COMPLAINT FILED ON 25/07/2019

                                                                            DISPOSED ON 20/03/2023

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, CHITRADURGA.

CC.NO:425/2019

DATED: 20^th March 2023

PRESENT: Kum. H.N. MEENA, B.A., LL.B., PRESIDENT

                Smt. B.H. YASHODA, B.A., LL.B., LADY MEMBER                          Sri. H.JANARDHAN, B.A.L., LL.B., MEMBER  

:JUDGEMENT:

Delivered by Hon’ble President, Kum. H.N. MEENA.

The complainant has filed this complaint against the
OPs No.1 to 3, seeking for a direction to pay Rs.19,00,000/- with interest 24% per annum under policy bearing No.70000018310 under SBI Rinn Raksha Home Loan Scheme from the date of death of Sri Rangappa. N. The complainant has also sought for order to direct the OPs to pay Rs.25,000/- with 24% interest per annum towards the damages for the mental and physical agony suffered by the complainant and to grant such other reliefs as this  Hon’ble Commission may deems fit and proper in the  interest of Justice. 

BRIEF FACTS OF CASE:

         2. The complainant has asserted that, she is the wife of one Rangappa. N, was working as Veterinary Inspector at Hiriyur. During his life time he was taken a housing loan from the OP-3. At the time of sanctioning the loan, as per the advice and norms of the opponents, said Rangappa. N. had taken a policy bearing No. 70000018310 under SBI Rinn Raksha Home Loan Scheme on
11-9-2017 and had paid premium. After detail enquiry regarding family and health condition of said Rangappa. N. the opponents had issued above said policy.  Unfortunately, said Rangappa. N. died on 26-08-2018. After his death, the complainant applied for the claims due on the death of her husband and given original Policy and other original documents to the opponent No.3 as required by him to settle the claim. Later, the complainant had received a letter dated 28-12-2018 from Opponent No. 1, in which it is stated that “for the reason of non-disclosure of material facts in the proposal form, the claims is hereby repudiated” and refund the premium amount of Rs. 56,912/- and also stated that, in case, claimant is not satisfied with the above decision, the claimant may send representation for reconsideration of the claims to their claim Review Committee. Accordingly, the complainant being not satisfied with the above decision, has sent a representation to the opponent No.2 on 2-5-2019. But the opponent No.2 has not responded to the said representation properly up to this day. But, said Rangappa. N did not suppress any facts to the opponents at the time of taking the aforesaid Policy.                                                                                           

        3. The complainant has further stated that, the complainant approached the opponent No.3 several times regarding settlement of the claim under the above said policy, but the opponents neglected to settle the claim by stating one or other reasons and postponed to settle the claim of the complainant. It is the gross negligence and carelessness on the part of all the opponents. Again the complainant visited the office of opponent No.3 and requested to settle the claim, but OPs ignored by giving vague reply, the efforts made by the complainant went in vein. This clearly indicates opponents have committed deficiency in their service. Due to which the complainant suffered mental and physical agony and also financial loss. Hence, the husband of complainant took the policy from the opponent No.1 and 2. After his demise the complainant filed this complaint. Wherefore, the complainant has sought for the relief accordingly.

4. On registering this complaint and service of notice, the OPs has made its appearance through its counsel and filed written version.

5. Version filed by the OPs No.1 to 3 are submits as     hereunder:

Opponent No.1 and 2 are submitted that, all the contents of the referred complaint should be treated as not admitted and denied. The Opposite Parties emphatically denies all that is contained in the complaint which is contrary to or inconsistent with what is stated by the Opposite Parties herein. Unless any averment of the complaint is specifically admitted by the Opposite Parties herein, irrespective of whether a specific traverse is made or not and non-dealing with any particular averments may not be taken as implied admission. OPs have submitted defend their case in para wise, its version as follows:

a) OP No.1 and 2 stated in the version that, with regard to the contents of para no. 2, it is stated that the Deceased Life Assured, Late Rangappa N had insured under Master Policy No.7TOOOOO18310 vide loan account No. 37090815639 with Cover Start Date as 11.09.2017 for a Initial Sum Assured of Rs.19,00,000/-.The insurance cover granted to the DLA is based on the detail information given by the DLA in the membership form no. 7009815596 dated 24.08.2017 duly signed by him. In the membership form, there were Specific questions were asked regarding health condition, habit and family details, however, the DLA replied in negative to these specific questions. Thus suppressed the material information regarding his health that he was suffering from Chronic Kidney Disease 4, Type II Diabetes with retinopathy & Nephropathy, hypertension and availed the insurance cover fraudulently.

1.        b) That the contents of para no. 3 are accepted to the extent that the  OPs have received claim intimation on 17.10.2018 and during assessment it is revealed that the DLA had suppressed his pre-existing ailments of Chronic Kidney Disease 4, Type II Diabetes with retinopathy& Nephropathy, hypertension. Hence the claim was repudiated in view of non-disclosure clause of the policy and refunded the premium to the complainant. The same has been communicated to the complainant vide letter dated 28.12.2018. The contents of the letter are self-explanatory. However, the OPs did not receive any representation as alleged. It is stated that the OPs have repudiated the claim rightly based on the documentary evidence which amply proves that the DLA had suppressed the material facts at the time of availing the insurance cover. The present complaint is fictitious and is liable to be dismissed in limine.

c) That the contents of para no. 4 are distorted and hence denied. It is humbly submitted that the decision of the OPs to repudiate the claim is based on the documentary evidence and in accordance with the terms and conditions of the policy. Thus there is no negligence and carelessness or deficiency in service on the part of the OPs. The complainant has not suffered any mental and physical agony and financial loss as alleged. The rest of the contents of para are pertains to OP -3, Bank and hence denied for want of knowledge.

d) With regard to the contents of para no. 5, it is stated that the DLA had procured the insurance cover under group insurance scheme from the OPs by suppressing the material information regarding his pre-existing ailment. Therefore the insurance cover granted to him stands null and void in view of non-disclosure clause of the Policy. Hence the present complaint does not fall under the purview of Section 2 (1) (c) and 2 (1) (d) of the Consumer Protection Act, 1986.

e) That the contents of para no. 6 are distorted and hence denied. The OPs acted in accordance with the terms and conditions of the policy and hence there is no cause of action to the complainant to file the present complaint against the OPs.

f) That the contents of para no. 8 are denied. It is submitted that addresses of the OP - 1 & 2 are at Mumbai/Navi Mumbai whereas the present complaint has been filed before the Hon’ble Forum, Chitradurga. Hence the Hon’ble may kindly be examined the maintainability of the complaint on the ground of territorial jurisdiction.

g) With regard to the contents of para no. 10, it is stated that the OPs have not received any annexures along with the present complaint and hence reserves their rights to reply on receipt of the same.

h) That the contents of prayer clause and rest of the complaint are denied. It is specifically submitted the claim has been repudiated under the said policy as the insurance cover was availed by the DLA by suppressing his pre-existing ailment of Chronic Kidney Disease, Uncontrolled Diabetes mellitus, Diabetic Retinopathy and hypertension. There is no deficiency in service and there was no cause of action to file this complaint and the OP has not caused any mental and physical agony to the complainant. Hence the OPs are not liable to pay compensation or any other amount of whatsoever nature either jointly or severally.

6. The OP No.3 stated in the version that, the allegations made by the complainant in the entire complaint against the OP No.3 are all false. The averments made in the para No.3 of the complaint are the matter of record and proof. Hence, the complainant has to prove her case beyond reasonable doubts and the complainant is strictly put to strict proof of the same. But as per the information given by the OP No.1 and 2, the deceased Sri N. Rangappa, i.e., husband of the complainant has suppressed the very material facts, hence they have repudiated the claim of the complainant.

7. The averments made in the Para No.4 of the complaint the matter of record and proof. Hence, the complainant has to prove her case beyond reasonable doubts. But this OP No.3 have sent the necessary documents and etc., which have been submitted by the complainant to the OP No.1 in due course. OP No.3 is not the necessary party to the complainant since this OP No.3 is not the authority to settle the claim of the complainant. The complainant has made this OP No.3 as unnecessary party to the complaint. OPs are respectfully prayed the Hon’ble Commission may kindly pleased to dismiss the complaint against the OPs.

        8. Both complainant and opponents filed their evidence by way of Affidavit,  documents produced by complainant and marked as Ex.A-1 to Ex.A-5 and documents produced by Opponents marked as Ex.B-1 to Ex.B-10, Both complainant and OP filed their written arguments. Heard oral arguments of both side.

        9. On the assessment of the above facts, the following points arise for our consideration Viz.

1. Whether the complainant proves that, there is deficiency in service on the part of OPs?
2. Whether the complainant is entitled to reliefs as prayed in the complaint?
3. What order?

10. The findings of this commission on the Points for consideration are as below.

Point No.1: In the Negative

Point No.2: In the Negative

Point No.3: As per the final order for the following.

11. Point No.1 & 2: The complainant his case is that, she is the wife of one Rangappa.N, he was working as Veterinary Inspector at Hiriyur. During his life time he was taken a housing loan from the OP-3. At the time of sanctioning the loan, as per the advice and norms of the opponents, said Rangappa. N. had taken a policy bearing No. 70000018310 under SBI Rinn Raksha Home Loan Scheme on 11-9-2017 and had paid premium.

12. After detail enquiry regarding family and health condition of said Rangappa. N. the opponents had issued above said policy. The wife of assured Rangappa. N. has died on 26-8-2018. After his death, the complainant applied for the claims due on the death of her husband and given original Policy and other original documents to the opponent No.3 as required by him to settle the claim. Later, the complainant had received a letter dated 28-12-2018 from Opponent No. 1, in which it is stated that “for the reason of non-disclosure of material facts in the proposal form, the claims is hereby repudiated” and refund the premium amount of Rs. 56,912/- and also stated that, in case, claimant is not satisfied with the above decision, the claimant may send representation for reconsideration of the claims to their claim Review Committee. The complainant has sent a representation to the OP No.2 on 02/05/2019. But the opponent No.2 has not responded to the said representation. Again the complainant approached the opponent No.3 several times regarding settlement of the claim but the opponents neglected to settle the claim. This clearly indicates opponents have committed deficiency in their service it is case of the complaint.

13. The OPs contended that, the deceased life assured, late Rangappa.N. had insured under Master Policy No.7TOOOOO18310 vide loan account No. 37090815639 with Cover Start Date as 11.09.2017 for a Initial Sum Assured of Rs.19,00,000/-.The insurance cover granted to the DLA is based on the detail information given by the DLA in the membership form No. 7009815596 dated 24.08.2017 duly signed by him. In the membership form the Life insured had replied in negative to question No.5 (3) and their investigation had established that the Life Insured was hospitalized on 26/07/2016 and treated for Chronic Kidney Disease 4, Type II Diabetes with retinopathy & Nephropathy, hypertension. The DLA had suppressed his pre-existing ailments and also the complainant has suppressed the material facts, hence OPs have repudiated the claim of the complainant.

14. To prove the contention the OPs strong reliance on Discharge summary issued by Kasturba Hospital, Manipal which is noted in Ex.B-5 the DLA was hospitalized for a period from 26/07/2016 to 08/08/2016. In the discharge summary final diagnosis is noted as T2 DM, HTN, DIABETIC NEPHROPATHY, MILD NDPR i.e., Type II Diabetes, Mellitus, hypertension, Nephropathy, Mild non proliferative diabetic retinopathy.

15. In Ex.B-6 Discharge summary, it is mentioned that on 28/06/2017, the DLA admitted again in Kasturba Hospital, Manipal for a period from 28/06/2017 to 01/07/2017. In which final diagnosis “Acute on Chronic Kidney Disease-4, Acute Gastritis, uncontrolled Types II with Diabetic Retinopathy, Hypertension”.

16. In Ex.B-7 Discharge summary, it is mentioned that the life assured admitted to the Kasturba Hospital, Manipal on 14/12/2017 to 20/12/2017. In the discharge summary final diagnosis is noted as “Chronic Kidney Disease 5, Type 2 DM with Diabetic Retinopathy Hypertension HBSAG Weakly Positive.

17. In Ex.B-8 Discharge summary of Dept. of Nephrology of Apollo Hospital the DLA was hospitalized for a period from 12/01/2018 to 22/01/2018.  Under the course in the Hospital and discussion it is noted that, Mr. Rangappa, 48 years, suffering from K/e/o hypertension, diabetes mellitus Type II Diabetic, retinopathy, diabetic nephropathy, CKD on conservative management, chronic hepatitis B cholelithiasis  presented for acute abdomen and vomiting.

18. We have examined the said medical documents carefully. The said documents are the important and vital documents to prove that the deceased was diagnosed to be a case of T2 DM, HTN, DIABETIC NEPHROPATHY, MILD NDPR, CKD-4, Type II Diabetes with retinopathy, hypertension, Nephropathy, Mild non proliferative diabetic, HBSAG, Weakly Positive, Bone marrow aspiration on 07/01/2017 and acute on chronic kidney Disease-4/Acute gastritis, uncontrolled type-2, D.M. with chronic hepatitis B cholelithiasis  and admitted to the hospitals for treatment before obtaining Insurance Policy. The proposer replied in negative to the questionnaire No.5 (3) Master Policy and Personal detail….

Have you ever suffered from/been treated/Hospitalized for or diagnosed to have Diabetes, raised blood sugar or high blood pressure any genitourinary or kidney disorder, Hepatitis B/C or any other liver disease. The proposer also replied on negative to the questionnaire No.1 to 20.

19. The proposer, since deceased, replied to the questionnaires in negative specifically while filling proposal form on the record, we final that the assured was suffering from said diseases but, he withheld this vital information deliberately from the insurer. It cannot be said that the discuses was not within the knowledge of the assured while taking the Insurance Policy.

20. Even though the OP has not examined the treating doctors to prove the said documents. But the documents are prima-facie sufficient to hold that the deceased Life assured suppressed his past medical history, while taking the policy from the documents are found that the deceased life assured taking the treatment for the said diseases. Since from so many years at various hospitals. Only for the reason that the treating doctor has not examined before this commission the above said documents produced by the OPs can be considered at all. 

21. The Policy was taken by the assured on 11/09/2017 and he died on 26/08/2018 within 1 year of issuance of the policy. It means the deceased life assured knowing fully well that he has suffered grievous  diseases and by suppressive has past medical history obtained the policy only to gain profit as rightly contended by the OP we find that the assured was suffering from so many diseases not only diabetes and hypertension. Hence, Insurance company has refund the premium amount of Rs.56,912/- to the complainant account.

22. We rely upon ruling… The Hon'ble Apex Court held in case of Life Insurance Corporation of India V/s Smt. G.M Channabasemma, 1991 AIR (SC) 392,

That the assured is under obligation to make full disclosure of material facts. The allegations of assured being guilty of making false representation and suppressing material facts deliberately, the burden of proof to prove it is on the corporation. We find that the Ops have discharged the burden of proof in this case, as the above referred medical records cannot be held to be false.

The Apex Court has also held in Satwant Kaur Sandhu Vs. Vs. New India Assurance Company Ltd., VI (2009) SLT 338 - IV (2009) CP.78 & (SC) - 2009 CTJ 956 (SC) (CP) that in case of deliberate concealment of material facts by the insured, the repudiation of insurance contract is justified. The contract of insurance is based on utmost good faith and any deliberate suppression of information by the proposer could lead to repudiation of the contract.

Therefore, repudiation of claim of the complainant by the OP is justified.

We rely upon another ruling reported in 2020 ACJ 3009 in the Hon’ble Supreme Court of India, New Delhi, (CA No.3397/2020) (Branch Manager, Bajaj Allianz Life Ins. Co. Ltd., and others Vs. Dalbir Kaur) wherein it has been held as under;

Insurance Act, 1938, Section-45 - Life Insurance - Repudiation of claim - Suppression of material facts - Assured, while seeking life insurance policy, in the proposal form answered the queries in the negative indicating that he had not undergone any medical treatment or hospitalization and was not suffering from any ailment of disease - Assured died within one month and seven days from the issuance of the policy ~ Insurance Company repudiated the claim for not disclosing that assured as suffering from Hepatitis C and he had been availing treatment in hospital for stomach ailment and vomiting of blood - District Forum allowed the complaint - State Commission dismissed the appeal on the ground that death occurred due to natural cause and there was no nexus between the cause of death and nondisclosure of disease which was affirmed by the National Commission - A contract of insurance is one of utmost good faith and a proposer who seeks to obtain a life insurance policy is duty bound to disclose all material facts based on which insurance company would consider it appropriate to assume the risk which is proposed or not - Medical records indicate that assured was suffering from Serious pre - existing medical condition which was not disclosed to the insurance company - Assured was hospitalized for treatment of such condition in proximity to the date of his death which fact was also not disclosed in spite of specific queries mentioned in the proposal form - whether non-disclosure of disease in the proposal form entitles the insurance company to repudiate the claim - Held: Yes”.

23. The above citations are applicable to the present case. For the reasons discussed above, the complainant has failed to prove deficiency in service on the part of the OPs. Hence, the complainant has not entitled to any relief as stated in the complaint. Accordingly, we answer this Point No.1 and 2 in the negative.

24. The counsel for the complainant also relied on the following decisions;

1. Air 2008 Delhi 29 Hari Om Agarwal V/S Oriental Insurance Co. Ltd., Decided on 17/09/2007.
2. Neelam Chopra V/S Life Insurance Corporation Of India. On 8-10-2018 By Hon’ble National Consumer Disputes Redressal.
3. Sulabh Prakash Motegoankar V/S Life Insurance Corporation Of India. On 5-10-2015 By Hon’ble Supreme Court Of India
4. Branch Manager, Baja) Allianze Life Insurance Co. Ltd & Ors V/S Dalbir Kaur.
   On 9-10-2020 By Hon’ble Supreme Court Of India.

The above citations are not applicable to present case.

25. POINT NO.3: In view of the discussions made under Point No.1 and 2, we pass the following order.

::ORDER::

         The present complaint filed by the complainant under section 12 of C.P. Act 1986, against the opponents is dismissed.

                      Communicate the order to parties.

(Typed directly on the computer to the dictation given to stenographer, the transcript corrected, revised and then pronounced by us on 20 March 2023.)

       LADY MEMBER               MEMBER                    PRESIDENT

-:ANNEXURES:-

Witness examined on behalf of Complainant:

1. Smt T.R.Nagambika W/o Late Rangappa.N, by way of   

affidavit of evidence.

Witness examined on behalf of Opponent:

DW-1:-Sri M. Bheemaraju S/o Murudappa, by way of affidavit of   

           evidence.

DW-2:-Sri. Naveen.C. S/o Chandran.S, by way of affidavit of   

           evidence.

Documents marked on behalf of Complainant:

Documents marked on behalf of Opponent:

LADY MEMBER              MEMBER                    PRESIDENT

GM*