IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Monday the 29th day of February, 2016
Filed on 19.12.2013
Present
- Smt. Elizabeth George (President)
- Sri. Antony Xavier (Member)
- Smt. Jasmine D (Member)
in
C.C.No.387/2013
between
Complainant:- Opposite Parties:-
Smt. Sini. T.S 1. State Bank of Travancore
W/o Ramesh Babu Cherthala Branch
Sheela Mandiram Represented by its Manager
CMC – 25, Cherthala Taluk (By Adv. Mariadas John)
Cherthala
(By Adv. N. Ratheesh) 2. SBI Life Insurance Company Ltd.
Central Processing Centre
Kapas Bhavan, Plot No.3A
Sector – 10, CBD, Belapur
Navi Mumbai – 406 614
(By Adv. Azeem Muhammed)
O R D E R
SMT. ELIZABETH GEORGE (PRESIDENT)
The case of the complainant is as follows:-
The complainant and her husband had taken a housing loan for Rs.8 lakhs from the first opposite party. While taking the loan, as per the direction of the first opposite party they have taken an insurance policy. The complainant’s husband died on 19.8.2012. The first opposite party has not taken any proceedings for closing the loan as per the insurance policy. The claim for the insurance amount was repudiated by the second opposite party. While taking the policy, the husband of the complainant had no illness and only after that he was suffering from liver disease. They repudiated the claim stating that the complainant’s husband did not disclose the pre-existing disease in the proposal form for insurance coverage. The complainant is entitled to get all the benefits as per the insurance policy. The opposite party has no right to deny the same. Alleging deficiency in service on the part of the opposite parties hence the complaint is filed.
2. The version of the first opposite party is as follows:-
The complainant and her husband availed a housing loan of Rs.8,83,379/-. The insurance amount has to be given by the second opposite party. The first opposite party has no right to take any decision about that. The complainant has remitted Rs.56,000/- towards loan amount with the first opposite party. There is no deficiency in service on the part of the first opposite party.
3. The version of the second opposite party is as follows:-
The death claim of the complainant’s husband was repudiated on the ground that he did not disclose the existing disease in the proposal form for insurance cover and thereby availed the insurance cover fraudulently. The deceased life assured had suppressed the facts of the pre-existing disease and hence the policy issued is void ab initio as per the terms and conditions of the policy. The complainant is not eligible for any claim amount.
4. The complainant was examined as PW1. The documents produced were marked as Exts.A1 and A2. From the side of the opposite parties six witnesses were examined as RW1 to RW6. Documents produced were marked as Exts.B1 to B15.
5. The points came up for considerations are:-
- Whether there is any deficiency in service on the part of the opposite parties?
2) Whether the complainant entitled to get any reliefs?
6. It is an admitted fact that the complainant and her husband had taken a home loan from the first opposite party and had applied for Dhanaraksha Plus LPPT insurance scheme. Complainant’s husband died on 19.8.2012. Thereafter she applied for the insurance amount as per the policy. But the second opposite party repudiated the death claim on the ground that the deceased Ramesh Babu did not disclose the pre-existing disease in the proposal form for insurance coverage. According to the opposite party it is clear from the medical record submitted that Mr Ramesh Babu was suffering from and was under the treatment for liver disease, hypertension, and diabetic and that he had undergone ligation of Esophageal variceal prior to the date of signing the proposal form. In order to prove the contention of the opposite parties, they produced the medical records from KVM Hospital and it marked as Ext.B12. In the death summary of deceased Ramesh Babu noted in page No.15 of the file it is categorically stated that, “This 44-year-old male patient was directly admitted to MICU from Medical College Hospital, Vandanam with history of chronic liver disease, pedal oedema, jaundice, altered sensorium ascites and portal hypertension. Esophageal variceal ligation (EVL) was performed for esophageal variceal bleed in 2009 at MCH., Alappuzha. He has history of moderate alcohol consumption (less than 120 ml/day) for 20 years.” Under the past medical history it is also stated that, “Cirrhosis of liver with portal hypertension EVL performed in 2009.”
As per the policy certificate produced by the opposite party, the complainant and her husband had taken the policy from 26.2.2010 and the term of cover is 240 months. Ext.B1 is the Dhanaraksha Plus LPPT Membership form. In page No.3 of the Ext.B1 under the title Medical questionnaire the details give as follows:-
“ iii. Have you ever been treated for or told that you have diabetes or raised blood sugar, high blood pressure, heart attack, chest pain or any heart disease, stroke/paralysis or any other disorder of the circulatory system, HIV infection or a positive test to HIV? No.
iv. Have you been treated or told that you have cancer, tumor, growth or cyst of any kind, Genitourinary or kidney disorder, hepatitis B, C of any other liver disease, any digestive disorders (eg. ulcer, colitis etc.) disease of the gall bladder or spleen, any musculoskeletal disorders, any blood disorder, or disorder of any gland (eg. Thyroid), asthma, tuberculosis, pneumonia, or any other disease of the lungs, any psychiatric disorder, mental or nervous disorder? No.
ix. a) Do you consume more than 10 cigarette/bidis per day, or chew more than 5 pouches tobacco per day? No.
ix. b) Do you consume more than 2 pegs of alcohol per day in any form, if yes, please provide type of alcohol and daily quantity consumed? No.”
On the contrary the medical record reveals that the deceased was admitted at Medical College Hospital, Alappuzha in 2009 as a history for chronic liver disease. It is also clear from the medical records that the deceased had a history of moderate alcohol consumption for 20 years. Ext.B15 is the true copy of the case records of the complainant’s husband issued from the Medical College Hospital, Kottayam. On perusal of records it reveals that the complainant’s husband was admitted in the Medical College, Kottayam on 24.8.2009 for doing procedure Esophageal Variceal Ligation (EVL). While cross examining the RW4, he categorically stated that as per the history, “Liver Cirrhosis was diagnosed in 2009. On perusing the Ext.B15 in the clinical history it is written that, ALD Cirrhosis Liver Portal Hypertension – Esophageal Variceal Ligation (Grade II – IV). RW2 Dr. Joshy Joseph who issued Ext.B4 treatment certificate also deposed before the Forum that he has treated the complainant’s husband for diabetes, liver cirrhosis. Ext.B2 is the treatment certificate issued by Dr.Anitha. She was examined as RW3. In Ext.B2 it is clearly stated that the complainant’s husband was admitted in the hospital on 24.8.2009 and discharged on 27.8.2009, and was treated there for “Type 2 diabetes, mellitus, chronic liver disease, portal highpertension, esophageal variceal ligation 4 bands deployed.” On perusal of records produced by the opposite party, it prooves that the complainant’s husband’s health was not good and he was admitted in the hospital prior to obtaining the insurance policy. The proposal form produced shows that the insured had suppressed material facts regarding his health and illness and previous treatment. In a judgment by the Hon’ble Apex Court reported in VI (2009) CPJ page 178, Satwant Kaur Sandhu Vs. New India Assurance Co. Ltd., in which it was held that: “A. Insurance – Health insurance – Mediclaim policy Nature and object of – objection of insured to disclose true and full information sought in proposal form – Extent of said disclosure necessary – When information on a specific aspect is asked for in the proposal form, held, the assured is under a solemn obligation to make a true and full disclosure of the information on the subject which is within the knowledge – Obligation to disclose extends only to facts which are known to the applicant and not to what he sought to have known – Whether the information sought for is material for the purpose of the policy is a matter not to be determined by the proposer.” In the instant case although the complainant’s husband was aware of the fact that he was suffering from Type 2 diabetes, mellitus, and chronic liver disease, he did not disclose the said fact in the proposal form for the policy. While cross examining the complainant, she admitted that her husband died due to liver cirrhosis. Ext.B5 is the true copy of the certificate issued by Dr. Vinod Kumar, M.D., KVM Hospital, Cherthala. Ext.B5 shows that the complainant’s husband died due to hepatic failure cirrhosis of liver and the duration of illness is stated as since 2009. In the light of above discussion, it becomes clear that the second opposite party has not committed any deficiency in repudiating the claim on account of suppression of material facts while taking the policy from the second opposite party.
In the result, complaint is dismissed.
Dictated to the Confidential Assistant transcribed by her corrected by me and pronounced in open Forum on this the 29th day of February, 2016. Sd/- Smt.Elizabeth George (President):
Sd/- Sri. Antony Xavier (Member) :
Sd/- Smt.Jasmine.D (Member) :
Appendix:-
Evidence of the complainant:-
PW1 - Sini T.S. (Witness)
Ext.A1 - Death Certificate
Ext.A2 - Reconsideration acknowledgement letter dated 17.4.2013
Evidence of the opposite parties:-
RW1 - William Pethireenju (Witness)
RW2 - Dr. Joshy Joseph (Witness)
RW3 - Dr. Anitha S.P. (Witness)
RW4 - Dr. Vinodkumar Pavithran (Witness)
RW5 - Seby I.V. (Witness)
RW6 - Dr. Mathew J. Choorackan (Witness)
Ext.B1 - SBI Life – Dhanaraksha Plus LPPT Membership form of deceased Ramesh Babu
Ext.B1(A) - SBI Life – Dhanaraksha Plus LPPT Membership form of the complainant
Ext.B2 - Attested true copy of the treatment certificate dated 23.2.2013
Ext.B3 - Attested true copy of the death summary
Ext.B4 - Attested true copy of the treatment certificate dated 8.2.2013
Ext.B5 - Attested true copy of the Medical Attendant’s certificate
Ext.B6 - Attested true copy of the Hospital treatment
Ext.B7 - Attested true copy of the application dated 4.2.2013
Ext.B8 - Attested true copy of the discharge summary
Ext.B9 - Attested true copy of the hospital records of K.V.M. Hospital
Ext.B10 - Copy of the letter dated 28.2.2013
Ext.B11 - Letter dated 22.11.2014
Ext.B12 - Medical records from KVM Hospital
Ext.B13 - Letter dated 29.12.2014
Ext.B14 - Medical records from Lakeshore Hospital
Ext.B15 - Copy of the medical records from Medical College, Kottayam
// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite party/S.F.
Typed by:- pr/-
Compared by:-
