BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, MYSURU

SMT.A.K.NAVEEN KUMARI.

PRESIDENT

The complainant has filed complaint against the opposite party for issue of direction to the opposite party to satisfy the claim with respect to the Postal L.I.C and release the sum assured of Rs.20,00,000/-. And pass such other reliefs such as mental agony, hardship, litigation expenses incurred by the complainant in the circumstances of the case in the interest of justice.

2. The complaint in brief avers as follows:-

That the husband of the complainant Sri.Venkatesh Prasad was working as Inspector of Income Tax in the Office of the principal Commissioner, Income Tax, Mysuru situated at Nazarbad, Mysuru. The husband of the complainant passed away on 25.08.2016 at J.S.S. Hospital, Mysuru. At the time of demise of the husband of the Complainant he was aged about 43 years. On 23.08.2016 the husband of the complainant complained of chest pain, breathlessness and cough and therefore he was taken to the emergency Room of J.S.S. Hospital, Mysuru. Due to the respiratory distress the husband of the complainant was incubated and put on assisted ventilation. Thereafter, necessary scan and procedures were initiated. Unfortunately he could not be revived and was declared dead on 25-08-2016.

3. That during the lifetime of her husband he had availed a Life Insurance Policy with Life Insurance Corporation of India bearing policy No:721727563. Likewise, another policy was also availed bearing No:722087937. The third policy availed bears No:722190007. After the demise of the husband of the complainant necessary claim application was submitted to L.I.C. of India wherein the aforesaid policies were availed. Accordingly, in the Month October 2016 the claims of the complainant were processed and the claim amounts under the above mentioned policies were directly credited to the nominee.

4. That apart from the aforesaid policies the husband of the complainant had also submitted a proposal on 11-08-2016 for availing the postal life insurance floated by the Department of Posts represented by the opposite party. The proposal of the husband of the complainant was accepted on 21-08-2016 and a policy was issued and the sum assured was Rs.20,00,000/- and the premium amount was Rs.9,900/- which was also paid. That in view of the untimely and unfortunate demise of Sri.Venkatesh Prasad, the complainant submitted a claim with respect to the policy availed with the opposite party. However, for reasons best known to the competent Authority of the opposite party the claim was rejected on 30-082017. That the competent authority of the opposite party i.e., the Assistant Director (PLI) Office of the Post Master General, South Karnataka Region has made an observation that the death summary dated 19-06-2016 said to have been issued from J.S.S. Hospital, Mysuru discloses that the deceased is a known case of hypertension. Whereas at the time of availing the policy and declaration submitted that the deceased was not suffering from hypertension, diabetics nor has he availed any such treatment.

5. That the act of the opposite party in repudiating the claim put forth by the complainant is absolutely baseless and without having any material proof. Though the enquiry and verification conducted at the behest of the opposite party did not in any manner enable this opposite party to conclude that the deceased husband of the complainant during his lifetime suffering from hypertension. That the opposite party has arrived at such a conclusion by assumptions on the basis of the cause of death reported in the death summary. The observation to the effect that a death summary was issued dated 19-06-2016 itself reveals that the concerned official of the opposite party has not applied his mind since the date of death of Venkatesh Prasad is 25-08-2016 and therefore examining the death summary of 19-06-2016 does not arise at all. Hence, it is a clear case of non-application of mind which has resulted in repudiation of the claim which amounts to deficiency of service and unfair practice. It is essential to note that the cause of death is reflected as IHD-ACS-NSTEMI which is the abbreviation for Ischemic Heart Disease-Acute Coronary Syndrome-Non-ST-Elevation Myocardial Infarction. As per the medical manual more than 20% of such cases would be asymptomatic which cannot be recognized as illness. In this backdrop the observation of the opposite party is erroneous. Hence, the repudiation of the claim amounts to deficiency of service. Hence, the complaint.

6. After filing of the complaint notice was issued to the opposite parties. The 1^st opposite party appeared through counsel and filed version, which avers as follows:-

The application was made by the late insured on 11.08.2016. He underwent medical examination before the Doctor on 11.08.2016. Based on this the policy bond was accepted on 21.08.2016. Based on this the policy bond was accepted on 21.08.2016. The insured passed away on 25.08.2016 and the complainant reported to the department on 15.09.2016 about the death of the insured on 25.08.2016 and requested for the settlement of the claim. As per Rule No.53 of post Office Life Insurance Rules 2011, which is annexed as annexure1, the cases of death before 3 years of taking policy will be inquired into to see if the policy was taken suppressing the material fact, thereby securing insurance of substandard life.

7. Accordingly, investigations were taken up, as this case of death was within 3 years. While confidential inquiries with two neighbors of the late insured did not point to suppression of facts. But, the death summary dated 25.08.2016 issued by J.S.S. Hospital Mysuru clearly indicated that it was a known case of Hypertension (k/c/o HTN). However, in the proposal form for Postal Life Insurance, in page 5, under the heading ‘Declaration of the Proponent’, the late insured has declared that he was not suffering from Hypertension. As the contradiction between the declaration of the insured and the death summary clearly indicated suppression of facts, the complainant’s claim was rejected.

8. It is contended that while the death summary states that it is a ‘Known case of hypertension’. There is very obvious contradiction between the death summary and the declaration made by the insured which has led to rejection of the claim by the competent authority. That in the office noting the date 19.06.2016 is referred to instead of 25.08.2016. The officer was actually referring to the death summary which was filed at serial No.19 in the file and as such the said correspondence/document at serial no.19 is referred to as 19/c and not 19/06/as assumed by the complainant. The office note in 5/N refers to pre page i.e.4/N  and reads as “‘X’ prepage and death summary at 19/c which states that the deceased was a known case of hypertension are contradictory” the fact that the insured was suffering from a known case of hypertension mentioned in the death summary cannot be ignored. The fact that the insured had declared that he was not suffering from hypertension also cannot be overlooked. As it is clear case of suppression of facts, the claim was rejected. Hence prays for the dismissal of the complaint.
9. The complainant amended the complaint subsequent to filing of this complaint and notice was issued to the 2^nd & 3^rd opposite parties. The 3^rd opposite party remained absent in spite of service of notice. Hence placed exparte. But subsequently the 3^rd opposite party appeared through counsel and by filing application got set aside the exparte order passed. The 2^nd opposite party appeared through counsel and filed version which avers as follows:-

It is contended that this opposite party  was in service at J.S.S. Hospital as a professor & HOD, Dept. of Cardiology during the period from 2013 to May 2017. He is a Senior Citizen and settled down at Bangalore. It is true that, Mr.Venkatesha Prasad expired on 25-08-216 at J.S.S. Hospital, Mysuru and the patient's records are in J.S.S. Hospital, Mysuru, who is the custodian of the records. It is contended that, Venkatesha Prasad was brought to the Hospital on 23-08-2016 with a complaint of chest pain breathlessness and cough. Hence, he was immediately taken to the Emergency ward of J.S.S. Hospital, where the Resident Doctor and the members of the staff carried out the admission procedures. The concerned Doctors and the members of the staff have recorded the statement of the patient, wherein it was recorded that he had high blood pressure and he was diabetic. It was diagnosed as a case of heart attack and it is recorded as Ventricular Fibrillation (cardiac arrest) requiring repeated electric shocks. Though he recovered his cardiac rhythm, his parameters remained critical and he was put on intubation ventilation.

10. That, the recording has been done, based on the information furnished by the patient and there was no reason to disbelieve the version of the patient when recording was done. Further, as there was emergent situation since he already had a cardiac arrest, treatment process had to be started giving priority and without losing time. When the patient was directly taken to the I.C.U. for managing his heart condition, there was no scope for verifying his past records and even at that moment call upon him to produce the past records. It was found that the patient was in deep trouble as the reading had shown that he was finding it difficult to breath, he had low blood pressure, his clinical parameter were abnormal, requiring further intervention like angiography and angioplasty. As the attendants of the patient (members of the family) did not agree to subject the patient for angiography and the required angioplasty, the situation had gone from bad to worse, as there was enormous delay. Ultimately, they were convinced and the Doctors made them to agree for conducting the angiography and angioplasty. Thereafter, the angiography was done with the consent of his wife and the procedure was finished at 2.50 p.m.

11. It is contended that, the 2^nd opposite party visited the patient again on 24-08-2016 in the morning and the case was reviewed. However, there was no improvement in the condition of the patient, whatsoever. Unfortunately, the patient could not be revived and he expired on 25-08-2016. It is contended that the deficiency in service on the part of this opposite party is baseless, unimaginable. That the complainant has come up with this plea subsequently by filing an amendment application, with creation of certain false allegations. Hence this opposite party prays for rejecting the claim against this opposite party in the interest of justice and equity.

12. The complainant has filed affidavit in lieu of evidence and  Produced documents.

The 2^nd & 3^rd opposite parties have filed affidavit in lieu of evidence and got marked document as Ex.R.1.

13. The complainant has filed interrogatories for which the 2^nd opposite party has answered the interrogatories.

14. Heard arguments of the learned counsel for the complainant.

The learned counsel for the 3^rd opposite party has filed written arguments.

15. Now the points that arise for the consideration of this Commission are:-

1. Whether the complainant has proved the deficiency in service by the opposite parties?
2. Whether the complainant is entitled for the relief sought?
3. To what order?

16. Our findings on the above points are as follows:-

Point No.1   :-       In the negative

Point No.2   :-       In the negative

Point No.3   :-       As per the final order

                            for the following:-

REASONS

17. Point No.1:- The complainant is the wife of one Sri.Venkatesh Prasad who was the insured. At the first instance, the complainant has filed complaint only against the 1^st opposite party. Then impleaded the 2^nd opposite party by filing application. Again by filing application impleaded the 3^rd opposite party in the complaint. Though the complainant has not sought for amendment of the prayer column in the amended complaint in the prayer column has included the alternative relief for issue of direction to the 2^nd opposite party to pay Rs.20,00,000/- for having committed deficiency in service in making erroneous entries in the death summary. The complainant has filed complaint for issue of direction to the 1^st opposite party to release the sum assured amounting to Rs.20,00,000/- insured by her husband Sri.Venkatesh Prasad. As per the evidence of the complainant during her wedlock with Venkatesh Prasad she gave birth to 2 children namely Srinidhi and Sinchana. The evidence of the complainant discloses that her husband Sri.Venkatesh Prasad was working as Inspector of Income Tax in the office of the Principle Commissioner Income Tax, Mysuru situated at Nazarabad Mysuru. He died on 25.08.2016 at J.S.S. Hospital, Mysuru at the age of 43 years.
18. As per the evidence of the complainant since her husband was complaining of chest pain, breathlessness and cough on 23.08.2016 he was taken to emergency room of J.S.S. Hospital, Mysuru. Due to the respiratory distrust her husband incubated and put on assisted ventilation. But he died on 25.08.2016. As per the evidence of the complainant her husband submitted a proposal on 11.08.2016 for availing the postal life insurance floated by the department of posts represented by the opposite party. The proposal of her husband was accepted on 21.08.2016 and the policy was issued. The premium amount is Rs.9,900/- and the sum assured was Rs.20,00,000/-. The document produced by the complainant discloses that before the receipt of the policy the insured died. The evidence of the complainant discloses that she has submitted a claim with respect to the policy availed with the opposite party. But her claim was rejected and the same was communicated to her on 30.08.2017.

19. The complainant has produced the acceptance letter of the proposal which is dated 29.08.2016 and she has produced the first premium letter dated 29.08.2016. She has also produced the claim rejection letter dated 30.08.2017. As per the evidence of the complainant after receipt of the communication on 30.08.2017 she has filed application on 06.10.2017 seeking for detailed information under Right to Information Act and she was provided with the information on 09.11.2017. In the said letter they have furnished information stating that as per the death summary the deceased was a known case of hypertension and it amounts to non-disclosure of material facts in the proposal is a suppression of material facts. Hence, the claim is rejected.

20. The copy of the proposal form produced by the complainant obtained under Right to Information Act discloses that proponent health information Sl.No.5 any disease of heart and lungs is shown as No by the proponent. The death summary issued by the J.S.S. Hospital discloses that when Venkatesh Prasad was brought to emergency on 23.08.2016 he was known of K-C-O HTN, which means he is a known case of hypertension. This information has been given by the patient. No patient will lie when he is having serious health issue and on the line of the same treatment is to be given. No doubt hypertension and diabetes are life style diseases, but the same has to be disclosed. Then it is left to the insurer to accept or reject. High blood pressure can damage the health in many ways. It can seriously hurt important organs like heart, brain, kidneys and eyes. High blood pressure can damage arteries by making them less elastic, which decreases the flow of blood and oxygen to the heart and leads to heart disease. In addition, decreased blood flow to the heart can cause: chest pain, also called angina.

21. The medical superintendent in the hospital of the 3^rd opposite party has stated that the doctors and the members of the staff have recorded the statement of the patient, wherein it was recorded that he had high blood pressure. It was diagnosed as a case of heart attack and he developed soon ventricular fibrillation (cardiac arrest). The inpatient record produced by the 3^rd opposite party is marked as Ex.R.1.  In the outpatient record dated 23-08-2016 the problem suffered by the patient is recorded which is similar to the line of the evidence of the complainant. Further it discloses that K/C/O HTN since 1 year on medication. Further it is written as chronic alcoholic and smoker. The hypertension has not been disclosed in the proposal form. The acceptance of the letter of the proposal discloses that the 1^st opposite party has accepted the proposal on 21.08.2016 and the same was communicated to the deceased Venkatesh Prasad on 29.08.2016. But before the receipt of the acceptance letter of the proposal by the insurer the insured died on 25.08.2016. As such before the receipt of the communication the insured died. Since in the death summary, it is written as known case of hypertension, the complainant has impleaded the doctor and the hospital as parties in this case subsequent to the filing of the case.

22. The 2^nd opposite party was the Professor and head of Cardiac Sciences in the 3^rd opposite party hospital. He is now retired and has filed affidavit stating the facts of the health issues and the treatment given in the 3^rd opposite party hospital and also about the correctness of the entry made in the case records of the patient.  As per the terms and conditions of the policy the cases of death before 3 years of taking policy will be enquired into to see if the policy was taken suppressing material fact. In this case, the death was within 3 years. The death summary issued by the J.S.S. Hospital Mysuru clearly indicated that it was a known case of hypertension. As such the non-disclosure of the hypertension by the insured in the proposal form is suppression of material facts. Moreover the death of the insured is due to cardiac arrest. In the death summary it is clearly noted the cause of death as IHD-ACS-NSTEMY sever LV dysfunction - Cardiogenic Shock in Pulmonary Edema.

23. The death summary discloses that patient was taken up for PCI CAG showed double vessel disease. PCI with stunting was done for LCX. He was also found to have versioning renal function. When the insured died within 15 days of submitting of proposal form and within 4 days of the acceptance of the proposal form and before the receipt of the communication of acceptance, the 1^st opposite party has rightly rejected the claim of the complainant. The contention of the complainant stating that the 2^nd opposite party has wrongly shown in the death summary as known case of hypertension though her husband was not suffering from any heart related disease could not be believed. There was no reason for the 2^nd and 3^rd opposite parties to mention in the death summary as known case of hypertension. The doctors/staffs will write what is stated by the patient or his attenders.

This principle has been formulated in McGillivray on Insurance Law12 succinctly, thus: ―[Subject to certain qualifications considered below], the assured must disclose to the insurer all facts material to an insurer’s appraisal of the risk which are known or deemed to be known by the assured but neither known or deemed to be known by the insurer. Breach of this duty by the assured entitles the insurer to avoid the contract of insurance so long as he can show that the non-disclosure induced the making of the contract on the relevant terms…‖

When the 1^st opposite party has rightly rejected the claim of the complainant it can be said that there is no any deficiency in service by the opposite parties. Hence, we answer this point in the negative.

24. Point No.2:- The complainant has sought for issue of direction to the 1^st opposite party to release the insured amount of Rs.20,00,000/- or in the alternatively sought for issue of direction to the 2^nd & 3^rd opposite parties to pay Rs.20,00,000/- as compensation for having wrongly mentioned in the death summary as known case of hypertension. When the complainant has failed to prove the deficiency in service by the opposite parties, the complainant is not entitled for the relief sought. Hence, we answer this point in the negative.

25. Point No.3:- In view of answering point no.1 & 2 as above we proceed to pass the following;

ORDER

Complaint is dismissed.

No order as to costs.

Furnish free copy of the order to all the parties.

(Dictated to the Stenographer, transcribed, typed by him, corrected by us and then pronounced in the Open Commission on this the 16^th day of August 2023)