State Consumer Disputes Redressal Commission
Smt.Champa Bhagatsingh Pardeshi vs Hdfc Standard Life Insurance Company on 31 October, 2013
1 F.A.No.:1203/2008
Date of filing :20/11/2008
Date of order :31/10/2013
MAHARASHTRA STATE CONSUMER DISPUTE REDRESSAL
COMMISSION,MUMBAI, CIRCUIT BENCH AT AURANGABAD.
FIRST APPEAL NO. : 1203 OF 2008
IN COMPLAINT CASE NO.: 39 OF 2008
DISTRICT CONSUMER FORUM : AHMEDNAGAR.
Smt.Champa Bhagatsingh Pardeshi
R/o.3880 Ghumare Lane,
Near Bedekar Classes,
Ahmednagar. Appellant
VERSUS
HDFC Standard Life Insurance Company
Near Hotel Natraj nagar,
Aurangabad road,
Ahmednagar. Respondent.
CORAM : Mr.S.M.Shembole, Hon`ble Presiding Judicial Member.
Mrs.Uma Bora, Hon'ble Member.
Mr.K.B.Gawali, Hon`ble Member.
Present : Adv.Shri.Avinash R.Borulkar is present for the appellant.
Adv.Smt.Vaishali Hire is present for the respondent.
O R A L O R D E R Per. Mr.K.B.Gawali, Hon`ble Member.
1. This appeal is filed by the original complainant against the judgment and order dated 24/10/2008 passed by the Dist. Forum, Ahmednagar in CC. No. 39/2008 whereby complaint is dismissed. The respondent herein is the original opponent. For better understanding the appellant hereinafter is termed as the "Complainant", whereas, the respondent is termed as the "Opponent Insurance Company".
2. Facts giving rise to this appeal are as under.
2That, the complainant is the widow of late Bhagatsingh Pardeshi who was working as Engineer in the Maharashtra State Electricity Distribution Company Ltd, at Ahmednagar. That, on 16/03/2007 late Bhagatsingh had obtained "Unit Linked Endoment"
insurance policy for the sum insured of Rs 1,00,000/-. That, the premium amount for first year amounting Rs 20,000/- was also paid by him. The said policy was for the term of 5 years. That on 22/03/2007 Shri.Bhagatsingh had fallen ill having sever temperature and during the treatment he died on 29/04/2007
3. That, following his death, the complainant who is the only successor had filed insurance claim of Rs 1,00,000/- with the opponent insurance company. However, her claim was repudiated by the opponent insurance company vide letter dated 01/10/2007 on the ground of suppression of material fact about his health. It was contended by the complainant that her deceased husband was not having the disease of diabetes as alleged by the opponent insurance company. That, he had died only due to the high temperature which affected his brain etc. She therefore contended that the opponent insurance company denied her claim on false ground and therefore filed complaint before the Dist. Forum seeking direction to the opponent insurance company to pay her Rs 1,00,000/- towards insurance sum along with interest @ 18 % p.a. from 16/06/2007 onwards. He also sought Rs 5000/- as compensation towards mental harassment and further more Rs 5000/- as the cost of the complaint
4. The opponent insurance company appeared before the Dist. Forum and resisted the claim. It did not dispute the insurance policy given to the deceased Bhagatsingh. However, her claim was denied on the ground that the policy holder did not disclose that he was suffering from diabetes meilitus at the time of submitting the proposal form with insurance company and that he had made false statement to the questions given in the proposal form about his health 3 F.A.No.:1203/2008 and habit etc. It was contended that as per the discharge summery dated 19/04/2007 of Sahyadri Speciality Hospital where policy holder Shri.Bhagatsingh Pardeshi had taken treatment before his death, it was revealed that he was suffering from diabetes meilitus for the last 10 to 12 years. That, the opponent insurance company had also obtained medical hospital certificate from Dr. Girish Soni to that effect. It was averred that as per Sec. 45 of the Insurance Act if the material information is suppressed the insurance company is empowered to repudiate the claim. It was therefore contended that since the policy holder did not disclose the correct information about his health of earlier disease at the time of submitting the insurance proposal, the complainant was not entitled for the insurance sum for the said policy and hence her claim had rightly been repudiated and there was no deficiency on the part of opponent insurance company.
5. The Dist. Forum after going through the papers and hearing the parties has dismissed the complaint. The Dist. Forum while passing the impugned order held that on the discharge summery issued by the Sahyadri Hospital, Pune it was revealed that policy holder had suppressed material fact about his disease of diabetes meilitus at the time of submitting the proposal for the said insurance policy. It is further held by the Dist.Forum that as per Sec. 45 of the Insurance Act the opponent insurance company is empowered to repudiate the insurance claim, if it is proved that policy holder have suppressed the material facts about his health. Thus accordingly the complaint was dismissed.
5. Feeling aggrieved by the said judgment and order the present appeal is filed by the complainant. This appeal was finally heard on 31/10/2013 Adv. Shri.Avinash R.Borulkar was present for the appellant and Adv.Smt.Vaishali Hire was present for the respondent. Adv.Borulkar has submitted written notes of arguments, whereas Adv.Shri.G.S.Sirsikar who is appearing for the respondent has 4 already submitted written notes of arguments. We also heard them finally and the appeal came to be adjourned for judgment and order.
6. Adv.Shri.Borulkar appearing for the appellant submitted that the opponent insurance company rejected the claim of the complainant on the ground that the policy holder did not disclose that he was suffering from diabetes meilitus. However, policy holder did not died due to diabetes but due to infection in his ear and other health complications. It was further contended that the policy holder had never taken any treatment for the diabetes before his death and that he was not having any knowledge that he was suffering from diabetes Therefore it can not be said that he made false statement about his health and suppressed the material fact about his disease. It was further averred that during his hospitalization at Sahyadri Hospital, Pune the policy holder was in unconscious state and therefore he had not given any statement in the hospital about his health. Thus he contended that the opponent insurance company on the false ground rejected legimate insurance claim of the complainant. In support of his above said contention he relied on the following citations.
i. Life Insurance Corporation of India - V/s- Vinod Patil 2007 NCJ 454 (NC).
ii. Life Insurance Corporation of India & Ors. -V/s- Dr.P.S.Agarwal 2005 NCJ 181 (NC).
iii. National Insurance Company Ltd - V/s- Bipul Kundu 2005 NCJ 340 (NC) 2005 NCJ 340 (NC).
On the other hand, Ld. Counsel Shri. Sirsikar appearing for the respondent by way of his written notes of arguments submitted that the opponent insurance company has rightly repudiated the claim of the complainant on the ground that suppression of material fact and giving false statement about the status of health at the time of submitting insurance proposal by the deceased policy holder Shri. 5 F.A.No.:1203/2008 Bhagatsingh. It is contended by Ld. Counsel Shri. Sirsikar that policy is a contract between the insurance company and the policy holder which is based on the principles of utmost good faith. That the policy holder did not disclose the correct information as asked in the proposal form of insurance policy. Hence, as per Sec. 45 of the Insurance Act, 1938 the opponent insurance company is empowered to repudiate the claim on the ground of non disclose of the material fact about his health. He thus contended that the Dist. Forum has rightly appreciated the evidence on record placed by the opponent insurance company and rightly passed the impugned order. Therefore the appeal be dismissed with cost.
7. We have carefully gone through the paper as well as written notes of arguments and the authorities as relied on by the Ld. Counsel for the Adv.Shri. Borulkar for the appellant/complainant There is no dispute about the policy issued to the deceased Bhagatsingh. There is also no dispute that complainant is the only successor of the deceased policy holder. However, the only ground for repudiating the claim of the complainant is the suppression of material fact by the deceased policy holder at the time of submitting the insurance proposal. It is contended by the opponent insurance company that deceased policy holder was suffering from diabetes meilitus much prior to his application for insurance which is revealed through it's investigation. It is only on the basis of discharge summary dated 19/04/2007 issued by Sahyadri Hospital Pune and the certificate by Dr. Girish Sony the opponent insurance company has contended that deceased policy holder was suffering from the disease of diabetes meilitus. However, the opponent insurance company has not produced on record any documentary evidence regarding the treatment taken by the deceased policy holder for said disease of diabetes meilitus. It is a well settled principle that mere history of the patient as recorded at the time of treatment can not be taken as the ground for suppression of material fact. In fact it is the contention of 6 the complainant that when the policy holder Shri.Bhagatsingh was hospitalized in the said Sahyadri Hospital he was unconscious and therefore he has not disclosed having about his past disease of diabetes meilitus as alleged by the opponent insurance company.
8. To put in to short the discharged summery report dated 19/04/2007 and the hospital certificate can not be considered for concluding that the policy holder was suffering from the said disease of diabetes meilitus etc. There is no other cogent evidence produced by the opponent insurance company on record to prove that the deceased policy holder had suffered from such disease of diabetes meilitus. It is also to noted as contended by the Ld. Counsel for Shri.Borulkar for the appellant that the policy holder Shri. Bhagatsingh has not died due to diabetes meilitus but due to infection in the ear. The ratio given in the citation in respect of LIC - V/s- Vinod Rani (Supra) the burden of proof to prove suppression of material fact is on the insurance company. In the case under citation the death of the insured was due to accident and not by any disease. Hence, the contention of suppression of material fact was rejected. In the present case the policy holder is died not because of diabetes meilitus but because of sum other health complications which has also not been denied by the opponent insurance company. In the second case under citation i.e. LIC of India and others -V/s- Dr.P.S.Agrawal it is held by Hon'ble National Commission that the insurance company has to prove material concealment and the information collected from hospital is not the primary piece of evidence. In the present case also the opponent insurance company has relied on the hospital report which can not be treated as primary piece of evidence regarding the disease of diabetes meilitus to the insured.
9. In view of the aforesaid facts and observation it is very much clear that the opponent insurance company has rightly repudiated the claim of the complainant as contended by the opponent insurance 7 F.A.No.:1203/2008 company. The insurance company contract is based on utmost trust between the insured and the insurer. This principle is also applicable to the insurance company. However, it appears that it has violated the said principle by repudiating the legitimate claim of the complainant . The Dist. Forum has utterly failed to appreciate this fact and the legal position placed on record by the complainant and wrongly passed the impugned judgment and order by dismissing the complaint. We therefore find much substance in the present appeal and therefore it deserves to be allowed. Hence, the following order.
O R D E R
1. Appeal is alowed.
2. The impugned judgment and order passed by the Dist.Forum is hereby quahed and set aside.
3. The opponent insurance company is hereby directed to pay the insurance sum of Rs 1,00,000/- ( Rs one lakh only ) to the complainant alongwith interest @ 6 % p.a. from the date of repudiation of claim i.e. 02/11/2007.
4. The opponent insurance company is also directed to pay a compensation of Rs 5000/- towards mental harrassment and Rs 1000/- as cost of the complaint.
5. Copies of the judgment and order be sent to both the parties.
K.B.Gawali Mrs.Uma Bora S.M.Shembole
Member Member Presiding Judicial Member
Patil A.H.
Steno H.G.
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