STATE CONSUMER DISPUTES REDRESSAL COMMISSION OF TELANGANA :

                                           At  HYDERABAD

                                           CC 164 of 2015

Between :

Smt. Padmavathi Chakilam,

w/o Chakilam Uma Shankar,

aged about 45 years, Indian,

Occ: Housewife, R/o 1-2-217/4/1,

Street No. 10, Dhomalguda,

Himayath nagar, Hyderabad – 500 029.                ..        Complainant

And

M/s. Bajaj Allianz Life Insurance Company Limited

Registered and head office : GE Plaza

Airport Road, Yerwada,

Pune – 411 006, Maharashtra,

Rep. by its Managing Director                      ..        opposite party

Counsel for the Complainant                       :         M/s. V. Gourisankara Rao

Counsel for the opposite Party                     :         M/s. G. Anand Kumar

Coram       :

Hon’ble Sri Justice B.N. Rao Nalla …      President

And

Sri PatilVithal Rao                        ..       Member

Monday, the Thirtieth Day of April

Two Thousand Eighteen

Oral order :         ( Per Hon’ble Sri Justice B.N.RaoNalla, Hon’ble President )

                                                  *****

1. This is a complaint  filed Under Section  17(1)(a)(i) of the Consumer Protection Act, 1986 by the complainant to direct the opposite party to pay the insured amount of Rs.90,00,000/- along with interest @ 12% pa from 01.04.2015 till the date of realization, to pay an amount  of Rs.5,00,000/- towards inconvenience, hardship and mental agony and costs of Rs.1,00,000/-.
2. For the sake of convenience, the parties are described as arrayed in the complaint
3. The case of the complainant   in brief, is that her husband, Uma Shankar Chakilam, during his life time was the Account holder of YES Bank Limited, which, got insurance tie-up with the opposite party Insurance company to cover insurance to  all its  account holders under Group Master Policy No. 0313402356.  The opposite party Insurance company issued a certificate of insurance to her husband for the assured sum of Rs.30,00,000/- on payment of annual premium amount of Rs.22,403/- for the period from 20.03.2014 to 19.03.2015 vide application No. 5925459802 & Membership No. GTLN 089207588   and another policy for the assured sum of Rs.60,00,000/- on payment of annual premium amount of Rs.44,804/- for the period from 20.03.2014 to 19.03.2015 vide Application No. 5925459804 & Membership No. GTLN 089207587.  Her husband was admitted in Indo-US Super Specialty Hospital on 04.11.2014 with the complaint of shortness of breath associated with profuse sweating and abdominal pain. In spite of the best treatment given, he expired on 5.11.2014 in the said hospital at 10.25 AM. As per the Death summary he was suffering from sepsis with severe metabolic acidosis, Acute renal failure, Cardiopulmonary arrest, Atrial Fibrillation and Diabetes.  The two claims submitted by her were repudiated on the ground that her husband suppressed about the elevated fasting blood sugar values dated 20.09.2013 and 09.10.2013 ( pre-proposal)  in the proposal form. In fact, her husband was suffering from diabetes subsequent to taking of the policy. She got issued  common legal notice dated 28.04.2015 to the opposite party as well as the Claims Review Committee, but, the opposite party did not give any reply. She got the insurance claim amount of Rs.49,00,000/- under Bharti AXA Elite Secure Policy after death of her husband. There was no proof that the insured was suffering from pre-existing disease diabetes. Repudiation of the claims amount to deficiency in service and unfair trade practice. Hence the complaint.
4. The opposite party opposed the above complaint by way of written version, while admitting that the  husband of the complainant , Uma Shankar Chakilam, during his life time was the Account holder of YES Bank Limited, which, got insurance tie-up with the opposite party Insurance company to cover insurance to  all its  account holders under Group Master Policy No. 0313402356 and the husband of the complainant took two policies in question for an amount of Rs.30,00,000/- and another for an amount of Rs.60,00,000/-, contending that after receipt of the death claim during their investigation they found that the Life assured was suffering from Diabetes Mellitus : Elevated  Fasting Blood Sugar Values dated 20.09.2013 to 09.10.2013 prior to making the proposal dated 10.04.2014.  The deceased life assured was under an obligation to mention the actual illness or disease in the proposal form at the time of applying for the insurance policy. As per the Death summary he was suffering from sepsis with severe metabolic acidosis, acute renal failure, cardiopulmonary arrest, Atrial Fibrillation, DC Cardio version, and Diabetes for four years and he suppressed the Diabetes Millets in the proposal form.  The Life assured died within 6 months 24 days from the date of availing the said two policies in question. As per Section 45 of the Insurance Act, Policy not to be called in question on ground of mis-statement after two years.The investigation reports clearly establish that the policy was obtained by suppressing material facts and also by fraudulent manner, the policy was obtained only with malafide motive and in such circumstances they have repudiated the claim, there is no deficiency in service on their part and hence prayed to dismiss the complaint.
5. During the course of enquiry, in order to prove her  case, the complainant  filed her  evidence affidavit and got marked Ex. A1 to A-10  and on behalf of the opposite party filed the evidence affidavit and got marked Ex. B-1 to  B-11.
6. .Counsel for the complainant and the opposite party   had advanced  their arguments reiterating the contents of complaint, written statement , affidavit evidence in addition to filing of written arguments.
7. The points that arises for consideration are
   1.  
2.  
8. POINT NO. 1:

There is no dispute that the husband of the complainant , Uma Shankar Chakilam, during his life time was the Account holder of YES Bank Limited, which, got insurance tie-up with the opposite party Insurance company to cover insurance to  all its  account holders under Group Master Policy No. 0313402356 and the husband of the complainant took two policies in question for an amount of Rs.30,00,000/- and another for an amount of Rs.60,00,000/- through the YES Bank from the opposite party.  There is no dispute that the complainant obtained two policies on 10.04.2014. There is no dispute that the claims submitted by the complainant were repudiated on the ground of suppression of material fact, i.e, the deceased life assured suppressed that he was suffering from Diabetes Miletus at the time of submission of proposal form.

9.       The contention of the complainant is that her husband was admitted in Indo-US Super Specialty Hospital on 04.11.2014  with the complaint of Shortness of breath associated with profuse sweating and abdominal pain and died on  05.11.2014 due to sepsis with severe metabolic acidosis, Acute renal failure, Cardiopulmonary arrest, Atrial Fibrillation and Diabetes vide Ex. A7. Further, it is false to allege that the husband of the complaint was suffering from diabetes ever prior to the proposal dt. 10. 04.2014.

10).    On the other hand, the opposite party rebutted the same contending that during their investigation they found that the Life assured was suffering from Diabetes Mellitus for four years prior to  the proposal form  dated 10.04.2014 and the deceased life assured suppressed the same in the proposal form and hence they have repudiated the claims.

11).    Counsel for the complainant further argued that there was no nexus between diabetes and sudden breathlessness and cardiopulmonary arrest. Even in the claimant statement, the doctor never categorically stated that the Diabetes was existed prior to one year, it was, mentioned only about one year.  Absolutely, there was no contemporaneous evidence, such as, Medical prescriptions, investigation reports, Medical bills, case sheet, discharge summary, the affidavit of the treating doctor etc to establish that the insured was suffering from pre-existing diabetes. As such, the repudiation of the claim is unjust and unreasonable.

12.     The point that is to be considered is, whether the husband of the complainant/deceased life assured suppressed the disease of Diabetes Mellitus at the time of submission of proposal form.

13).    We have perused Ex. B5, Discharge Summary of Indo-US Super Speciality Hospital, reveals that the deceased was diagnosed for Coronary artery disease – Unstable angina with complaints of chest pain and 2 episodes of vomiting. Therein, it is mentioned that it is a known case of  DM and the patient was conservatively managed on anticoagulants, antacids, antiemetic and insulins. Now, the patient is hem dynamically stable and is being discharged on further medical management. Along with Tab. PAN 40 mg, Inj. Human Insulin Nova was prescribed. Again, the husband of the complainant had  joined the Indo-US Super speciality Hospital on 04.11.2014 and  died on 05.11.2014 and he was  diagnosed as, Sepsis with severe metabolic acidosis, cardiopulmonary arrest, Atrial fibrillation – DC cardio-version and Diabetes Mellitus since one year. Patient came with shortness of breath since morning on 04.11.14 associated with profuse sweating and abdominal pain vides Ex.B-6.

(i)       The first cause of death is sepsis with severe metabolic acidosis.  Sepsis means presence of micro-organisms in tissue. Metabolic Acidosis means abnormal increase in blood acidity – a failure of the mechanism that controls the acidity of the blood, other body fluids, or body tissues, commonly caused by untreated diabetes. We have to go through the literature in this connection.

What is acidosis?

When your body fluids contain too much acid, it’s known as acidosis. Acidosis occurs when your kidneys and lungs can’t keep your body’s pH in balance. Many of the body’s processes produce acid. Your 

The acidity of your blood is measured by determining its pH. A lower pH means that your blood is more acidic, while a higher pH means that your blood is more basic. The pH of your blood should be around 7.4. According to the American Association for Clinical Chemistry (AACC), acidosis is characterized by a pH of 7.35 or lower. 

Metabolic acidosis

Metabolic acidosis starts in the kidneys instead of the lungs. It occurs when they can’t eliminate enough acid or when they get rid of too much base. There are four  major forms of metabolic acidosis:

•  occurs in people with 
• Hyperchloremic acidosis results from a loss of sodium bicarbonate. This base helps to keep the blood neutral. Both 
• Lactic acidosis occurs when there’s too much lactic acid in your body. Causes can include chronic alcohol use, , , , and . Even prolonged exercise can lead to lactic acid buildup.
• Renal tubular acidosis occurs when the kidneys are unable to excrete acids into the urine. This causes the blood to become acidic.

Symptoms of acidosis

Both respiratory and metabolic acidosis share many symptoms. However, the symptoms of acidosis vary based on its cause.

Respiratory acidosis

Some of the common symptoms of respiratory acidosis include the following:

•  occurs when too much CO2 builds up in the body. Normally, the lungs remove CO2 while you breathe. However, sometimes your body can’t get rid of enough CO2. This may happen due to:

  • chronic airway conditions, like 
  • sedative misuse
  •  in the chest
  • problems with the 
  • deformed chest structure

  Metabolic acidosis

  Some of the common symptoms of metabolic acidosis include the following:

  • confusion
  • fatigue
  • headache
  • sleepiness
  • lack of appetite
  • breath that smells fruity, which is a sign of diabetic acidosis        (ketoacidosis)

  What are the symptoms of diabetic ketoacidosis?

  Symptoms of DKA can appear quickly and may include:

  • frequent urination
  • extreme thirst
  • high blood sugar levels
  • high levels of ketones in the urine
  • nausea or vomiting
  • abdominal pain
  • confusion
  • fruity-smelling breath
  • a flushed face
  • fatigue
  • rapid breathing
  • dry mouth and skin

  Risk factors

  Factors that can contribute to your risk of acidosis include:

  • a high-fat diet that’s 
  • obesity

  • 14).   After considering all the foregoing facts and circumstances and also having regard to the contentions raised on behalf of the complainant and opposite party,  this Commission is of the view that there are no merits in the complaint and hence it is liable to be dismissed.

     

     

     

    POINT NO. 2:

    15.  In the result, the complaint is dismissed, but, in the circumstances, there shall be  no order as to costs.

     

                                                                          PRESIDENT                     MEMBER

     

                                                                                    DATED : 30.04.2018.

     

     

    APPENDIX OF EVIDENCE

                                               DOCUMENTS MARKED

    FOR COMPLAINANT                      :

    Ex.A-1:        Certificate of Insurance with App. No. 5925459802

    Ex.A-2:       Repudiation Letter dated 31.03.2015 of ID No. 5925459802

    Ex.A-3:        Certificate of Insurance with App. No. 5925459804.

    Ex.A-4:        Repudiation Letter dated 31.03.2015 of ID No. 5925459804

    Ex.A-5:        Claimant statement dt. 08.12.2014.

    Ex.A-6:        Representation  dt. Nil.

    Ex.A-7:        Death Summary dt. 05.11.2014.

    Ex.A-8:        Death Certificate dt. 15.11.2014.

    Ex.A-9:        Bharti AXA Life Elite Insurance Policy.

    Ex.A-10:      Legal notice dt. 28.04.2015.

    FOR OPPOSITE PARTY :

    Ex.B-1:        proposal Form for the assured sum of Rs.30,00,000/-

    Ex.B-2:        proposal Form for the assured sum of Rs.60,00,000/-

    Ex.B-3:        Certificate of Insurance Appl. No. 5925459802

    Ex.B-4:        Certificate of Insurance Appl. No. 5925459804

    Ex.B-5:        Discharge summary of Indo US Super specialty Hospital,  dt. Of

                        Admn dt. 11.10.2014.

    Ex.B-6:        Death Summary from Indo Indo US Super specialty  dt. Of

                        Admn dt. 04.11.2014, date fodeath 05.11.2014.

    Ex.,B7:        Death Certificate  of Life assured

    Ex.B8:         Repudiation of claim vide letter  dt. 31.03.2015 ID No.                                           5925459802

    Ex.B9:         Repudiation of claim vide letter  dt. 31.03.2015 ID No.                                           5925459804

    Ex.B10:       Clinical Bio Chemistry Report dt. 20.08.2013.

    Ex.B11:       Clinical Bio Chemistry Report dt. 09.10.2013.

     

     

     

                                                                          PRESIDENT                     MEMBER

                                                                                              DATED :30.04.2018.