade practice. Hence it is prayed to direct the OPs to  settle her claim of Rs. 12,62,244/- with interest with Rs. 2 lakh compensation.

3.      The O.P.1 in reply denied the allegations of unfair trade practise and deficiency in service. Admitting that the O.P.2 is corporate agent of the O.P.1, it is stated both are separate legal entities. The husband of the complainant had applied for insurance policy and based on his information and declaration in proposal form insurance policy was provided to him. It is stated he was suffering from Sickle Cell problem since prior to the proposal, but he suppressed this fact and as it amounts to breach of policy condition, the claim was rightly rejected. Hence prayed for dismissal.

4.      The O.P.2 in reply stated the complainant is not a consumer as he has not hired any services from it. It is not involved in insurance or insurance related business and hence any decision on insurance claim is not in its hand. The complainant and her husband had obtained home loan of Rs. 12 lakh from it. It is not mandatory to avail insurance while obtaining loan and it never asked him to get insurance from the O.P.1. Her husband, on his own accord assigned the policy to it. In the event of death of Assigner, the O.P.2 holds right to secure loan out of claims arising out of said policy. It paid Rs. 62,244/- to the O.P.1 for and on behalf of her husband towards payment of insurance. The claim was rejected by the O.P.1 for reasons stated by them and is based on hematology report. He was aware of his health and did not disclose it. Thus denying any deficiency on its part it is submitted to dismiss the complaint.

5.      Heard Ld counsels for the complainant and the O.P.2. None appeared for the O.P.1 for making any oral submissions. Perused documents. We record our findings with reasons as under.

FINDINGS  AND  REASONS

6.      The complaint is regarding repudiation of the claim on the ground of suppression of pre existing disease. Therefore the O.P.2, which is a bank, is not directly concerned with the insurance claim of the complainant. Merely because the O.P.2 works under the protege of the O.P.1 does not, ipso facto, make it liable in respect of insurance claim. The policy was given by the O.P.1 and it was the responsibility of the O.P.1 to take decision on the insurance claim. The policy was assigned to the O.P.2 only to secure the loan obtained by the complainant from the O.P.2. That itself does not make the complainant a consumer of the O.P.2. The claim was not repudiated by the O.P.2, so there was no cause of action to file complaint against it.

7.      The insurance claim was repudiated by the O.P.1 on the ground that her late husband who was insured under the policy was suffering from Sickle Cell which was not disclosed by him while filling in proposal form for the insurance policy. It is submitted a contract of insurance is based on utmost faith and both the parties are expected not to hide any material fact from each other. The insured was to give correct and true facts about his health in the proposal form. The insured husband of the complainant gave reply to his health queries in the negative in proposal form, meaning thereby he had no health problem whatsoever. Relying on his declaration the O.P.1 issued him a policy. However, when after his death claim was submitted, an investigation was carried out by the O.P.1 into the cause of his death and it was revealed he was suffering from Sickle Cell problem since long. On this reason the claim was repudiated.

8.      Ld. Counsel for the complainant in his argument submitted the deceased was never had any problem of Sickle Cell and there is no such clinching evidence. Therefore, he submits, repudiation is illegal. He pointed out the death certificate issued by Arneja Heart Institute, where the deceased died, reveals cause of death was Pulmonary Embolism with Ischamic Heart Disease with Cardio-respiratory Arrest. There is no reference of Sickle Cell in the certificate. It was in the investigation report of the O.P.1 that Sickle Cell problem for the first time mentioned. The Physician statement taken by the O.P.1 is that of Dr. Arneja of Arneja Heart Institute. The diagnosis mentioned therein is ¨Sickle Cell with Pulmonary Embolism with Cardio Respiratory Arrest¨. However in death summery issued by the same doctor it is mentioned that the deceased had Sickle Cell Trait.

9.      Sickle Cell is a disorder that causes red blood cells (RBC) to become misshapen and break down. People with Sickle Cell Disease have abnormal hemoglobin in their RBCs. It can distort RBC into a sickle, or crescent shape. It is a genetic disease of RBC. In this case the deceased was in Arneja Heart Institute for one day only. Obviously the doctor could not get enough time to investigate. It is stated by the doctor the deceased had Sickle Cell Trait. It occurs when a person inherits a sickle cell gene from one parent. It is  not the same as sickle cell disease, in which a person inherits two sickle cell genes, one from each parent and which is a serious disease. People with Sickle Cell Trait usually do not have any of the symptoms of Sickle Cell disease. So there may be possibility that the deceased husband of the complainant might not have any symptoms of Sickle Cell disease during his life time. Because there is no medical history of him suggesting serious problems. The most common type is known as Sickle Cell Anemia and common symptoms are attacks of pain, anemia, swelling in hands and feet, bacterial infection, etc.  But if a person has Sickle Cell Trait, it means he or she carries or has inherited a single Sickle Cell gene. In general, people with Sickle Cell Trait enjoy normal life span with no medical problems.

10.    Thus, after due examination of the medical papers available on record and considering the facts, we are of the opinion that the deceased had, at the most, Sickle Cell Trait, which did not show any symptoms till few days before his death. There is no sufficient evidence to show the deceased had any medical emergency or required blood transfusion in the past. His problems surfaced just few days before his death. It was in July 2010 that he had visited his regular doctor with complaints of joints pain, anemia, loss of appetite, etc. that time he was advised to undergo few tests. It was only after the tests it was revealed he was suffering from Sickle Cell Anemia. People can live for years without knowing that they have Sickle Cell Trait. It is often discovered accidentally after medical checkup. As observed by the Chhattisgarh State Commission in LIC v/s Kanchan Thawait I (2015) CPJ 7 (Chha), the burden to prove that the insured has taken medical treatment within period of preceding 12 months and he fraudulently suppressed the same was on the insurer and mere production of medical certificates is insufficient. In this case also before his tests in July 2010 there is no medical history of him. Therefore it would be wrong to say that he was aware of this genetic problem but deliberately hide this fact from the O.P.1. As such repudiation of the claim by the O.P.1 must be held to be incorrect and therefore it is liable to be set aside. Hence the following order.

ORDER

1. The complaint is allowed against the O.P.1 only.
2. The O.P.1, IDBI Federal Life Insurance Company, is directed to pay a sum of Rs. 12,62,244/- with 9% p.a. interest from the date of the complaint to the complainant.
3. The O.P.1 shall also pay compensation of Rs. 15,000/- for physical and mental agony and litigation cost Rs. 3000/- to the complainant.
4. The order shall be complied within 60 days from the date of the order.
5. The complaint is dismissed against the O.P.2.
6. Copy of the order shall be given to all the parties, free  

of cost.