Date of Filing:17.04.2009<br /> Date of Order: 09.11.2009<br /> <br /> <br /> <br /> BEFORE THE II ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE-20<br /> <br /> Dated: 9TH DAY OF NOVEMBER 2009<br /> <br /> PRESENT<br /> <br /> <br /> <br /> Sri S.S. NAGARALE, B.A, LL.B. (SPL.), President.<br /> Smt. D. LEELAVATHI, M.A.LL.B, Member.<br /> Sri BALAKRISHNA. V. MASALI, B.A, LL.B. (SPL.), Member.<br /> COMPLAINT NO: 880 OF 2009<br /> <br /> Lakshmidevi<br /> W/o. Late H. Ranganath<br /> R/at Marasandra Village<br /> Kanasawadi Post, Doddaballapura Taluk<br /> Bangalore Rural District<br /> <br /> Presently at<br /> C/o. L. Kumar<br /> No. 839/2, ‘Sharada Nilaya’<br /> S.R.S. Road, Peenya I Stage<br /> Peenya, Bangalore 560058 Complainant<br /> V/S<br /> M/s. Bajaj Alliance Life Insurance<br /> Co. Ltd., 2nd Floor<br /> Akshaya Commercial Complex<br /> No. 26, Victoria Road<br /> Bangalore 560047<br /> Represented by its Manager<br /> Bangalore Branch Opposite Party<br /> <br /> ORDER<br /> By the President Sri. S.S. Nagarale<br /> <br /> This is a complaint filed under section 12 of the Consumer Protection Act.<br /> The facts of the case are that complainant’s husband H. Ranganath had obtained policy with the opposite party by paying Rs. 10,000/-. Sum assured is Rs. 1,35,000/-. Complainant’s husband died on 02.11.2008 due to Hepatic failure. He was at no point of time suffered any type of disease. All of a sudden he developed hepatic problem and due to that he died. There is no violation of conditions of policy. The complainant requested the company to release the death benefit of her husband. The opposite party issued a letter on 27.01.2009 rejecting the claim. There was deficiency of service on the part of opposite party. Complainant got issued legal notice and demanded policy amount. Opposite party neglected to settle the claim. Therefore, the complainant has filed this complaint for getting justice. <br /> 2. After admitting the complaint notice issued to opposite party. Opposite party put in his appearance through advocate and defence version filed taking defence that the deceased H. Ranganath though obtained the policy bearing No. 103003658, the terms and conditions of the said policy is that the policy holder has to pay the premium of Rs. 10,000/- each for a period of 27 years and the maturity period of policy is after 27 years, from the date of issuance of policy i.e. from 15.07.2008, the said policy was issued subject to the material facts disclosed in the proposal form it should be true and correct but, the policy holder H. Ranganath has not disclosed the actual ailments which is already suffering and he intentionally avoided and cancelled the very important material fact that he was already suffering from Diabetes Mellitus Type – II / Hepatic failure which he was suffering for the past 2 years and he is taking regular medical treatment for the said disease and fully knowing well about this material aspect and intentionally avoided to disclose the same in the proposal form and subsequently he died due to the Diabetes Mellitus Type – II / Hepatic Failure this disease is not developed all of a sudden i.e. after obtaining the policy, hence the policy holder has intentionally not disclosed the material fact and fraudulently obtained the policy to get the benefit, hence this opposite party has rightly repudiated the policy for the breach of terms and conditions of the policy. The opposite party has taken defence that the policy holder has not disclosed the pre-existing disease and ailments and about his present health condition and treatment. Therefore, he has given false declaration about his health in the proposal form to make it believe by the opposite party to issue policy. Hence, the opposite party has repudiated the claim under the policy and complainant is not entitled for any compensation. Therefore, opposite party requested to dismiss the complaint.<br /> 3. Complainant has filed her affidavit evidence. On behalf of opposite party Mr. Vinod, Assistant Branch Supervisor has filed his affidavit evidence.<br /> 4. Arguments are heard.<br /> 5. The points for consideration are:<br /> 1. Whether the complainant has proved deficiency of service on the part of opposite party?<br /> 2. Whether the repudiation of the claim by the opposite party is justified?<br /> 3. Whether the complainant is entitled for the claim amount?<br /> 6. It is admitted case of the parties that the husband of the complainant Mr. Ranganath has taken Bajaj Alliance Life Insurance policy. The date of commencement of risk of policy was from 15.07.2008. The policy term was 27 years. The premium amount was Rs. 10,000/-. The sum assured is Rs. 1,35,000/-. The present complainant Lakshmidevi is the nominee under the policy and she is wife of assured. Unfortunately, the assured Ranganath admitted to the Nayak Hospital, Bangalore on 30.10.2008 and he died in the hospital on 02.11.2008. As per the certificate of Nayak Hospital Ranganath died on 02.11.2008 at 9 p.m. due to Hepatic failure. Death certificate of Ranganath is also produced. After death of Ranganath his widow requested the opposite party to settle the death benefit of her husband under the policy and requested to release Rs. 1,35,000/- as per the terms and conditions of the policy. But the opposite party rejected the claim of the complainant vide letter dated 27.01.2009 on the ground that deceased was under treatment for diabetes mellitus type II since one year and this fact was also disclosed in the proposal form dated 02.07.2008. Hence, claim has been repudiated due to non-disclosure of material facts. The opposite party relying on the death summary issued by the Nayak Hospital, Bangalore repudiated the claim. Admittedly, deceased Ranganath was first time admitted to Nayak Hospital on 30.10.2008 and he died on 2.11.2008 in the hospital. There are no hospital records or any other documents to show that Ranganath had admitted to hospital at any time before 30.10.2008. The opposite party has not produced any medical documents or records or any hospital certificate to show that deceased had taken treatment for his disease before taking the policy. The death summary of Nayak Hospital that deceased was suffering from diabetes mellitus Type II and for that he was admitted in the hospital and during the course of stay in hospital and treatment the patient developed Hypo tension. CPR was started and necessary drugs were given, condition not improved and ultimately, patient declared died. Nayak Hospital has no basis to issue death summary stating that deceased was under treatment for one year because admittedly, for the first time deceased was admitted to the Nayak Hospital on 30.10.2008. Earlier to that date deceased never admitted under the Nayak Hospital or any other hospital. Therefore, it is clear that the deceased though might be suffering from diabetes but he was not aware of the said disease before admitting to the Nayak Hospital on 30.10.2008, the opposite party has to establish and prove the fact that the assured was having knowledge of the disease and intentionally suppressed the fact while taking the policy. Diabetes is a disorder. Even it will not be considered as disease. The person may not be knowing that he had a diabetes disorder and he may lead a very normal life like any other healthy person. He will come to know having diabetic disorder only on admitting to hospital and on blood test. So under these circumstances there is no occasion for the deceased Ranganath to know the fact that he was having diabetic disorder. Admittedly, deceased has not admitted to any other hospital and no records have been produced by the opposite party to establish the fact that deceased was aware of the diabetic disorder at the time of taking policy. In the policy form at clause 14 it has been asked “Have you ever been treated or currently under treatment for any of the following conditions:”. From (a) to (m) diseases and injuries have been stated. By going through all the diseases from (a) to (m) under clause 14 there is no question in respect of diabetes. Therefore, when there is no question in respect of having disorder of diabetes mellitus in the questionnaire under clause 14 of the policy the question of suppressing of disease by the assured does not arise at all. The claim of the complainant under the policy has been illegally repudiated by the opposite party company. The opposite party has to establish and prove under section 45 of the Insurance Act 1938 that the assured suppressed the facts which it was material to disclose and that it was fraudulently made by the policy holder and that the policy holder knew at the time of making it that statement was false. But in this case none of these things have been established or proved by the opposite party. The opposite party before issuing policy might have obtained the medical officer’s certificate or report in respect of health condition of the assured. The report of the medical officer had not been produced by the opposite party. Taking into consideration of all the documents and the evidence produced by both parties, the opposite party in this case not proved that the assured had suppressed the material fact while taking policy. Therefore, the repudiation of the claim is not justified. The complainant being the widow of deceased and she is also nominee under the policy is entitled for the claim amount. The opposite party submitted investigation report. In that report it is stated the life assured was a ticket collector in a temple and was earning salary of Rs. 1,500/- p.m. and the family had been facing financial problems as their house fell down. In this investigation report also it is clearly stated that the assured for the first time admitted in the Nayak Hospital, Gayathrinagar, Bangalore on 30.10.2008 and he was diagnosed to be suffering from Hepatic failure and he was given treatment in hospital for 3 days, but did not respond to the treatment and died on 02.11.2008 at 11.00 p.m. When this is the investigation report where is the proof or any documentary evidence to show that deceased had taken treatment in the hospital before taking the policy. Even in the investigation report also nothing has been investigated or found that the diseased was having knowledge of the ailment and he had intentionally and purposefully withheld the material fact at the time of taking policy. The investigator appointed by the opposite party has not found any record or document to show that deceased had taken treatment in any other hospital before he was admitted to Nayak Hospital on 30.10.2008. So under these circumstances the repudiation of the claim by the opposite party is not at all justified. The repudiation of the claim put up by the complainant amounts to deficiency in service on the part of opposite party. Therefore, the complaint is liable to be allowed. In the result I proceed to pass the following:<br /> ORDER<br /> 7. The complaint is allowed. The opposite party is directed to pay Rs. 1,35,000/- the death benefit to the complainant within four weeks from the date of this order. In the event of non-compliance of the claim amount within four weeks the said amount carries interest at 9% p.a. from the date of this complaint till payment / realization.<br /> 8. The complainant is also entitled for Rs. 1,000/- as costs of the present proceedings from the opposite party.<br /> 9. Send the copy of this Order to both the parties free of costs immediately. <br /> 10. Pronounced in the Open Forum on this 9TH DAY OF NOVEMBER 2009. <br /> Order accordingly,<br /> <br /> PRESIDENT<br /> We concur the above findings.<br /> <br /> MEMBER MEMBER<br /> <br />