BEFORE THE KARNATAKA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BENGALURU (ADDL. BENCH)

DATED THIS THE 04^th DAY OF MAY 2023

PRESENT

MR. RAVISHANKAR                        : JUDICIAL MEMBER

MRS. SUNITA CHANNABASAPPA BAGEWADI :         MEMBER

APPEAL NO. 47/2015

V/s

O R D E R

BY SMT. SUNITA .C.BAGEWADI, MEMBER

This appeal is filed by the appellants/Opposite parties being aggrieved by the order dated 27.11.2014 passed in CC.No.73/2011 on the file of District Consumer Disputes Redressal Commission, Udupi and prays to set-aside the order and to allow the appeal in the interest of justice and equity.

2.     The brief facts of the case are as under:

        The Complainant submits that as she is residing out of India i.e. in Michingan, United States of America and accordingly she is represented by her General Power of Attorney Holder in this complaint through Sri. K. Laxmikanth Shenoy dated 14.03.2011 and further submits that her daughter Late Pooja Arora had taken 2 Life Insurance Policies bearing Nos.622513777 and 62489017 for Rs.5 lakhs each with Opposite Party NO.2 and that the said Pooja Arora had nominated the Complainant/ her mother as nominee for the said policies and that she died on 06.06.2008 at Berrien, United States of America.

3.     That the Complainant submits that after the death of her above said daughter, the Complainant requested Opposite Party’s to settle her claim in respect of the said policies and in that behalf she had submitted necessary documents for compliance thereof which was also acknowledged by Opposite Party No.2 and Opposite Party No.2 was good enough to settle her claim un respect of policy No.622513777 without raising any objections whatsoever after thoroughly investigation Complainant’s claim. The Complainant submits that surprisingly in respect of another unsettled policy No.624890117 for Rs.5 lakhs unfortunately the Opposite arty No.1 under latter dated 22.09.2010 repudiated Complainant’s claim on flimsy and untenable grounds contending that the Complainant’s daughter Pooja Arora in her proposal for Assurance dated 22.07.2006 had answered falsely and that they have evidence and reason to believe that Complainant daughter Pooja Arora had been suffering from systematic Lupus Erythenatosus and was on follow up and that she was also a known case of CRF, Lupus Nephritis and Hypertensive since 6 years and that she did not however disclose these facts in her proposal.  It is evident from the records that Complainant’s daughter was keeping good health and was not suffering from any serious health problems either during the submission of proposal to Opposite Party or issuance policy by Opposite Party and also before hospitalization and subsequently till death of Complainant’s daughter.  That it may be noted that when Opposite Party’s have never raised any objection while settlement of earlier claim in respect of policy No. 622513777.  Accordingly, the Complainant through her GPA Holder above said issued lawyers registered notice dated 24.03.2001 to the Opposite Parties which was served on them.  That in reply the Opposite Party No.1 informed under letter dated 28.03.2011 that the file is forwarded to their Zonal Office, Hyderabad and the same will be reviewed by the Claims Review Committee at their end and will revert to the subject on hearing from them. But however till date even after lapse of more than 5 months the Complainant has not relieved any reply which is also amounts to another act of deficiency of service on the part of the Opposite Parties.

4.     After service of notice to the Opposite Parties by  R. P. A. D., Opposite Parties No.1 and 2 have appeared through their counsel and Opposite Party No.1 filed version contending that complainant is false, frivolous and vexatious to the own knowledge of the Complainant and the same is not maintainable in law and on merits.   The Opposite Party No.1 while admitting the “life assured” had taken a policies referred to in the complainant and this Opposite Party submits that they settled the claim under policy No.622513777 to the extent of Rs.5lakh sum assured with accrued bonus, as the claim arisen after 3 years from the date of commencement of policy as provided under Section 45 of the Insurance Act, 1938. The said policy was obtained with the date of commencement from 15.12.2003 and the death occurred on 06.06.2008.

5.     Opposite Party No.1  further contended that the other policy, viz. bearing No.624890117 was obtained with the date of commencement from 25.07.2006 has been treated as an early claim as the death occurred within 3 years from the date of commencement of policy as per their regular procedures.  On investigation it was revealed that the deceased life assured had been suffering from Systematic Lupus Erythematosus since 2002 and was on follow up treatment.  She was also known case of CRF, Lupus Nephritis and Hypertensive since 6 years.  These facts were stated by the deceased who was in medical profession (as a student) who knew very well about her own health.  She however did not disclose these facts in her proposal for obtaining the captioned policy. The deceased life assured had made deliberate mis-statement and with held correct information from the Opposite Party regarding her health, this Opposite Party had rightly repudiated the claim under the policy in question on 22.09.2010, in terms of policy contract and declaration contained in the Form of Proposal for Assurance.  For the first time that the life assured was being formally seen in Medicine Department of KMC Hospital, Manipal on 04.10.2007.  The discharge summary dated 23.05.2008 to 06.06.2008 obtained from aboard show the nexus between the cause of death and the treatment taken earlier to proposal for the captioned policy.  It is also can be seen from the Discharge assured had been diagnosed in the United States as having as SLE in 2002 and was on follow up there. She had the knowledge of her illness very well she had taken the above policies with a dishonest intention to defraud this Opposite Party and there is no question of any deficiency of service and also unfair trade practice as alleged on the part of this Opposite Party, as they have acted in lines with the terms and conditions of the policy contract.

6.     After trial the District Commission allowed the complaint and directed the Opposite Parties jointly and severally to pay the Complainant a sum of Rs.5,00,000/- towards sum assured with an interest @9% per annum from the date of repudiation till the date of payment and Rs.7,000/- and Rs.3,000/- towards compensation and litigation expense respectively.  The order shall be complied within 30 days from the date of order received.

7. Being aggrieved by the said order, the appellants/Opposite Parties have preferred this appeal on various grounds.

8. Heard arguments from the appellant. In spite of sufficient opportunities, the respondent not argued the matter.

9.     Perused the appeal memo, order passed by the District Commission and materials on record, we noticed that it is not in dispute that deceased life assured Miss. Pooja Arora, daughter of the complainant had taken 2 policies bearing No.622513777 and 624890117 of Rs.5,00,000/- each.  It is also not in dispute that life assured died on 06.06.2008 at Berrien, United State of America.  It is also not in dispute that claim in respect of policy No.622513777 was settled by the Insurance Company by paying an amount of Rs.5,00,000/- with accrued bonus to the complainant.

10.   The allegations of the Respondent is that, after death of her daughter appellant company has settled the claim in respect of policy No.622513777 which was not in dispute but, the complainant submitted the claim form in respect of policy No.624890117 to the appellant company along with all necessary documents, Appellant company has repudiated the claim of the respondent on the ground that daughter of the respondent suppressed the material facts of her illness while submitting the proposal form. 

11.   Perused the appeal memo, order passed by the District Commission we noticed that, the appellant company in appeal memo and version in lower court contended that after investigation it revealed that, the deceased life assured had been suffering from Systemic Lupus Erythematosus (SLE) since 2002 and was on follow up treatment and depending on two documents namely discharge summary of hospitalization dated 01.10.2007 and 06.10.2007 and discharge summary issued by the US hospital, Original Health Commission  medical record No.000452506 dated 06.06.2008 repudiate the claim of the respondent.   The discharge summary reveals that…Under Past History: A known case of SLE, CRF, lupus nephritis and Hypertension since 6 years.  However, the documents such as treatment report/diagnosis reports regarding the same were not produced by the appellant company to show that the deceased life assured was suffered SLE, CRF in 2002 and she was on follow up.  Appellant company has not produced proper documents and evidence to prove his contention  The documents produced by the appellant company which are in the year 2006 and 2008 which does not throw enough light to prove the deceased life assured has suffering from pre-existing disease.   If as per the discharge summary no previous records were available for perusal burden on appellant company to prove that the deceased life assured had suffered pre-existing disease before taking the policy and she has suppressed the material facts at the time of submitting the proposal form.  

12.   Morever, District Commission after perusal of the Medical examiner on confidential report examined by the appellant dated 23.07.2006 and 22.11.200, noticed that both does not speak pre-existing disease to the deceased life assurance. Hence, considering the facts and discussion made here, we are of the opinion that the order passed by the District Consumer Commission is just and proper. No interference is required. Accordingly, we proceed to pass the following:-

O R D E R

The appeal is hereby dismissed.  No order as to costs.

The amount in deposit shall be transmitted to the concerned District Consumer Commission to pay the same to the complainant.

Send a copy of this order to both parties as well as concerned District Consumer Commission.

     sd/-                                                       sd/-

MEMBER                                 JUDICIAL MEMBER

SP*