National Consumer Disputes Redressal
Lic Of India & Ors. vs N.P.Nagarathna on 14 March, 2012
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO.3201 OF 2007 (From the order dated 13.06.2007 in Appeal No.1811/2006 of the State Commission, Karnataka) LIC of India & Ors. Petitioners(s) Versus N.P.Nagarathna Respondent(s) BEFORE : HONBLE MR.JUSTICE ASHOK BHAN, PRESIDENT HONBLE MRS. VINEETA RAI, MEMBER For the Petitioners(s) : Mr.Ashok Kashyap, Advocate For the Respondent(s) : NEMO. Pronounced on 14th March, 2012 ORDER
PER VINEETA RAI, MEMBER This revision petition has been filed by Life Insurance Corporation of India (hereinafter referred to as the Petitioner) being aggrieved by the order of the State Consumer Disputes Redressal Commission, Karnataka (hereinafter referred to as the State Commission) in Appeal No.1811/2006 decided in favour of N.P.Nagarathna, Respondent herein who was the original complainant before the District Forum.
In her complaint before the District forum, Respondent had contended that her deceased husband, Pundalika Rao (hereinafter referred to as the insuree) has purchased one Medi-claim insurance policy from the Petitioner/Insurance Company on 24.07.2002 for a sum of Rs.2 lakhs. Unfortunately, the insuree passed away on 16.09.2002 and as nominee of the insuree, Respondent filed a claim with the Petitioner/Insurance Company enclosing the required documents including the death certificate etc. and although the Petitioner assured her that the claim would be duly settled, Respondent was shocked to receive a letter dated 24.10.2003 informing her that the claim had been repudiated on the grounds that her late husband has withheld information regarding his health at the time submitting his proposal for insurance since he was suffering from a pre-existing disease. The repudiation was challenged by the Respondent since at the time of purchasing the policy and before it was issued, the insuree was subjected to a series of medical tests by a qualified medical doctor appointed by the Petitioner/Insurance Company and it was only thereafter that the insurance policy was issued to him. She further contended that prior to 15.09.2002, her husband enjoyed good health and on that date he was rushed to the hospital with breathing problems and despite the doctors best efforts, he passed away the next day i.e. 16.09.2002 due to cardiac respiratory arrest as certified by the doctor. Therefore, aggrieved by the repudiation of her claim, she filed a complaint before the District Forum on grounds of deficiency in service and requested that Petitioner/Insurance Company be directed to pay her, the sum assured under the policy with interest @ 21% per annum from the date of claim till realization, Rs.50,000/- as general damages and Rs.1,000/- as litigation costs.
Petitioner challenged these contentions and stated that there was credible proof on record that prior to his having taken the insurance policy, the insuree had been admitted to Karnataka Cancer Therapy & Research Institute, Hubli on 01.06.2002 for treatment of Non-Hodgkins Lymphoma but he suppressed this fact by replying in the negative to a specific query whether he had consulted a medical practitioner for any ailment requiring treatment for more than a week or if he had been admitted to any hospital or a nursing home for treatment etc. during the last 5 years, whether he had suffered from any diseases etc. Since, this amounted to suppression of a material fact and breach of utmost good faith on which a contract of insurance is based, the claim was rightly repudiated.
The District Forum allowed the complaint by observing that the insuree died due to cardiac respiratory arrest and not due to Non-Hodgkins Lymphoma and therefore, there was no relation between the two and therefore, no material facts were suppressed. Petitioner was directed to pay the Respondent, Rs.2 lakhs along with interest @ 6% per annum from 27.07.2002 till realization.
Aggrieved by this order, Petitioner filed an appeal before the State Commission which dismissed the same by inter alia observing that although the Petitioner/Insurance Company had produced hospital record of Karnataka Cancer Therapy & Research Institute in support of its case, no affidavit of any doctor to prove the contents of the hospital records had been filed. Further, Dr.Narendra who had examined the Respondent had stated that he had only examined the insuree in respect of his cardiac problems after the insurance proposal form was filled up and therefore, his statement could not prove that insuree was suffering from any pre-existing diseases.
Hence, the present revision petition.
Counsel for Petitioner was present. Although notices were issued, none appeared on behalf of the Respondent.
Since, service is complete, it was decided to hear the case and dispose of the case ex parte.
Counsel for Petitioner contended that the Fora below erred in not taking into account the detailed medical records produced from the Karnataka Cancer Therapy & Research Institute which clearly stated that the insuree had been suffering from Non-Hodgkins Lymphoma which was detected on 12.06.2002 and he was given Chemotherapy. Further, the pathology and other reports also confirm these findings. All these documents have been certified and attested by the Administrative Officer of the Karnataka Cancer Therapy & Research Institute and filed in evidence.
It is an admitted fact that the insuree expired following cardiac respiratory arrest and in the medical attendant certificate which has not been disputed, it is clearly stated that while the primary cause of death was left vascular failure, the secondary cause was Lymphoma. Also in his deposition before the District Forum, Dr.Narendra has clearly stated that the insuree died due to cardiac failure which was the result of the Chemotherapy he had undergone for Non-Hodgkins Lymphoma. He further stated that although he cannot say when exactly the disease started, it appears to be a long standing ailment. In view of these facts, it is clearly established that the insuree suffered from a pre-existing disease at the time when he took the insurance policy and in fact expired only 39 days thereafter. The claim was, therefore, rightly repudiated on grounds of suppression of material facts as per the terms and conditions of the policy.
We have heard learned Counsel for Petitioner and have gone through the evidence on record. We find force in the contention of Counsel for Petitioner that there is adequate and credible evidence on record to show that Respondent had been under treatment in the Karnataka Cancer Therapy & Research Institute w.e.f. 12.06.2002 for Non-Hodgkins Lymphoma and this fact is fortified by the laboratory reports confirming the same. Apart from this, as stated by Dr.Narendra who attended on the patient when he was brought with cardiac problems on 15.09.2002 that one of the causes of death was Chemotherapy for Non-Hodgkins Lymphoma which led to the cardiac respiratory arrest. The Fora below erred in not looking at all these aspects of the case in its totality and erroneously concluding that there was no credible evidence on record that insuree had suppressed material facts. In fact as discussed earlier there is credible documentary evidence that the insuree had been suffering from Non-Hodgkins Lymphoma and had taken treatment for the same whereas in the insurance proposal form, he had clearly denied that he had consulted a medical practitioner for any ailment requiring treatment for more than a week or if he had been admitted to any hospital or a nursing home for treatment etc. during the last 5 years, whether he had suffered from any diseases etc. The State Commissions finding that although the documents were there since there was no affidavit to support of them, these cannot be treated as admissible evidence, is not acceptable since no credible evidence has been produced to controvert the fact that these were genuine documents. Further as stated earlier, the doctor(Dr.Narendra) who treated the insuree for his cardiac problem has also confirmed that one of the causes for this was Chemotherapy. These facts have not been challenged before the Fora below.
It is well settled through a number of judgments including of the Apex Court that an insurance policy between the two parties is based on the principle of utmost good faith and breach of the same would justify repudiation of the insurance claim. In the instant case, by suppressing material facts regarding his pre-existing diseases the insuree breached the principle of utmost good faith as also the terms and conditions of the policy. We, therefore, have no option but to set aside the order of the State Commission and allow the revision petition with no order as to costs. Complaint is dismissed.
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(ASHOK BHAN J.) PRESIDENT Sd/-
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(VINEETA RAI) MEMBER /sks/