ORDER

1.       This Revision Petition is directed against the impugned order  dated 05.06.2017 of the State Consumer Disputes Redressal Commission of Telangana, Hyderabad (for short “State Commission” ) whereby the appeal was dismissed and the order dated 21.5.2015 of the District Consumer Disputes Redressal Forum , Adilabad (for short “District Forum” ) was affirmed.

2.       The complainant’s husband, Praveen Kumar Chukka (since deceased) had obtained a Unit Linked Plan Insurance Policy. The complainant was the nominee and legal heir of deceased policy holder. After the death of her husband, as a nominee, she submitted the claim form to the opposite party no. 1 but insurance claim was repudiated on 26.12.2011 and issued a discharge voucher for fund value of Rs.3, 472.22 as a full and final settlement. However, according to the complainant, as per the terms and conditions of the policy, she was to receive the entire claim amount of Rs.5,13,600/-. Being aggrieved by the deficiency in service of the opposite party, the complainant filed a complaint before the District Forum, Adilabad.

3.       The opposite party resisted the complaint by filing the written version.  According to the opposite party – insurance co. the claim was repudiated because the nominee failed to produce the necessary documents of the deceased viz. report of Sonee Clinic and the case sheet of Asian Institute of Gastroenterology, Hyderabad. According to insurance co. at the time of submitting the proposal form, the deceased has suppressed his pre-existing health condition. He was in a habit of consuming alcohol. The   repudiation was legal and justified and there was no deficiency from the opposite party.

4.       The District Forum after considering the evidence and material on record, allowed the complaint and directed the opposite parties to pay Rs.5,13,600/- with interest @ 7.5% per annum from the date of death till realization with compensation &  costs of Rs.5,000/-.

5.       Being aggrieved, the opposite parties preferred first appeal before the State Commission. The State Commission dismissed the appeal.

6.       Being aggrieved, the insurance company filed this instant revision petition.

7.       Heard learned counsel for both the sides.  Perused the material on record. 

8.       Admittedly, the insurance policy was in force from 17.09.2009 and valid for 20 years and the policy holder died within 3 months i.e. on 6.12.2009. The insured was admitted in Asian Institute of Gastroenterology, Hyderabad on 5.12.2009 and died on the next day due to Multi Organ Dysfunction Syndrome (MODS) in the case of Acute severe pancreatitis.  The hospital medical record (progress sheet) the clinical history mentioned that patient had severe pain since 2 days, alcohol dependent for six years 360 ml. per day.  The medical record nowhere stated that the MODS was due to alcohol induced injury. The insured died on 06.12.2009. 

8.       Learned counsel for the petitioner brought my attention to one medical literature “Alcohol and Acute Pancreatitis” [Yele Journal of Biology and Medicine 70(1997),pp 77-87]  which reveals – Alcohol abuse can lead to chromic pancreatitis and bouts of acute pancreatitis super imposedon chronic disease. 

9.       The medical record of Asian Institute of Gastroenterology, Hyderabad confirms the diagnosis of acute pancreatitis and ethanol induced with  MODS – renal failure.   In the proposal form, the deceased insured had declared that he was not using alcohol, never used alcohol. However, from the medical record it is clearly established that in insured suffered ethanol induced acute pancreatitis which subsequently led to MODS and death. It is pertinent to note that the insured died within three months of issuance of the policy.  There is no reason to disbelieve medical record maintained by Asian Institute of Gastroenterology, Hyderabad. The clinical findings of the deceased were recorded by a qualified doctor without a bias mind.  

10.     The opposite party had conducted its investigation through their private investigator. It was found that the deceased was treated by Dr. Prabhakar and Dr. Dhoomsingh in Sonee Clinic, at Nirmal and also at Asian Institute of Gastroenterology, Hyderabad for severe abdominal pain and gas problems.  For processing insurance claim, complainant did not produce case sheet/medical reports of the deceased. 

11.     In my view, both the fora have erred on the point of alcohol induced pancreatitis. It is a clear case of concealment of material fact by the complainant. As there is enough evidence to prove that the deceased insured had concealed that he was an alcoholic at the time of filling the proposal form, the opposite party cannot be burdened with the liability of paying the complainant (nominee). A contract of insurance is a contract of ‘uberrima fides’. In the present case, the assured has breached the trust of the opposite party.  In Satwant Kaur Sandhu v. New India assurance Co. Ltd IV (2009) CPJ 8 (SC), the Hon’ble Supreme Court held:

“20. The upshot of the entire discussion is that in a Contract of Insurance, any fact which would influence the mind of a prudent insurer in deciding whether to accept or not to accept the risk is a “material fact”. If the proposer has knowledge of such fact, he is obliged to disclose it particularly while answering questions in the proposal form. Needless to emphasise that any inaccurate answer will entitle the insurer to repudiate his liability because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering into a Contract of Insurance.

12.     On the basis of forgoing discussion, it was clear suppression of material fact in regard to the health of the insured. The repudiation by the insurance co. was justified.  This revision petition is allowed and the orders of both the fora are set aside. Consequently the complaint is dismissed.