DR. S. M. KANTIKAR, MEMBER

1.       Ms. Shail Devi, since deceased, took an insurance policy from Sahara India Life Insurance Co. Ltd. (OP) for the amount of Rs.1,00,000/-. The policy was issued on 04-01-2010. During subsistence of the policy, she expired on 16-12-2010 due to cardio respiratory failure. Her son, Shailender Kumar Pandey, the complainant herein filed a death claim before the OP, but it was repudiated on the ground that the insured had given false answers to the questions Nos.7(6)(d) and 8 of the proposal form. Also, ground was taken that the deceased was suffering from diabetes mellitus for more than a decade. It was concealed while filing the proposal form. The complainant also contacted the review committee of OP, but there was no positive response even after lapse of five months. Hence, the complainant filed a complaint against OP for alleged deficiency in service before the District Consumer Disputes Redressal Forum, Vaishali, Hazipur (herein referred as District Forum).

2.       The OP resisted the complaint on the ground of territorial jurisdiction, as the policy was issued from Muzzafarpur branch of OP. Therefore, the District Forum Vaishali had no jurisdiction. The OP further stated that the insured had concealed material information in the proposal form about her past illness of Diabetes Mellitus(DM), and hence, the claim was correctly repudiated. Past illness of DM was proved from the discharge summary of Heart Hospital at Patna where she was admitted at the time of death.

3.       The District Forum vide order dated 15-06-2015 allowed the complaint and directed the OP to pay an amount of Rs.1,00,000/- with interest at the rate of 10% per annum from the date of filing of the complaint within one month. The District Forum held that doctrine of Good Faith i.e. “Uberimma Fides” is applicable to both the parties. Being aggrieved by the order of the District Forum, the OP approached the State Commission by way of appeal. It was also dismissed by the State Commission with cost of Rs.5,000/-. The State Commission held that the OP had failed to establish that the assured was suffering from Diabetes Mellitus for last 10 years. Aggrieved by the order of the State Commission, the OP filed this instant revision petition.

4.       We have heard the learned counsel for both the parties. The counsel for the petitioner vehemently argued that the deceased/insured had deliberately suppressed medical history in the proposal form that she was having good health. The counsel brought our attention to Annexure A-3/P-7, the letter issued by the Administrative Officer of Heart Hospital Ltd. which clearly mentioned about the patient that Shail Devi was suffering from diabetes mellitus for last ten years. On the basis of the said letter the claim was repudiated by the OP-insurance company. The learned counsel for the complainant submitted that there was no concealment in the proposal form. The counsel denied that the patient was suffering from diabetes mellitus for more than ten years.

5.       We have perused the proposal form, the insurance policy and the Bed Head Ticket (BHT) of the Heart Hospital Ltd. The examination sheet of the Heart Hospital revealed that Shail Devi, aged 60 years, was admitted in that Hospital on 16-12-2010 with complaint of chest pain since 7:00 A.M. and at one end, it was written as “DM/10 yrs”. It is pertinent to note that under the caption “past history” it was written as “DM……yrs”. Thus it itself indicates controversy. Secondly, the examination sheet No.(iv) revealed the “advice” given by the doctor on admission of the insured and we do not find any medication given for diabetes mellitus except it was ordered that “to start NTG drip” and patient was under observation. She died at 6:50 P.M. by cardiac arrest. The certificate issued by the Heart Hospital Ltd. indicates that at the time of admission, she was suffering from acute myocardial infraction and died by cardio respiratory arrest.

6.       We do not find any weightage to the letter dated 31-05-2011 issued by the Administrative Officer of Heart Hospital. The letter is reproduced as below:

          “Subject:      Your letter No.47137618 dated 18-05-2011 regarding treatment details of late Shail Devi.

          Dear Sir,

                   With reference to the above, please be informed that according to our hospital records, Late Mrs. Shail Devi was suffering from Diabetes Mellitus for the last 10 years, as reported by the patient herself at the time of admission.”

          Such letters can be created at any time. It is pertinent to note that the vital record like bed head tickets and doctor’s notes in the medical record does not reveal anything about diabetes mellitus. There is nothing on record to show that the patient was diabetic. No laboratory tests are produced to prove that she was diabetic. Also nothing was on record about the administration of any diabetic drugs during hospitalisation. Thus, the letter issued by Administrative Officer is a vague and unreliable which appears to be a procured one for the benefit of insurance company.

7.       On the basis of the foregoing discussion, in our view, the OP failed to prove that the patient was diabetic. Moreover, the patient suffered acute EMI and died by cardio respiratory arrest as per the death certificate. We do not find any merit in the instant revision petition. The State Commission has passed a well-reasoned order which does not warrant any interference. The revision petition is dismissed with cost of Rs.20,000/- which is to be paid by the petitioner to the complainant within four weeks from the date of receipt of order, failing which the entire decreetal amount will carry interest at the rate of 12% per annum till its realisation.