Haryana

StateCommission

A/51/2017

AVIVA LIFE INSURANCE CO. - Complainant(s)

Versus

NAMITA YADAV - Opp.Party(s)

NITESH SINGHI

01 Jul 2019

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                                                             

 

First Appeal No :   51 of 2017

Date of Institution: 16.01.2017

Date of Decision : 01.07.2019

 

 

 

1.      Aviva Life Insurance Company India Limited, Head Office: Aviva Towers, Opposite Golf Course, DLF Phase V, Sector 43, Gurgaon through its Director.

 

2.      Aviva Life Insurance Company India Limited, Registered Office, 2^nd Floor, Prakashdeep Building, 7^th, Tolstoy Marg, New Delhi-110001 through its Director.

                                      Appellants-Opposite Parties

 

Versus

 

 

 

 

Namita Yadav wife of late Sh. Mukesh Kumar, resident of S-248, Uppals Southend, Sohna Road, Sector 49, Gurgaon, Haryana.

 Respondent-Complainant

 

 

 

 

CORAM:             Hon’ble Mr. Justice T.P.S. Mann, President.

                             Shri Diwan Singh Chauhan, Member                      

 

 

Argued by:          Shri Nitesh Singhi, counsel for the appellants-opposite parties.

                             Shri S.K. Jindal, counsel for the respondent-complainant

                            

                            

                                                   O R D E R

 

T.P.S. MANN J.

 

          Complainant-Namita Yadav wife of late Shri Mukesh Kumar had filed the complaint under Section 12 of the Consumer Protection Act, 1986 praying therein that the opposite parties be directed to pay damages to the tune of Rs.11,61,000/- to her on account of deficiency in service alongwith interest @ 18% and Rs.5,00,000/- on account of mental and physical harassment.

2.      Vide order dated 22.07.2016, learned District Consumer Disputes Redressal Forum, Gurgaon allowed the complaint and directed the opposite parties to reimburse the claim of the complainant as per the terms and conditions of Policy No.TDW3186184 with interest @ 9% per annum from the date of filing of the complaint i.e. 11.08.2014 till realization and also to compensate her and to pay litigation expenses to the tune of Rs.15,000/-.

3.      According to the complainant, her husband Mukesh Yadav had obtained insurance policy under the name and style of Aviva Dhan Vridhi bearing Policy No.TDW3186184 from opposite party No.1. Her husband died on 22.05.2013 and the probable cause of death was heart failure.  Thus, there was no requirement of any postmortem.  The claim set up by the complainant was repudiated by the opposite parties vide letter dated 20.06.2013 on the ground of concealment of facts as the deceased allegedly suffering from hypertension, hypothyroidism, chronic pancreatitis, pulmonary embolism with gastric outlet obstruction and therefore violated clause B(i), (vii) and (xiv) of the policy.  The repudiation of the claim by the opposite parties tantamounted to deficiency in service.  Accordingly, the complainant prayed that the opposite parties be directed to pay damages to the tune of Rs.11,61,000/- to her on account of deficiency in service alongwith interest and Rs.5,00,000/- as compensation for mental and physical harassment.

4.      Upon notice, opposite party No.1 filed the reply that the complainant’s husband had misled the opposite party to issue the policy by concealing and suppressing material facts relating to his past medical condition.  If the deceased had declared about his past medical condition, the opposite party would not have issued the policy to him in the manner and at the premium.  The deceased had signed and submitted the proposal form on 19.12.2012.  The complainant’s husband had taken three policies bearing No.TDW3185066, TDW3179429 and TDW3886184 from the opposite parties.  As the life assured was suffering from various diseases, as mentioned above, he remained under treatment since 02.03.2012 i.e. prior to filling the proposal form for procuring the various policies.  The rejection of claim was intimated to the complainant vide letter dated 20.06.2013.  As per test report from Paras Hospital, the complainant’s husband was diagnosed as known case of Chronic Calcific Pancreatitis on 19.03.2010.  As per The Medicity, Gurgaon the life assured was suffering from pain upper abdomen for last 2-3 years and NIDDM six months on 07.08.2010.  He was taking treatment from Medanta on 07.08.2010 prior to the policy and during the treatment, he came to know that he was suffering from hypertension with hypothyroidism on 19.03.2012.  He was admitted in the hospital on 19.03.2012 with chronic pancreatitis with gastric outlet abstraction status GJ + FJ with pulmonary embolism and discharged from the hospital on 27.03.2012.  On 10.04.2012, he was operated for GI surgery.  He was continuously taking treatment at the hospital from 07.08.2010 to 09.05.2012 for having multiple diseases and cause of death was cumulative complication.  Other factors which complicated his disease were hypertension, hypothyroidism and chronic alcoholism.  All three diseases were deadly combination as by one or the other way, they help each other to aggravate and making condition of patient more worse.  Uncontrolled hypertension could also cause sudden death of patient.  The patient had history of pulmonary artery thrombosis which could also be the cause of his sudden death.  

5.      After hearing learned counsel for the parties and on going through the record, learned District Forum allowed the complaint and directed opposite party No.1 to reimburse the claim alongwith interest  besides Rs.15,000/- as compensation and litigation expenses.

6.      The State Commission has heard learned counsel for the parties and also perused the record, which stands requisitioned.

7.      The main grievance of the opposite parties in the instant appeal is that the assured had taken treatment for chronic calcific pancreatitis, hypertension, hypothecroidisim, chronic alcoholism and pulmonary embolism, which resulted in his death.  He had remained admitted in Medanta, The Medicity Hospital, Gurgaon on 19.03.2012 for lungs and stomach problem.  As per the record of Medicity dated 19.03.2012, it was observed as under:-

          “Multiple medical illness and tubes are noted.

          Lung parenchyma appears normal

          Trachea is central in position with normal trachea-bronchial angle

          Cardiaomediastinal contour is maintained.

          Blunting of bilateral CP angles suggestive of bilateral pleural effusion/exposure

          Raised right hemidiaphragm is noted

          Please correlate clinically.”

8.      On the other hand, the complainant stated in her affidavit that her husband had died due to heart failure.

9.      On perusal of the record, it is made out that there was nothing on the file from which it could be inferred that the life assured died due to pancreatitis.  The cause of death was heart attack and not pancreatitis, which had been allegedly suppressed at the time of taking the insurance policy.  The insured was taking treatment since 2010 for hypertension with hypothyroidism but the said treatment was neither for heart nor pancreatitis.  Even from the report of Medicity dated 19.03.2012, as quoted above, it is apparent that lung parenchyma appeared normal, trachea was central in position with normal trachea-bronchial angle, cardiaomediastinal contour was maintained, blunting of bilateral CP angles suggestive of bilateral pleural effusion/exposure and raised right hemidiaphragm.  Under these circumstances, there was no nexus between the cause of death and the alleged suppression of disease and thus, the opposite parties were not justified in repudiating the claim.

10.    In view of the above, no case is made out for any interference in the impugned order passed by the learned District Forum. The appeal is devoid of any merit and accordingly dismissed.        

11.    The statutory amount of Rs.25,000/- deposited by the appellants-opposite parties at the time of filing the appeal be released in favour of the complainant against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.        

 

Announced 01.07.2019

(Diwan Singh Chauhan) Member

(T.P.S. Mann) President

UK