BEFORE THE A.P STATE CONSUMER DISPUTES REDRESSAL COMMISSION AT HYDERABAD.
FA 1084 of 2011 against CC 150/2008, Dist. Forum, Srikakulam
Between:
1) The Branch Manager
SBI Life Insurance Company Ltd.
Near Krishna Park,
Srikakulam Town & Dist.
2) The Branch Manager
SBI Life Insurance
Servicing Branch Office
104, Dwaraka Plaza
Opp: SBI, Dwaraka Nagar
Visakapatnam.
3) SBI Life Insurance Company Ltd.
CPC Plot No. 3A,
Section-10, CBD Belapur
Navi Mumbai. *** Appellants/
Ops
And
Paidishetti Gopi
R/o. Post Office Street
Sompeta, Srikakulam *** Respondent/
Complainant
Counsel for the Appellant : M/s. Gosala Srinivasa Rao
Counsel for the Respondent : M/s. A. Rama Rao.
CORAM:
SMT. M. SHREESHA, PRESIDING MEMBER
&
SRI S. BHUJANGA RAO, MEMBER
THURSDAY, THE TWENTY FIRST DAY OF MARCH TWO THOUSAND THIRTEEN
ORAL ORDER: (Per Smt. M. Shreesha, Member)
***
1) Aggrieved by the order in CC No. 150/2008 on the file of District Forum, Srikakulam the Opposite Party insurance company preferred this appeal u/s 15 of the Consumer Protection Act.
2) The brief facts as set out in the complaint are that his mother Smt. Paidisetti Padma obtained SBI Life Insurance Policy for a sum of Rs. 1,20,000/- commencing from 10.10.2006 to 10.10.2011 keeping the complainant as nominee. While so, his mother died on 3.12.2006 and the said fact was intimated to the insurance company. In spite of submission of claim form along with relevant documents the insurance company sent an amount of Rs. 19,250/- instead of Rs. 1,20,000/- being the sum assured under the policy. The complainant got issued a legal notice and the insurance company sent an evasive reply. Hence this complaint seeking for a direction to pay the amount covered under the policy with interest, compensation and costs.
3) The appellant/opposite party insurance company filed written version contending that the policy was issued for an amount of Rs. 1,20,000/- commencing from 10.10.2006 based on the proposal submitted by the policyholder under non-medical scheme. As the claim was made within one month and 23 days stating that the assured died on 3.12.2006 it being an early claim, they investigated into the matter which revealed that she was suffering from diabetes mellitus, congestive heart failure, rheumatic heart disease and Epilepsy prior to submission of the proposal form. She did not disclose all these pre-existing diseases at the time of taking of the policy. They contended that Dr. D. Santhi Sree, family doctor of the deceased has given a medical certificate stating that she was diagnosed for MS/MR congestive heart failure (CHF), diabetes mellitus and Epilepsy on 5.6.2003 and was on treatment for more than three years which is prior to the commencement of the policy. However, the assured had replied in ‘Negative’ for the questions relating to her health in the proposal form. In view of suppression of material fact relating to her pre-existing diseases at the time of taking the policy, the insurance company was justified in repudiating the claim. Therefore it prayed for dismissal of the complaint with costs.
4) Based on the evidence adduced i.e., Exs. A1 to A8 and Ex. B1 to B3 and the pleadings put forwarded the Dist. Forum allowed the complaint directing the insurance company to pay Rs. 1,00,750/- with interest @ 9% p.a., from the date of complaint till the date of realization together with costs of Rs. 1,000/-.
5) Aggrieved by the said order the opposite party insurance company preferred this appeal.
6) It is the appellant/Ops case that the policy was issued for a sum of Rs. 1,20,000/- commencing from 10.10.2006 and that the life assured died on 3.12.2006 within 1 month 23 days and their investigation revealed that she was suffering from diabetes mellitus, congestive heart failure, rheumatic heart disease and Epilepsy prior to submission of the proposal form. She did not disclose the same at the time of filling of the proposal form. They justified their repudiation on the ground that the medical certificate of the family doctor reveals that the patient was suffering from diabetes mellitus, congestive heart failure, rheumatic heart disease and Epilepsy since June, 2003 prior to issuance of the policy.
7) The learned counsel for the appellant relied on the decision of the Hon’ble Supreme Court in Satwant Kaur Sandhu Vs. New India Assurance Company Ltd. in Civil Appeal No. 2776 of 2001 in which the Apex Court held that “the reliance can be placed on the noting made by a doctor in the medical record even though the hospital may not have treated the patient in the past and the non-examination of the doctor on oath does not invalidate the evidence placed on record.” It is the case of the complainant that the affidavit of the doctor was not filed and that it is a photostat copy of the medical certificate wherein the age of the patient is not mentioned and that the signature of Dr. Shanti Sree is also not present on the certificate filed by the Op.
8) It is pertinent to note that the medical certificate issued by Dr. Shanti Sree dt. 5.3.2007 (Annexure-E) reads as follows :
“This is to certify that I know Mrs. Paidishetty Padmavathy for the past four years as my patient. She was diagnosed as having chronic Rheumatic Heart Disease with MS, MR, CHF. Non-insulin dependent diabetes mellitus and also epilepsy since 5.6.2003. She had been on medical treatment for the above problems since June, 2003.”
This certificate read along with Annexure-D which is also a certificate given by Dr. Shanti Sree shows that the patient was suffering from CHF, diabetes mellitus and epilepsy from 5.6.2003 and was under treatment for 3-1/2 years. The doctor who issued the certificate is a Civil Asst. Surgeon in Govt. Dispensary, Sompeta, Srikakula.
9) Keeping in view the aforementioned judgment of the Hon’ble Supreme Court and along with medical record, we are of the considered view that the policyholder was suffering from the above diseases since 2003 and had suppressed the same prior to taking of the policy and Ex. B1 is the proposal form and in Col. 11 with respect to heart disease and nervous system/stroke she had clearly stated “No” Even in Col. 10 with respect to diabetes her answer was “No”. The contention of the complainant that Annexure-D certificate was not signed by the doctor is unsustainable as the name and stamp of the doctor is present and this document read along with Annexure-E which is the certificate issued by the same doctor shows that it was signed by the same doctor stating the same diseases for which the patient was taking treatment from June, 2003 onwards. This material on record clearly establishes that the assured did not disclose these diseases in the proposal. The appellant insurance company established that the deceased suppressed her pre-existing diseases before taking the policy.
10) The Hon’ble Supreme Court in P. C. Chacko Vs. Chairman, LIC of India reported in III (2008) CPJ 78 (SC) 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.”
In the light of medical record filed by the appellant and in the light of aforementioned judgement of the Apex Court, we are of the considered view that this appeal is liable to be allowed.
11) In the result the appeal is allowed and order of the Dist. Forum is set-aside. Consequently the complaint is dismissed. No costs.
1) _______________________________
PRESIDING MEMBER
2) ________________________________
MEMBER
21/03/2013
*pnr
UP LOAD – O.K.
