O R D E R<br /> <br /> <br /> <br /> SRI.D. KRISHNAPPA, PRESIDENT:<br /> <br /> <br /> The grievance of the complainant against the Ops in brief is, that she is the wife of late Mr. Anand Trimbak Yaragattikar who had taken an insurance policy from Ops No.1 to 3 which is a non-medical life insurance policy linked to SBI Housing Loan Account maintained with Op No.4. At the time of taking the policy her husband was working as a Professor in UAS College Dharwad who died on 24/04/2008 in Spandana Hospital, Dharwad. She after death of her husband submitted a claim to Ops No.1 and 2 with all documents for settling the insurance claim but those Ops vide their letter dated 27/09/2008 repudiating her claim on the ground that the deceased had given false good health declaration at the time of entry into the scheme and the cause of death is directly attributable to pre-medical condition of the deceased. Thereafter she sent a letter to Op No.3 on 10/01/2009 disputing the ground of repudiation but the Ops 1 to 3 again reiterated that the death of the insured was due to pre-existing disease. It is stated that her husband was treated in Jayadeva Institute of Cardiology, Bangalore who has issued a certificate on 03/01/2009 certifying that the deceased had ‘No inducible Ischemia’ and that he had no heart problem. Therefore, the complainant attributing deficiency to Ops has prayed for a direction to Ops 1 to 3 to pay the insurance benefits with interest or in the alternative to direct the Op No.4 to adjust the insurance amount with interest payable to the housing loan account of the deceased and also to award compensation of Rs.5.00 lakhs for mental agony and cost of Rs.5,000/-.<br /> <br /> Ops No.1 to 4 have appeared through their advocate and filed version. Ops 1 to 3 have filed common version admitting to had issued a group insurance policy in favour of the deceased on the basis of declaration of good health given by the insured. The sum insured will be the outstanding loan as on the date of the death as per the original EMI schedule. That they are not liable for any EMI defaults. In the case on hand outstanding loan amount of the deceased as on the date of death is Rs.3,63,054/- and insurance cover is available to so much of amount. It is further alleged that the declaration of good health given by the deceased has been destroyed as per the records and these Ops by producing a format of that declaration of good health have contended as if the deceased had given such a format after filling that he was not ailing from any disease. It is further contended that declaration of good health is a basic documents for the insurance of contract and if the deceased had given correct information about his good health could have been refused to him and stated that since the year from 2002 the deceased was suffering from Acute Anterior Myocardial Infarction and DM Type II and it was diagnosed in Spandana Hospital and thus have contended that insured after suppressing his health condition obtained the policy and acted against the utmost good faith reposed and therefore the Ops justifying their action in repudiation of the claim of the complainant have prayed for dismissal of the complaint.<br /> <br /> Op No.4 is a bank who had advanced the housing loan to the deceased denying his knowledge about the correspondence that took place between the deceased and Ops No.1 to 3 and complainant, admitted to had advanced a housing loan to the deceased and it had link with the group insurance benefit and stated that no relief is sought against them and thereby has submitted for dismissal of the complaint against him.<br /> <br /> In the course of enquiry into the complaint, the complainant and Ops have filed their affidavit evidence reproducing what they have stated in their respective complaint and version. The complainant along with the complaint has produced death certificate of the deceased, repudiation letter issued by the Ops, copy of repudiation she had given to Ops No.1 to 3 and medical certificate of Jayadeva Institute of Cardiology, Bangalore, with a copy of legal notice she got issued to Ops No. 1 to 3. Ops No.1 to 3 have produced a copy of SBI home loan insurance master policy which contain general conditions and a copy of the certificate of insurance issued in favour of the deceased, with a copy of the report of their investigator enclosed, with copies of case sheet of Spandana Hospital, Dharwad. We have heard the counsel for both parties and perused the records.<br /> <br /> On the above contentions, following points for determination arise.<br /> 1. Whether the complainant proves that the Ops No. 1 to 3 have caused deficiency in their service by repudiating the insurance claim made by her?<br /> 2. To what relief the complainant is entitle to?<br /> <br /> Our findings are as under:<br /> Point No.1: In the affirmative<br /> Point No.2: See the final order.<br /> <br /> <br /> REASON:<br /> Answer on Point No.1: As narrated above, the complainant aggrieved by the letter of repudiation sent by Ops 1 to 3 dated 27/08/2009 has come up with this complaint attributing deficiency to the Ops. As per the letter of this repudiation, the said Ops have refused to honour the claim on the ground that declaration of good health given by the deceased was false. As per records available with them the insured was suffering from Ischemia heart disease prior to the enrollment of the above policy on 10/08/2005, and alleged that insured had pre-existing diseases at the time of enrolment under the scheme and thereby have refused to pay the insurance amount. <br /> <br /> Before we proceed to consider the justification of the Ops in repudiating the claim of the complainant, we shall bear in mind the nature of the policy floated by Ops No.1 to 3 and the terms and conditions of the policy. Admittedly, Op No.4, SBI floated the scheme of group insurance for their home loan borrowers through Ops 1 to 3 called home loan policy/master policy. Under the scheme 194933 borrowers were insured by paying the total premium amounts to Ops 1 to 3 by way of single premium and that risk has commenced with effect from 19/09/2002. Under the conditions of the policy meaning of the word ‘benefits’ say that in the event of death of the member at any time after 45 days (except for accidental death) from the date of commencement of risk, subject to the policy being in full force but not later then the member completing the age of 75 years to pay the grantees or any person so authorized by the grantees the sum assured. Then under the general conditions as found from schedule 4 of the conditions of the policy says that the company shall not be liable to pay the benefits referred to under Para 5 in Schedule II if death of the member shall be caused by intentional self injury, insanity or immorality while the member is under the influence of intoxicating, drug etc., and if the member is engaged in aviation etc. and death caused by injuries resulting from riots, civil commotion, committing any breach of law or under any other such circumstances. But under these general conditions, we do not find any exclusion of the benefit to a member if the death is caused due to any decease as that of deceased in this case. The complainant and the OP have also produced certificate of insurance issued to the deceased. This certificate contain summary of terms and conditions of the scheme printed on the back of it. The first condition speaks of the scheme, which says group life insurance covered to housing loan borrowers of the SBI Group as protection against the risk of death due to any reason (Here we emphasize the word death due to any reason). During tenure of the loan, the group insurance comes under Super Suraksha plans of SBI Life Insurance Company Limited. Then we come to the condition No.5 which is titled as ‘benefits’, under which it is stated, in the event of death of the insured, housing loan borrower due to any cause, the sum assured would become payable to the group administrator, the sum assured will be equivalent to the outstanding loan amount including interest as per the original EMI Schedule. Here again we emphasize the word the death of the insured housing loan/borrower due to any cause and thereby we hold that condition of the policy issued in favour of the deceased do not carry any restriction for the payment of the insurance amount in the event of the death of the insured. The Ops have not disputed these conditions of the policy under which insurance amount become payable on the death of the insured. On the contrary they themselves have admitted to have issued the certificate to the deceased. In these conditions of the policy there is mentioning of critical illness which shows that the borrower should not have suffered or suffering from cancer, conditions requiring open chest surgery, history of typical chest pain, Kidney failure, brain stroke or paralysis having undergone organ transplantation such as heart, lung, liver or kidney. Therefore, it proves that the borrower should not have suffered or suffering from such serious ailments. Ops No.1 to 3 have produced a copy of the report of their investigator who has stated as if the deceased had got himself admitted into Spandana hospital Dharwad on 13/11/2002 vide IP No.1248 and diagnosed for IHD Acute Anterior Myocardial Infarction DM type II and he was discharged on 18/11/2002. Op has also enclosed the copies of case sheet which of course discloses that the diseased ailment was diagnosed as IHD acute anterior myocardial infarction DM Type II. But Ops No.1 to 3 have not stated anywhere as to when the complainant filled up the proposal form or gave good heath declaration to find out whether he had suppressed this fact in them. Ops No.1 to 3 in their version and also in the affidavit evidence have sated as if they have destroyed declaration of good health given by the complainant as per their records. It is not understandable as how these Ops No.1 to 3 can destroy such an important material document when the claim period under the policy has not expired. The Ops No.1 to 3 appears to have purposely not produced the declaration given by the deceased declaring that he was having good health. If they had produced it, it would have thrown light whether he had suppressed or not. Ops have also not stated during which month and year the deceased had given them declaration of good health form and signed to the proposal form. There is no dispute that the policy came into effect from 19/09/2003. In the repudiation letter issued by Ops they have stated as if the deceased enrolled himself to the policy on 10/08/2005, which is wrong. Therefore, in the absence of production of declaration of good heath stated to had been given by the deceased, we cannot determine whether as on the date of giving declaration of good health, the deceased was aware of his ailment and despite that he has given false information. The allegation that the deceased had given false declaration about his health cannot be believed, because the Ops have failed to produce such a declaration given by the deceased. Therefore, even assuming that the deceased as on 13/11/2002 had the knowledge of his ailment that cannot be held to have been suppressed or concealed by giving false declaration as we are not in a position to see the declaration and that declaration was given either prior to 13/11/2002 or subsequent to 13/11/2002.<br /> <br /> It is further found that the deceased was treated in Spandana Nursing Home, Dharwad and thereafter, he was treated in Jayadeva Institute of Cardiology, Bangalore on 03/01/2009. The said hospital has issued a certificate stating that this deceased had underwent coronary angiogram and have opined that deceased was diagnosed conservative medical management based on the result and he was stable at the time of discharge. These documents prove that the deceased ailment was not so serious or severe warranting any bypass surgery or replacement of organs as found from the terms and conditions of the scheme. Therefore, the Ops in our view considering the object of the policy and conditions of the policy should not have repudiated the claim and that repudiation would amounts to deficiency in their service. As found from the condition No.7 of general conditions of the scheme the complainant would be entitle for the relief of adjusting the insurance amount to the housing loan account. As per condition No.7 of general conditions as given in Schedule IV of the policy, condition provides for the company to pay the sum assured to the grantees where the premiums have been paid in full towards this sanctioned loan amount. In the nature of the policy issued in favour of the complainant specific insured amount is not mentioned and the conditions provide the sum assured would be equivalent to the outstanding loan amount including interest as per the original EMI schedule. Now in the case on hand Op No.1 to 3 themselves have stated that the deceased was due Rs.3,63,054/- and that amount is available and that has to be adjusted towards loan amount of Rs.3,63,054/- due by the insured to Op No.4. Therefore, Ops 1 to 3 are to be directed to pay that amount to Op No.4 who shall adjust that amount to the loan account of the deceased and to give a discharge note. With this, Ops 1 to 3 forgetting the object of floating the scheme by Op No.4, the premium paid which was to the benefit of the loanees ought to have considered in the right spirit and granted a relief to the complainant a widow of the borrower, but by misinterpretating the terms and conditions have pushed her to this litigation. As such, they are liable to compensate the complainant for her hardship and mental agony. With this, we answer Point No.1 in the affirmative and pass the following order. <br /> O R D E R<br /> <br /> 1. Complaint is allowed. Ops 1 to 3 are directed to pay Rs.3,63,054/- to the 4th Op Bank who shall adjust that amount to the housing loan account of the deceased insured inclusive of interest and issue No Due Certificate or Clearance Certificate to the complainant in respect of the housing loan.<br /> 2. Ops 1 to 3 shall pay Rs.5,000/- to the complainant towards hardship and mental agony caused to her.<br /> 3. Ops 1 to 3 are directed to pay the above amounts within 60 days from the date of this order failing which they shall pay interest @ 9% p.a from the date of this order till the date of payment. <br /> 4. Ops 1 to 3 shall also pay cost of Rs.2,000/- to the complainant.<br /> <br /> <br /> Dictated to the Stenographer. Got it transcribed and corrected. Pronounced in the Open forum on this the 12th July 2010.<br /> <br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />