State Consumer Disputes Redressal Commission
Edelweiss General Insurance Company ... vs Mr.Sri Gangaram Vinod Kumar on 26 September, 2024
1
BEFORE THE TELANGANA STATE CONSUMER DISPUTES
REDRESSAL COMMISSION : HYDERABAD.
F.A.No. 491 OF 2022
AGAINST ORDERS IN C.C.03/2020
DISTRICT CONSUM ER COMM ISSION-III, HYDERABAD
Between:
1.Edelweiss General Insurance Company Ltd., Represented by its Managing Director, Registered Office : 5th Floor, Tower-3, Kohinoor City Mall, Kohinoor City, Kirol Road, Kurla (West), Mumbai-400 070.
2. Edelweiss General Insurance Company Ltd., Represented by its Regional Manager, Having office at Model Town Colony, Jahanuma, Nawab Saheb Kunta, Hyderabad-500 053.
...........Appellants/Opposite Parties And:
1. Mr.Sri Gangaram Vinod Kumar, S/o Gangaram Yadaiah, Aged about 43 years, Occupation-Private Employee.
2. Smt.Gangaram Kalpana, W/o G.Vinod Kumar, Aged about 37 years, Occupation-House Wife.
3. Mr.Sri Gangaram Yadaiah, S/o G.Pentaiah, Aged about 65 years, Occupation-Retired Employee.
All are residing at H.No.1-11-93/7, Shyamlal Building, Begumpet, Hyderabad - 500 016.
........Respondents/Complainants Counsel for the Appellants/Opposite Parties : M/s Manav Gecil Thomas Counsel for the Respondents/Complainants : M/s Gopi Rajesh & Associates.
QUORUM :
HON'BLE SMT. MEENA RAMANATHAN, I/c PRESIDENT & HON'BLE SRI. V.V.SESHUBABU, MEMBER - (JUDICIAL) THURSDAY, THE 26th DAY OF SEPTEMBER TWO THOUSAND TWENTY FOUR ********** Order : (PER HON'BLE SRI V.V.SESHUBABU, MEMBER - JUDICIAL)
1. The appeal is filed u/s 41 of Consumer Protection Act, 2019, by the Opposite Parties, aggrieved by the order of District 2 Consumer Commission-III, Hyderabad, dated 19.04.2022 in CC 03/2020, where under the opposite parties was directed to pay Rs.5,87,893/- along with interest @ 9% p.a. from the date of claim till the realization; to pay compensation of Rs.25,000/- and costs of Rs.10,000/-. Time for compliance is 45 days from the date of receipt of this order.
2. The brief averments of the complaint are that the complainant No.1 is the husband of complainant No.2 and son of complainant No.3; that the opposite parties issued policy certificate vide No.900003283, by mentioning Loan Care Policy (Plan ultima- 25 critical illness) for the period from 03.07.2018 to 02.07.2021, with sum assured amount of Rs.5,87,893/-, covering major medical illness, like permanent paralysis; that the complainant No.1 was admitted in ESIC Super Specialty Hospital, Sanathnagar, Hyderabad on 22.12.2018 for paralysis to upper limbs and lower limbs etc., and had undergone treatment in the said hospital, was discharged on 09.01.2019; that the complainant No.1 submitted a a claim for the sum assured amount; that at the instance of opposite parties submitted all the documents to prove the ill-ness; that the opposite parties issued a repudiation letter, dated 16.10.2019 stating that he is not entitled for the claim, as he has suppressed the health issues while obtaining the policy and not disclosed his health issues in the proposal form; hence, the complaint.
3. The brief averments of the written version of Opposite Parties No.1 & 2 are that the complaint is not maintainable either on facts or under law; that there is no deficiency of service or any unfair trade practice in the repudiation of claim; that the complainant is put to strict proof of all the averments made in the complaint except those that are admitted; that the complainant submitted the proposal form on 30.06.2018 stating that he has no health issues; that basing on the said proposal form, the policy was issued; that after the complainant was admitted in the ESIC 3 Hospital, Sanathnagar, on 12.12.2018 and on his discharge submitted the claim for the sum assured as he suffered paralysis to the lower and upper limbs which is covered under the critical ill- ness diseases as mentioned in the policy; that on the request of the opposite parties, the complainant submitted the medical record and it shows he was having hyper-tension since five years by the date of admission; that the complainant suppressed the said fact in the proposal form; that if he had submitted the said fact, the opposite parties might not have issued the policy; that for the said suppression the claim was repudiated, vide letter, dated 16.10.2019 by cancelling the policy; that several case law is in support of the cancellation of the policy by the opposite parties for suppression of material facts. With this requested to dismiss the complaint with costs.
4. Before the Commission below, complainant filed evidence affidavit as PW1 and marked Ex: A1 to A8. One Sri Sameer Karekatte, Chief Legal and Compliance Officer of opposite parties filed evidence affidavit as DW1 and got marked Ex.B1 to B5. Both parties filed their written arguments respectively.
5. The Commission below, settled the following points for discussion viz..:
Whether there is any deficiency of the service on the part of Opposite Parties?
Whether the complainants are entitled for the reliefs prayed for?
To what extent?
6. Having heard the arguments of the complainants, the Commission below basing on the material available on record passed the order as stated supra. Aggrieved by the same, the present appeal is filed by the opposite parties with the following grounds:
The order of the Commission below is contrary to law, weight of evidence and probabilities of the case.4
The Commission below failed to go through the Ex.B1 to B5 submitted by the opposite parties which will prove the suppression of material facts by the complainant No.1 in the proposal form.
The Commission below failed to appreciate the case law submitted by the opposite parties.
The Commission below failed to observe that the contract of Insurance depends upon absolute good faith and in case of any suppression of facts, the contract shall be treated as void.
With these grounds and others that will be urged at the time of arguments requested to set aside the order of the Commission below and to dismiss the complaint.
7. Now the points for determination in the appeal are :
(1) W hether there is any deficiency of service and unfair trade practice on the part of the opposite parties? (2) W hether the impugned order is sustainable under law? (3) Relief?
8. Heard both sides. For the sake of the convenience the parties will be addressed as they arrayed in the impugned order.
9. POINTS 1 to 3: PW1 obtaining the policy is not in dispute. It is also an undisputed fact that paralysis can be considered as a critical ill-ness as given the list of critical diseases mentioned in the policy. Admittedly, PW1 filed Ex.A4 discharge summary. At the beginning of the document itself, the diagnosis was hypertension and he was admitted with weakness of left upper limb. The hospital noting of the duty doctor dated 22.12.2018 at 01:10 P.M. shows that PW1 is having "hyper-tension for five years- on irregular medication". So, it was very clear that as per the document of PW1 itself, was having hypertension for the last five years, prior to 22.12.2018 i.e. prior to the taking policy/Proposal Form.
510. Ex.B2 is the proposal form- loan care. Under the head Medical Information there are four questions. The 1st question is have you suffered in past or currently suffering from any disease/Medical (Physical)/ Mental condition. The answer is "No". The 2nd question is "have you advised in past or currently consuming any type of medication/drug"? The answer is "No". The 3rd question relates to habits of the insured like consuming alcohol, smoking, pan masala, gutka, tobacco etc. No answer is recorded for this. The 4th question relates to height and weight of the insured. Giving answers in negative for the questions No.1 & 2 amounts to suppression of facts, for the reason that as per the discharge summary and case sheet, he was having hypertension for the last five years, with irregular medication. It means PW1 suppressed the facts for both the questions. The OPD slip dated 22.12.2018 issued by ESIC Hospital shows that he was admitted with history of HTN+.
11. The contract of insurance is based on absolute "good faith" by both the parties to the contract. Often, hypertension with high readings may lead to paralysis. If, PW1 had disclosed the said fact, the opposite parties might have increased the premium or might not have issued the policy. Therefore, we are of the view that the repudiation of the claim is perfectly valid under law. It seems the Commission below without properly going through the medical record submitted by PW1 as well as the opposite parties, negative the contention of the opposite parties with an observation "that opposite parties have satisfied wi th the proposal form submitted by the complainant issued the Ex.A2 policy. In these circumstances, the case laws relied on by the opposite parties are not relevant to the present case". It had forgotten the basic tenets of the contract of "Uberrima fide/utmost good faith". In the case on hand, there is deficiency of service at all, because for the reason of suppression of facts, the claim was repudiated. So, the points are answered in favour of the appellants.
612. In the result, the appeal is allowed without costs, by setting aside the order in the appeal in CC 03/2020, dated 19.04.2022, by the DCDRC-III, Hyderabad. The appellants/opposite parties is entitled for the refund of amounts deposited i.e. Rs.3,76,600/- while preferring the appeal along with accrued interest after the lapse of revision period.
Typed to my dictation by Stenographer on the System; corrected by me and pronounced by us in the Open Court on this the 26th day of September' 2024.
Sd/- Sd/-
I/c PRESIDENT MEMBER-JUDICIAL
Dated : 26.09.2024
*AD