DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.



Complaint no.207 of 7.4.2008. Date of Order 5.3.2009.



Kuldeep Singh son of Sh. Sohan Singh resident of B-IV-1268/19, Baba Thaan Singh Nagar, near Bank of Baroda, Ludhiana.

….Complainant.

Versus



ICICI Prudential Life Insurance Company Limited, ICICI Prulife Tower, 8089, Appasaheb Marathe Marg, Prabhadevi, Mumbai 400 025, through its Managing Director/Chairman.

….Opposite party.



COMPLAINT UNDER SECTION 12 OF THE CONSUMER PROTECTION ACT, 1986.

Quorum:

Sh. T.N. Vaidya, President.

Sh. Rajesh Kumar, Member.



Present: Sh. S.S. Chopra Adv. for the complainant.

Sh. S.S. Ahuja Adv. for opposite party.



O R D E R



T.N. VAIDYA, PRESIDENT:



1- Sh. Harsimran Singh was son of the complainant, having purchased insurance policy bearing no.05507557 for a sum of Rs.5,00,000/- from the opposite party. Sh. Harsimran Singh unfortunately died on 24.10.2007 in SPS Apollo Hospital, Ludhiana, due to breathlessness associated with cough. Father of the complainant being nominee in the insurance policy, lodged claim with the opposite party, who then called for certain documents vide letter dated 24.12.2007. Before complainant could comply with the letter and supply additional documents demanded, rejected the claim vide letter dated 4.1.2008. This repudiation has been challenged to be null, void and illegal, by filing the present complaint under section 12 of the Consumer Protection Act, 1986. It is averred that son of the complainant was not suffering from any disease nor he suppressed any such disease while purchasing the policy. So, repudiation was illegal. Hence, he is entitled for insurance amount of Rs.5 lacs with 10% interest and compensation of Rs.50000/- as well as litigation costs of Rs.11000/-.

2- Opposite party in their reply admitted obtaining insurance policy by son of the complainant, lodging insurance claim after death of policy holder and repudiating the same. They have justified repudiation on the ground that policy holder was suffering from coronary artery disease and had undergone cardio pulmonary bypass on 16.8.2004. But had not disclosed full and correct facts regarding his health and medical history. The duration of the policy was just four months. He was also hospitalized for the diseases for 14 days in 2004. Had son of complainant disclosed true state of his health and ailment with which he was suffering, the policy would have been refused. So, by repudiating the claim, opposite party acted in terms of conditions of policy and not arbitrarily. Therefore, complaint having no base, liable to be dismissed.

3- Both parties adduced evidence in support of their claims and stood heard through their respective counsels.

4- The only question to be decided is whether son of the complainant, while purchasing the insurance policy, made false disclosure qua his health and ailment. The policy commenced on 19.6.2007 and within four months of its purchase, policy holder died. Ex.A application for purchasing policy by Harsimran Singh goes to show that he had answered all columns of para no.27 in affirmative. Column no.27 deals with health situation of the policy holder at the time of filling the form. Questionnaire no.27 (b) (e) (g) and (h) are relevant for the purpose, which all were answered in negative by him. They are re-produced as under-





Question No.


Question in the application for insurance


Reply

27(b)


Have you ever consulted any doctor or are you Currently undergoing/have undergone any tests, investigations, awaiting results of any tests or investigations and have you even been advised to undergo any tests, investigations or surgery or been hospitalised for general check up, observation, treatment or surgery?




No

27(e)


Did you have any ailment/injury requiring treatement/medication for more than a week?




No

27(g)


Have you ever suffered or are suffring from any of the following:

x. Chest pain, Palpitation, Rheumatic Fever, Heart Murmr, Heart Attack, Shortness of breath or any other heart related disorder.




No

27(h)


Any other illness or impairment not mentioned Above.


No



5- After death of the policy holder on 23.10.2007, complainant being father and nominee under the policy, made claim vide application Ex.C14, containing certificate of the doctor/hospital. In that certificate, cause of death was mentioned cardio respiratory. Also it was intimated that from 5.8.2005 to 7.8.2005, had remained as OPD patient and indoor patient in the hospital. Three years back in August, 2004, got treatement in Escort Hospital, New Delhi, qua breath and cough related problem. He had complained of dysponea and was advised to consult Cardiac Consultant and referred to Escort Hospital, New Delhi. He had problem of severe dysfunction for which in August, 2004, had taken treatement as indoor patient. As per doctor of SPS Apollo Hospital, Ludhiana, qua which reference has come in claim form Ex.C14, the patient was suffering from shortness of breath with tachyponea, resulting in cardiac arrest, continuing since 4 years.

6- Ex.C17 report dated 18.10.2007 of SPS Apollo Hospital, Ludhiana, qua Sh. Harsimran Singh and conclusion drawn on the report, goes to show that he was suffering from:-

1- Post AVR.

2- Normal functioning of prosthetic aortic valve.

3- No significant gradient across it.

4- Mild to moderate MR/Trivial AR.

5- Mild TR.

6- Moderate PAH.

7- Grossly dilated LV with severe LV systolic dysfunction.



7- But qua such ailment and treatement earlier, he had not disclosed anything. It is in these circumstances question whether son of complainant obtained insurance policy by suppressing his ailment from opposite party, amounting to breaching the faith. Because such ailments with which he was suffering, were never disclosed by him while purchasing the policy, as is apparent from answers given in the application form to questionnaire no.27.

8- According to ld. counsel for complainant, the so called ailment relied by opposite party, to repudiate the claim, wasn’t in near proximity of purchasing the insurance policy in June, 2007. That ailment of 2004 had nothing to do with his purchasing the policy and at that time, was not suffering from such disease for which, had taken treatement in August, 2004. Hence, opposite party was not justified in repudiating the claim.

9- The ailment for which, policy holder had taken treatement as indoor patient in New Delhi hospital, in August, 2004, had relation and link with his ultimate cause of death, due to breathlessness and cough. As he had some heart problem which he did not disclose while purchasing the policy from the opposite party. His arteries were affected, creating heart problem since 2004. This problem was continuing and consequently, has to be taken in near proximity of purchasing the policy in June, 2007. Consequently, can not be said that the ailment suppressed, was not in near proximity of purchasing the policy. The ailment was long and continuing. The policy holder was bound and required to disclose such ailment with which, was suffering while purchasing the policy, but failed to do so.

10- Hon’ble National Commission in a case titled as “Goparatnam & Ors. Vs LIC”, reported in I(2006)CPJ-78(NC), on account of suppression of material information at the time of revival of policy and obtaining of new policy, has held that the insurance is a contract of good faith and violation of it, by any party, ousts its claim against other and consequently, justified the repudiation.

11- In LIC of India & Ors. Vs Smt. Shashi Bala IV(2003)CPJ-91(NC), Hon’ble National Commission upheld the repudiation of the claim, as deceased was suffering from diabetes, which was not disclosed while purchasing the insurance policy.

12- In D.K. Jain Vs United India Ins. Co. Ltd. reported in I(1995)CPJ-33, as complainant has suppressed material intimation qua his health, so claim was held rightly repudiated.

13- Same view was held by the Hon’ble Supreme Court in P.C. Chacko & Anr. Vs Chairman, Life Ins. Corp. of India & Ors. 2008(1)Civil Court Cases-206(SC).

14- So, in these circumstances, keeping in view the above aspects and facts of the case in mind, we are also of the opinion that the opposite party was justified in repudiating the claim. As it is proved that while purchasing the policy, the policy holder suppressed material information qua his health and ailment from the opposite party and by such mis-statement, obtained the same, therefore, the opposite party was justified in repudiating the claim.

15- Sequel to the discussion, we find no merits in the complaint and the same is dismissed, leaving the parties to bear own costs. Copy of order be made available to the parties free of charge. File be consigned to record room.





Announced on 5.3.2009. T.N. Vaidya, President.