1. The brief history of the case of the complainant is that he had obtained a policy from the Ops namely GSIP on the life of his wife Mrs. Rama Padal vide application No.44638675 dt.16.4.2012. The subject policy was for 15 years whereas premium payment term was 7 years for a sum assured of Rs.3, 50,000/- and the complainant paid Rs.51, 545/- towards 1st premium and the Ops issued Policy No.16588045 in favour of the complainant on 23.4.2012. It is submitted that the Life Assured (LA) during the month of May, 2012 became ill and was hospitalized at District Headquarters Hospital (DHH), Koraput and Dr. B.N.Padhi diagnosed the illness and symptoms of diseases and found as Fever, Headache and weakness and the doctor came to the conclusion that the LA suffered complicated Malaria Fever and accordingly treatment was given for 5 days and as the condition did not improve, the patient was referred to higher centre. It is further submitted that the LA was admitted at Bharati Hospital, Visakhapatnam and during course of treatment; the LA expired due to Septicemia and Shock on 21.6.2012 as opined by the treating doctor of said hospital. It is also submitted that the complainant advanced his claim under the policy along with original policy certificate and relevant documents and also complied all queries of the Insurance Co. but through a letter dt.10.9.2013 the Ops repudiated the claim on the ground of suppression of material information at the time of proposal by the LA and they have noted that the LA had suffered from Tuberculosis and had received ATT Category-1 from 16.3.2012 to 02.4.2012. The complainant further submitted that there was no test done or symptom of Tuberculoses was found in the body of the LA at DHH, Koraput and similarly no test of Pulmonary Tuberculosis was ever done by Bharati Hospital, Visakhapatnam. Thus describing the action of the Ops as illegal and arbitrary and alleging deficiency in service on the part of the Ops, the complainant has filed this case praying the Forum to direct the Ops to settle the death claim of Rs.3, 50,000/- with interest @12% p.a. from 21.6.2012 in favour of the complainant and to pay Rs.1, 20,000/- towards compensation and costs to the complainant.
2. The Ops filed counter in joint admitting the insurance policy bearing No.16588045 issued on 23.4.2012 under non medical category in favour of the wife of the complainant for annual premium of Rs.50, 000/- with sum assured Rs.3, 50,000/- and the life assured died on 21.6.2012. It is contended that the OP conducted enquiry regarding claim process as the present claim was under early claim category and found that the LA as well as the complainant had suppressed the material facts with regard to the correct health status of the LA at the time of proposal and the Ops got information that the LA had suffered Tuberculosis and had received ATT Category-1 from 16.3.12 to02.4.12. It is further contended that the LA later died due to Pulmonary Tuberculosis and the said medical history was prepared before issuance of the policy and was well within the knowledge of the complainant and thereby violated the terms of the policy. It is also further contended that as the complainant deliberately misled the Ops to accept the proposal by concealing the material information and furnishing false replies while filling up proposal form, they have repudiated the claim of the complainant on 10.4.2013. Thus denying any deficiency in service on their part, the Ops prayed to dismiss the case of the complainant.
3. Both the parties have filed certain documents along with affidavits in support of their cases. Heard from the parties through their respective A/Rs and perused the materials available on record.
4. In this case issuance of insurance policy vide No.16588045 dt.23.4.2012 in favour of the complainant with annual premium of Rs.50, 000/- for a sum assured of Rs.3, 50,000/- by the OP is an admitted fact. The LA, Rama Padal, wife of the complainant died of Septicemia and Shock on 21.6.2012 and the complainant advanced the death claim of his wife with compliance of all formalities but the Ops on 10.9.2014 repudiated the claim inter alia on the ground of suppression of materials information at the time of proposal by the LA to which the complainant objected. Hence this case.
5. From the rival contentions of the parties, the following issues emerge importance for just decision of this case. (1) Whether the complainant or LA had suppressed material information at the time of proposal, (2) whether the LA died of Tuberculosis or primary cause of death of the LA was due to Tuberculosis, (3) whether the repudiation of the claim by the Ops is genuine, (4) whether the Ops committed any deficiency in service by not settling the claim of the complainant and (5) if so, as to what relief?
6. Issue No.1 is whether the complainant or the LA had suppressed the material information at the time of proposal:- While deciding this issue, it is seen that according to the Ops, the LA died within 2 months from the issuance of the policy and during investigation and evaluation of documents submitted by the complainant it was found that the LA had suffered from Tuberculosis and had received ATT Category-1 from March 16, 2012 to April 02, 2012. The Ops also found from the medical report submitted by the complainant that the LA later died of Pulmonary Tuberculosis and the said medical history was prepared prior to issuance of the policy and was well within the knowledge of the complainant.
7. Perused the medical report available on record issued by Dr. B.N.Padhi which was obtained by the Ops on 24.7.13 which reveals that the LA was admitted to DHH, Koraput on 2.5.12 for 5 days i.e. after obtaining the policy. Dr. Padhi diagnosed the illness and symptoms of disease and found as Fever, Headache and Weakness. The tests conducted are MP, FBS, Widal, Urea and Creatnine and the treating Doctor came to the conclusion that the LA suffered complicated Malaria Fever and accordingly given treatment for 5 days. As the condition of the patient did not improve, the Doctor referred the patient to higher centre. Not a scrap of paper has been filed by the Ops showing that the LA had suffered from Tuberculosis and received ATT Category-1 from 16.3.12 to 02.04.12.
8. In absence of any evidence, when the Ops have repudiated the claim of the complainant basing upon the sole reason that the complainant as well as the LA had suppressed the material information that the LA had suffered Tuberculosis prior to obtaining the policy and the said fact was well within the knowledge of the complainant, it became incumbent on our part to go one step ahead in order to test the veracity of the contentions of the Ops. Now we believe for some time that the complainant had suffered Tuberculosis prior to the policy. It is within everybody’s knowledge that the Government of India as well as State Government of Odisha is giving treatment and giving medicines to Tuberculosis patients free of cost and as per statistics 99% is the success rate of either cure or control of such disease. As is apparent, any malady, which is controllable with medication and does not involve such a treatment that needs hospitalization for days together or needs operation to cure, is not a “disease” for the purpose of insurance policy. If medication of any such malaise can keep the then fit for doing daily chores and ordeals, such a malaise can, by no stretch of imagination, be termed as a disease much less a “pre-existing disease”. Therefore, unless a person is hospitalized for the treatment or operated upon as discussed above, he can not be held to be suffering from a pre existing disease as he undertaken day to day activities. Further non disclosure of factum of having been hospitalized or operated upon for the treatment or cure of a specific disease may be used for repudiation of claim but not in this clear case.
9. In this case no evidence is adduced by the Ops in any form that the LA had suffered from Tuberculosis and received treatment at DHH, Koraput form 16.3.12 to 02.04.12. In view of above discussions, it can be easily concluded that the LA had not suffered from Tuberculosis for which she received treatment at DHH, Koraput. Hence ground for repudiation of claim adopted by the Ops is not a valid ground and also not accepted by us. This issue goes in favour of the complainant.
10. Issue No.2 is whether the LA died of Tuberculosis or the Tuberculosis is the prime cause of death of the LA :- While deciding the said issue, it is seen that the LA was admitted at DHH, Koraput on 02.5.12 and after 5 days she was referred to higher centre as her condition did not improve. The LA was admitted at Bharati Hospital, Visakhapatnam and received treatment from 14.5.12 to 21.6.12 on which date she died. We have carefully gone through the death report as well as the certificate of treating physician, Dr. B.V. Rama Chandra of Bharati Hospital. In the death report, the doctor mentioned the cause of death as Septicemia/Toxic Epidemal/Drug Induce/Immune Incompetence/Pulmonary Tuberculosis and Hepatitis. From the Bed Head Tickets of Bharati Hospital filed by the Ops, it was found that no treatment or test has been conducted for Pulmonary Tuberculosis, perhaps not given importance by the treating doctor.
11. The certificate of treating physician, Dr. B.V.Rama Chandra is reproduced here for a clear picture. “ I hereby certify that Mrs. Rama Padal, W/o. Raghuram Padal has developed drug induced Jaundice and extensive skin damage and was treated by me for about 40 days and finally she expired due to Septicemia and Shock.” This being the certificate of the doctor, which is filed by the Ops, repudiation of claim on the ground that the complainant suffered Tuberculosis and received ATT prior to the policy and finally died of Pulmonary Tuberculosis, is unfortunate. From the certificate of the doctor it became very much clear that the primary cause of death of the LA was due to Septicemia and Shock and the Ops in spite of knowing the fact, had repudiated the claim. This propensity and tendency on the part of the Insurance Company needs to be curbed with heavy hand as the claim is being repudiated without any strong contentions followed by evidence. From the above discussions, we come to the conclusion that the LA had neither died of Tuberculosis nor was the primary cause of death of the LA due to Pulmonary Tuberculosis. This issue also goes in favour of the complainant.
12. Issue No.3 is whether the repudiation of claim by the Ops is genuine. We found that the ground of repudiation in the instant case is not based on proper application of mind. In our view, Sec.45 is not applicable to this case as no such material was found to be concealed by the complainant at the time of proposal because the LA had never hospitalized or operated upon for any disease in the near proximity of taking the policy. By not settling the legitimate claim of the complainant, the Ops in our opinion have committed gross deficiency in the service. Accordingly, all the issues decided in favour of the complainant and as such he is entitled for the sum assured with due interest besides compensation and costs.
13. In the above facts and circumstances, we are of the view that the repudiation in this case is arbitrary and non settlement of genuine claim of the complainant by the Ops amounts to deficiency in service on their part. Hence the complainant is entitled for the sum assured of Rs.3, 50,000/- under the policy with interest @ 9% p.a. from the date of repudiation i.e. 10.4.13. Further due to such inaction of the Ops, the complainant must have suffered some mental agony and physical harassments and also has filed this case incurring some expenditure. Considering the sufferings of the complainant we feel, a sum of Rs.10, 000/- towards compensation and Rs.5000/- towards costs in favour of the complainant will meet the ends of justice.
14. Hence ordered that the complaint petition is allowed in part and the OP No.1 & 3 being jointly and severally liable are directed to pay Rs.3, 50,000/- towards the sum assured with interest @ 9% p.a. from 10.4.2013 and also to pay Rs.10, 000/- towards compensation besides Rs.5, 000/- costs to the complainant within 30 days from the date of communication of this order.
(to dict.)
