State Consumer Disputes Redressal Commission
Icici Prudential Lic Ltd. vs Narlenka Chandravati on 19 July, 2022
Cause Title/Judgement-Entry IN THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION ODISHA, CUTTACK First Appeal No. A/280/2018 ( Date of Filing : 05 Jun 2018 ) (Arisen out of Order Dated 15/12/2017 in Case No. CC/289/2014 of District Rayagada) 1. ICICI Prudential LIC Ltd. Upper Basement Unit no. 1 A, Gr Floor Unit no. 2A, Raheja Tipco Plaza, Rani Sati Marg, Malad, East Mumbai-400097. 2. Branch Manager, ICICI Prudential Life Insurance Co. Ltd., R.K. Towers, M.G. Road, Jeypore, Dist- koraput. ...........Appellant(s) Versus 1. Narlenka Chandravati W/o- Late Narlenka Kesab Rao, Haraprasad Rao, Vidya Nagar, 4th Lane, Rayagada. ...........Respondent(s) BEFORE: HON'BLE MR. JUSTICE Dr. D.P. Choudhury PRESIDENT HON'BLE MR. Pramode Kumar Prusty. MEMBER HON'BLE MS. Sudihralaxmi Pattnaik MEMBER PRESENT: M/s. S. Daga & Assoc., Advocate for the Appellant 1 Dated : 19 Jul 2022 Final Order / Judgement
None appears for the parties. The matter was heard previously. However, we are inclined to dispose of the matter on merit basing on the materials available on record.
2. This appeal is filed U/S-15 of erstwhile Consumer Protection Act,1986(herein-after called the Act). Parties to this appeal shall be referred to with reference to their respective status before the learned District Forum.
3. The unfolded story of the complainant is that the complainant's husband purchased a policy from OP-Insurer during his life time for sum ssured of Rs.3,50,000/- commencing from 09.02.2013. It is alleged inter-alia that the husband of the complainant expired on 17.4.2013 due to sudden illness in Care Hospital,Visakhapatnam. Thereafter, the complainant made a claim before the OP but the OP repudiated the claim on the ground of suppression of material fact. Challenging the said repudiation, the complaint was filed.
4. The OP filed written version stating that the complaint petition is not maintainable and the complainant has deliberately purchased policy by suppressing his health condition. So, there is justification for repudiating the claim.
There is no deficiency in service on the part of the OP.
5. After hearing both the parties, learned District Forum passed the following order:-
Xxxx xxx xxx " In the result the complaint petition is allowed in part on contest against the Ops. The Ops ordered to pay sum assured amount of Rs.3,50,000/- to the complainant inter-alia to pay Rs.1,000/- towards litigation expenses. The Ops ordered to make compliance the aforesaid order within 60 days from the date of receipt of the order."
6. It is stated by the appellant that learned District Forum has committed error in law by not following the principles of uberrima fides i.e. contracts of utmost good faith between the parties. The policy holder while filling up the proposal form has made suppression the material information with regard to his healthy and as such learned District Forum has lost sight of this suppression of material fact by the policy holder. It is submitted that the policy holder was hospitalized at Care Hospital,Visakhapatnam in the month of March,2012 one year prior to insurance policy purchased being diagnonised as chronic clacific pancretitis with non insulin dependent diabetics mellitus(NIDDM). Thus, the policy holder has knowingly suppressed to show his disease in his proposal form. Not only this but also the policy holder in March,2012 has requested the Collector-cum-District Magistrate to cancel his transfer on medical ground stating that he is a prolonged patient of heart patient with diabetes and eye sight problem and he was in regular visit to Care Hospital,Visakhapatnam for medical treatment. When the policy holder has got own admission about his health condition, the non-mention about his disease in the proposal form is a suppression of material fact resulting to repudiate complainant's claim. Learned District Forum ought to have considered all such facts to reject the complaint. So, it is prayed to allow the appeal by setting aside the impugned order.
7. We have considered the appeal memo, perused the DFR and impugned order.
8. It is admitted fact that the policy holder had purchased a policy bearing No.17455239 being issued on 9.2.2013 from OP. It is admitted fact that the policy holder died on 17.04.2013 due to cirrhosis of liver with Hepatic Encephalopathy. It is well settled in law that the complainant has to prove its case and the deficiency in service on the part of the OP. In this present case the OP has taken plea that they have repudiated the claim because of the suppression of material fact while filled up the proposal form. It is held by the Hon'ble Supreme Court of India in Mithoolal Nayak-Vrs-Life Insurance Corporation of India in 1962 AIR 814,SCR Supl. (2) 571 that the OP before calling the policy in question within two years of commencement of policy has to prove following three pre-conditions:-
a) the statement must be on a material matter or must suppress facts which it was material to disclose;
b) the suppression must be fraudulently made by the policy-holder, and
c) the policy- holder must have known at the time of making the statement that it was false or that it suppressed facts which it was material to disclose.
9. With due regard to the aforesaid decisions the OP is to prove that the policy holder has suppressed the material fact while filling up the proposal form. In the instant case the OP has to prove that the policy holder was having health problem in 2012 being treated at Care Hospital,Visakhapatnam from 7th March,2012 to 12th March,2012. We have gone through the documents filed by the OP. Annexure-A is the proposal form of the policy holder who is husband of the complainant particularly it refers to the personal details at clause-5 in the following manner:-
c. Have you undergone or been advised to undergo any tests or investigations in the last 5 years ?
d. Have your ever undergone or been advised any surgery or hospitalized for observation or treatment in the past ?
f. Have you ever suffered or been diagnosed or been treated for any of the following ? (If Yes, please encircle the ailment/disease ) I. Diabetes or high blood sugar, high blood pressure, chest pain, palpitations, heart murmur, heart attack, shortness of breath, any other hear related disorder or undergone angioplasty, bypass surgery, heart surgery or any blood disorders like anemia, thalessaemia etc. or respiratory disorders like asthma,bronchitis, Tuberculosis etc. II. Cancer, tumor, growth, polyps or cysts III. Gastrointestinal or liver disorders like gastritis, ulcer, hernia, hepatitis, jaundice, thyroid disorders or genitourinary disorders related to kidney, prostrate, urinary system.
IV. Nervous system disorders, ailments related to brain, mental/psychiatric ailments, stroke, paralysis, epilepsy or musculoskeletal disorders like arthritis, any disorder of joints, spine, limbs or any disorder of the eye, ear, nose or throat.
g. Were you or your spouse ever diagnosed to have hepatitis B or C, HIV/AIDS or any other sexually transmitted disease ?
Have you ever suffered or are suffering from any other ailment/disorder which is specifically not mentioned above?
10. The OP has produced the discharge summary of Deptt. of Gastrointensology of care hospital vide Annexure-C. It reveals that the policy holder was admitted on 7.3.12 and discharged on 12.3.12 as he was diagonised chronic calcific pancreatitis,NIDDM,APD etc. Moreover Annexure D shows that policy holder has representation to Collector requesting to cancel the transfer as he is prolonged patient on hear problem, diabetis and eye sight. He made regular visit to medical at Visakhatpatam. Of course the letter related to 2012. Annexure C & D are enough to show that the complainant has got health problem prior to policy purchased but the proposal form is filled up with answer No with regard to the question put to him on above clause-5 concerning this health condition. When the policy holder has suppressed the material fact of his health problem during filling up the proposal form, it must be held that this is suppression of material fact. Learned District Forum has only observed that the death of the policy holder was having no cirrhosis of lever with hepatic encephalopathy earlier to his purchase of policy. It is not the issue in question. But the issue in question is whether he has suppressed the material in the proposal form. We have already discussed that he being indoor patient and suffered from various elements and suppression of such material fact is a material suppression being proved by the medical report. Therefore, with due regard to the decision of Hon'ble Supreme Court as stated above, the OP has rightly repudiated the claim.
11. In view of above, we are of the opinion that the impugned order being against the fact and law as discussed above, liable to be set-aside. Accordingly it is set-aside.
Appeal stands allowed. No cost.
Free copy of the order be supplied to the respective parties or they may download same from the confonet or webtsite of this Commission to treat same as copy of order received from this Commission.
DFR be sent back forthwith. [HON'BLE MR. JUSTICE Dr. D.P. Choudhury] PRESIDENT [HON'BLE MR. Pramode Kumar Prusty.] MEMBER [HON'BLE MS. Sudihralaxmi Pattnaik] MEMBER