FA 878/2008 in CC No.236/2007  on the file of the District Forum II, Hyderabad

Between :

G. Sharadha, W/o Late G. Koteswara Rao,

Aged about 48 years, Occ: housewife

R/o 1-3-931, Balaji Mansion,

Kavdiguda, Hyderabad                                  .. Appellant/complainant

And

1.                  Branch Manager, LIC of India,

1^st floor, APHB building,

Rep. by its Branch Manager,

Tuljaguda complex, M. J. Market,

Hyderabad.

2.                  LIC of India, The Zonal Manager,

S. C. Zonal Office, Secretariat Road,

Hyderabad – 500 063.                .. Respondents/Opp. Parties.

Counsel for the Appellant            :           M/s. N. Ramappa

Counsel for the Respondents    :           Dr. G. Shyamala

Coram           ;           Sri Syed Abdullah              …        Hon’ble Member

And

Sri R. Lakshminarasimha Rao…      Hon’ble Member

Friday, the Sixteenth Day of July, Two Thousand Ten

Oral Order     : ( As per Sri Syed Abdullah,  Hon’ble Member )

*******

Being aggrieved by the order dated  5^th July, 2007 passed  in C.C 236/2007 dismissing the insurance claim, this appeal is filed questioning the propriety and legality of the order.

The facts of the case disclose that the complainant’s husband had taken an insurance policy from the opposite party  in April, 2005 and it expired in August, 2005. when the complainant applied for insurance claim, the opposite party repudiated the same stating that the complainant’s husband suppressed the facts at the time of applying for the policy. The act or omission on the part of the opposite parties is  attributed as deficiency in service.

The version of the opposite parties is that the complainant’s husband had undergone major surgery in the year 1997 for his ailment for Low Back Pain in Apollo Hospitals and subsequently in the year 2005 he obtained an insurance policy by suppressing about his health and surgery.  Within four months after obtaining  the policy,  he expired in Care Hospital due to Brain Stem Bleeding. As there is suppression of material facts, the opposite parties repudiated the claim.

During enquiry, both the complainant and the opposite parties have filed Ex. A-1 to A6 and B-1 to B-8 along with affidavits respectively for consideration.

The District Forum, after going through the factual aspects and evidence on record, had taken the  view that the insured while furnishing information in the proposal form had suppressed material facts  of his previous ailment prior to the date of taking the policy and since the death is directly related to his previous ailment, it amounts to suppression of material facts, as such, the opposite parties are justified in repudiating the claim.

 The stand taken by the opposite parties in repudiating the claim is also supported by relying on the decisions of the National Commission reported in

(1)               Life Insurance Corporation of India Vs. Minu Kalita

III (2002) CPJ 10 (NC)

(2)               Sr. Divisional Manager, LIC of India Vs. Smt. Gangama

III (2002) CPJ 56 = 2002(3) CPR 24 (NC).

(3)               Smt B. Jayamma Vs. Sr. Branch Manager, LIC and others

(NCDRC) page 529.

The strong hold contention of the appellant/complainant is that the District Forum failed to take into consideration that the panel doctor of the Insurance Company who after examining him at the time of taking policy had recommended for issuance of policy, as such, the opposite party is estopped from it and there is no justification in repudiating the claim.

Points for consideration are,

(1)                                       whether the impugned order suffers from any factual and            legal infirmity in repudiating the claim ?

(2)                                       whether the opposite parties justified in repudiating the insurance claim ?

The facts are not in dispute about the issuance of the policy in favour of G. Koteswara rao and at the time of insurance policy, the insured had submitted a proposal form  mentioning the details of his health and previous ailments etc. Ex. B-8 is the copy of the proposal form which contains certain clauses.  Clause 11 relates to personal history of the insured person. This clause requires the insured person to furnish about his health condition and previous treatment taken by him.  Sub clause (a) requires during the last five years whether the insured had consulted any medical practitioner for any ailment requiring treatment for more than a week ?  which was answered as “ No”.  Similarly, next clause (b), requires, whether he was admitted in any hospital or Nursing Home for general check-up. Observation, treatment or operation ?  which was answered as  “No”.  similarly, the other details which are required were also answered as “ No” .  To contradict this information in detail, the opposite party had produced medical records of Apollo Hospitals and Care Hospitals covering  the period right from  08.07.97 to 12.7.97 and 1.8.2005 to 08.08.2005 respectively.  Ex. B-4 is the record of the Apollo Hospitals and the discharge summary given to the complainant’s husband, by name, G. Koteswara Rao for the treatment undergone by him  for the ailment ‘Spondylolisthesis’ L5 over S1.  Discharge Summary which disclose that the patient was operated for ‘ Posterior LT  Fusion  L5 over S1 DONE - 9.7.97.  It is also mentioned that the patient has history of Diabetes Mellitus of 10 years and on insulin since two years. So at the time of  discharge, he was advised to have diabetic treatment as advised by the specialists for which necessary drugs are prescribed.   Policy was taken in April, 05. while so,  the insured was admitted in the Care Hospital on 01.08.2005 in a critical condition  in Neurology I.C. Ward.  In Ex. B-6 discharge summary it is noted that the patient G. Koteswara Rao aged 52 years, Male,  presented with sudden loss of consciousness at 11 PMon 31.7.2005.  on being brought to hospital, was in deeply comatosed state, on ventilatory support with BP 210/120 mm Hg. Immediate CT scan showed brain stem bleed.   Patient was given necessary injection.  Patient’s relative decided to take him home on request.  So the patient was discharged on 08.08.2005.  As per the complaint, the insured died on 08.08.2005 itself after discharge  Undisputedly, there is a clear cut suppression of material facts while obtaining policy which has been established by the opposite party/insurance company by producing necessary cogent and satisfactory documentary evidence.  It is settled law that in case of suppression of material facts, the insurance company is justified  in repudiating the claim.  There is no flaw or infirmity in the findings arrived at by the District Forum in dismissing the claim.

In the result, the appeal is dismissed confirming the order dated 05.07.2007 passed by  the District Forum II, Hyderabad in CC 236/2007 as justified. No order as to costs in the appeal. 

Sd/-MEMBER

                                                                                                                                                      Sd/-MEMBER

                                                                                                                                                      DATED :       16.07.2010.