BEFORE THE KARNATAKA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BANGALORE.

DATED THIS THE 18^th DAY OF AUGUST 2021

PRESENT

MR. RAVISHANKAR                           : JUDICIAL MEMBER

MRS. SUNITA CHANNABASAPPA BAGEWADI :      MEMBER

APPEAL NO. 2222/2017

V/s

ORDER

BY MRS. SUNITA CHANNABASAPPA BAGEWADI , MEMBER

1.      The appellant/Opposite Party has preferred this appeal being aggrieved by the Order dt.27.09.2017 passed in CC.No.30/2017 on the file of District Consumer Disputes Redressal Commission, Koppal.

2.      The facts leading to the appeal are as under;

It is the case of the complainant that the son of the complainant during his lifetime had obtained an insurance policy from the Opposite Party vide policy No.02679258 dt.07.02.2013 by paying half yearly premium of Rs.10559/- and sum assured under the policy is Rs.7,00,000/- the complainant was made as nominee to the said insurance policy.  The complainant further alleged that insured son of the complainant Sri Hanamanthappa died on 18.05.2013 due to heart attack.  Thereafter the nominee under the policy i.e. complainant filed his claim along with required documents before the Opposite Party.  But the Opposite Party on 31.03.2015 sent a letter stating that the deceased life assured had not given information regarding other policies already obtained.  The complainant submitted all the necessary documents, but, the Opposite Party falsely repudiated the claim of the complainant for escaping from its liability, this act of the Opposite Party amounts to deficiency in service.  Hence, the complaint.

3.      After service of notice, Opposite Party appeared through his counsel and filed their version.  Opposite Party in its version submitted that the policy was issued on the basis of the information provided by the life assured was incorrect, hence, the Opposite Party has every right to repudiate the claim.  It is further submitted that the policy under question bearing vide policy No.02679258 dt.06.02.2013 by paying half yearly premium of Rs.10,559/- and sum assured under the policy is Rs.7,00,000/- believing the same to be true and correct.  It is further contended that the deceased insured had not taken insurance policy directly from the Opposite Party but, he obtained the same from an agent i.e. Allegro Insurance Brokers Pvt. Ltd., who is IRDA licensed broker, so the complaint is not maintainable against the Opposite Party.  It is further contended that it is found in the investigation that the DLA was undergoing Anti Retroviral Therapy at ART Centre, Koppal for HIV disease much prior to the signing of the proposal and risk commencement of the policy and the DLA suppressed the fact that he had taken policy from other insurer i.e., Aviva Life Insurance Company bearing policy No.20993148 for Rs.10 lakhs much prior to the date of issuance from Opposite Party.  The Opposite Party tried to trace the medical records of the DLA, but, due to NACO guidelines which say that no information would be given about the individual who was suffering from the said disease, therefore, the Opposite Party could not obtain the documentary evidence.  Therefore, there was a major non-disclosure and was intentional in order to induce the Opposite Party to issue the subject policy.  Therefore, there is suppression of material fact regarding the health status of the life assured and also existing other insurance policy.  Hence, the Opposite Party rightly repudiated the claim of the complainant vide letter dt.31.03.2015, on the ground of “pre existing policies and medical aliment of life assured”.  Hence, there is no deficiency in service on the part of the Opposite Party, hence, prays for dismissal of the complaint with costs.

4.      After trial, the District Commission allowed the complaint and directed the Opposite Party to pay a sum of Rs.7 lakhs to the complainant along with interest, compensation and costs.

5.      Being aggrieved by the same, the appellant/ Opposite Party is in appeal.  Heard the arguments.

6.     Perused the appeal memo, Order passed by the District Commission and materials on record, we noticed that there is no dispute regarding the son of the complainant Mr.Hanamanthappa had obtained the policy bearing by name Kotak Life Insurance under policy No.02679268 commenced from 07.02.2013 and had half yearly premium of Rs.10,559/- for sum assured of Rs.7,00,000/-.  There is also no dispute that the premium towards the policy is not paid by DLA and on 18.05.2013, the complainant died due to heart attack leaving the life assured as a nominee under the policy.  After the death of DLA, the complainant as a nominee approached the insurance company and claimed for assured amount along with benefits and submitted that the claim form and necessary documents, but, the appellant repudiated the claim on the ground that the life assured has suppressed the material facts as the deceased was going for ART (Anti Retroviral Treatment) from District Centre, Koppal and obtained the said policy. 

7.      Perused the materials on record, the appellant has produced the investigation report at lower court.  Perused the investigation report, the opinion of the investigator is “During the enquiry, it is informed that LA was HIV patient and has taken treatment in the local PHC prior to his death.  But despite of our thorough enquiry, the concerned authority refused to verify the HIV patient’s records.  In investigation report, Clause-F – Important Findings: “Only Gramsevak also informed that the LA was a HIV patient”.  In that only Gramsevak informed that the life assured was HIV patient.  Except that the appellant has not produced any documents showing that the DLA suffering from HIV and took treatment prior to taking the policy in question the DLA had taken treatment of HIV from any hospital.  The HIV is a Human Immunodeficienty Virus, acquired immunodeficiency syndrome means an illness which is caused by infection with retrovirus.  HIV transmitted in sexual fluids and blood in which opportunistic infection or malignant tumors developed as a result of the severe loss of cellular immunity.  Further, the disease HIV is such a disease that could be diagnosed only after some tests and since there is nothing on record to prove the fact that prior to taking the policy, the deceased had undergone for any tests.  Therefore, in the absence of that, it could not be said that the deceased was suppressed the material facts regarding his health.  Moreover, if a person who is HIV positive, the result will go in his medical record and may be shared with his healthcare providers and his health insurance company.  Apart from that the disease of HIV is such a disease which came into light when diagnosis is made.  In such case, there is nothing on record to prove the fact.  Mere investigation report is no sufficient to prove the contention of appellant.  The contention of appellant that the complainant has suffering from HIV and taken treatment for any hospital before taking the policy has no weightage if there is no any document placed before the Commission by the appellant.  Hence, the appellant are not justified in not settling the claim of the respondent on the ground of suppression of material facts regarding the health of DLA.  Hence, in our opinion, the District Commission has rightly passed the Order that there is no any irregularity and we found no error in the Order passed by the District Commission.  Hence, the following;

ORDER

The appeal is dismissed.

The amount in deposit shall be transmitted to the District Commission for disbursement of the same to the complainant. 

Forward free copies to both parties.

     Sd/-                                                                   Sd/-

MEMBER                                          JUDICIAL MEMBER

KCS*