Sri Shyamal Gupta, Member
This Appeal is directed against the Order dated 08-01-2016 of the Ld. District Forum, North 24 Parganas passed in C.C. No. 414/2015 whereof the complaint has been allowed.
Briefly narrated, case of the Complainant is that over the death of her husband in a case of ‘Septic Shock’, a claim was lodged with the OPs. However, such claim being arbitrarily repudiated by them, the complaint was filed.
Counter case of the OPs is that, treatment sheets revealed that the policyholder was a known patient of Hypertension and Ankylosing Spondylitis which he did not disclose while applying for the policy. For such suppression of material fact about his pre-existing diseases, the instant claim was rightly repudiated.
Decision with reasons
I have heard the Ld. Advocates of the parties and gone through the material on record, including the various citations referred to in the matter.
It appears from the documents on record that the patient died of ‘septic shock’. It is mentioned in the ‘Medical Attendant’s Certificate’ that patient’s wife reported that the patient was suffering from Hypertension (HTN) and Ankylosing Spondylitis for the last four years, i.e., prior to inception of the policy in question and was being treated by his family physician. Now, I have to decide, if on this score the claim was justifiably repudiated by the Appellant or not.
At the very outset, let me make it clear that no scientific/medical journal is placed on record by the Appellants to show any co-relation between Ankylosing Spondylitis and Septic Shock. Therefore, in my considered opinion, non-disclosure of this alleged disease cannot be treated as a material breach of policy condition.
Regarding HTN, it is to be stated that apart from the afore-mentioned Medical Attendant’s Certificate, which was prepared as per the statement of the wife of the policyholder, since deceased, no other treatment sheet/prescription is forthcoming before me to correlate the same in order to independently verify the authenticity of this statement.
Since the Respondent (wife of the deceased policyholder) was predictably not in her proper state of mind at that moment in the wake of serious condition of her husband, I do not deem it fit and proper to take much cognizance of such hearsay statement. Whether the patient (policyholder) was suffering from HTN for the last four years or three years or two years or last 1½ year, that ought to be evaluated/tallied after thorough scrutiny of relevant prescriptions/treatment sheets which is missing here.
It is also noteworthy here that the treatment sheets on record do not indicate any instance of treatment of the patient in any hospital previously. It becomes absolutely clear, therefore, that even if the patient was suffering from HTN, it did not reach an alarming stage.
In the opinion of Hon’ble National Commission, “Hypertension is a common ailment and it can be controlled by medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack”. [Satish Chander Madan Vs. M/s Bajaj Allianz General Insurance Co. Ltd., reported in 2016 (1) CPJ 613 (NC) relief upon]. As a corollary thereof, it can also be argued that not all cases of HTN lead to Septic Shock.
Again, in the matter of , reported in 1999 (1) R.C.R. (Civil) 646, Honble Punjab & Haryana High Court held that mere non-mentioning of insured being a patient of hypertension did not amount to suppression of material facts, so as to entitle the Respondent to repudiate the claim.
High blood pressure is almost always treatable with the right combination of medications (individually prescribed) and life style modifications (diet and exercise). A person would only be considered "untreatable" if there was complete failure of medications (unlikely) and failure to comply with lifestyle modifications (often happens) and compliance, which is certainly not the case here.
Again, it is important to note that It appears that, Sepsis commonly originates from: (1) abdominal or digestive system infections; (2) lung infections like (4) reproductive system infection.
Significantly, although the Appellants blamed alleged HTN of the policyholder behind his death, no immaculate document/certificate from the treating doctor is furnished by them to establish that the patient developed Septic Shock due to his alleged HTN. I afraid, merely on the basis of suspicion, a claim cannot be repudiated.
Since the Appellants hurled allegation against the deceased policyholder, it was incumbent upon them, in terms of Sec. 101 of the Indian Evidence Act, 1872, to put forth tangible proof in order to show that HTN or for that matter, Ankylosing Spondylitis, that the policyholder was allegedly suffering from, precipitated his death.
In this regard, I cannot lose sight of the fact either that in terms of Sec. 45 of the Insurance Act, 1938, life-insurance policy cannot be called in question after two years since its inception. Also, Sec. 19 of the Indian Contract Act, 1872 entails that sheer silence, fraud or misrepresentation of fact does not render a contract void if the party whose consent was so caused had the means of discovering the truth with ordinary diligence. In this case, the panel doctor examined the policyholder, since deceased, before issuance of the policy. Therefore, it is naïve to believe that he did not notice any abnormality while physically examining the policyholder; otherwise, it would surely not escape his careful attention.
For all these reasons, the decision of the Appellants to repudiate the instant claim cannot be supported at all. Therefore, in my considered opinion, the complaint was rightly allowed by the Ld. District Forum. However, in the facts and circumstances of the case, I struck off the order of the Ld. District Forum in respect of punitive damage which is too harsh.
Appeal, thus, succeeds in part.
Hence,
O R D E R E D
The Appeal stands allowed in part on contest against the Respondent. The impugned order is hereby modified to the extent that the Appellants need not pay any punitive damage. Rest of the impugned order shall remain intact. Parties do bear their respective costs.
