CONSUMER COMPLAINT NO.24/2007.
Friday, the 24th day of April, 2009.
1. Gottapu Uma Devi,
W/o. (Late) G.Venkata Rao,
Hindu, 42 years, Flat No.C-2,
Jaya Residency, Jawaharlal Nehru Road,
2. Gottapu Pravallika,
18 years, Minor.
3. Gottapu Praveen,
15 years, Minor.
(Being 2 and 3 minors Rep. by Mother
Guardian Flat No.C-2, Jaya Residency,
Jawaharlal Nehru Road, Rajahmundry.) ..Complainants.
1. Metlife India Insurance Co. Pvt. Ltd.,
Rep. by its Branch Manager,
Tilak Road, Rajahmundry.
2. Metlife India Insurance Co. Pvt. Ltd.,
Rep. by its Branch Manager,
10-1-31, Ist Floor, Signature Towers,
Waltair Uplands Road,
Visakhapatnam – 530 003. … Opposite parties.
This case is coming for hearing before this Forum and upon perusing the complaint, version of the opposite parties and other material papers on hand and upon hearing the arguments of Sri D.V.K.Ramesh, advocate for the complainants 1 to 3 and Sri P.Rajesh Babu, advocate for the Opposite parties 1 and 2 and having stood over for consideration till this day, this Forum has pronounced the following.
(PER SRI K CH MOHANTHY, PRESIDENT)
This is a complaint filed by the complainant under Section 12 of the consumer Protections Act to direct the opposite parties to pay the sum assured policy amount of Rs.3,30,000/- with interest at 12% p.a amounting to Rs.35,060/- , Rs.20,000/- towards compensation and to award Rs.10,000/- towards costs and other reliefs.
2. The case of the complainant as set out in the complaint is that the 1st complainant’s deceased husband obtained Life Insurance Policy bearing No.1200600158255 under Met Smart Plan for Rs.3,30,000/- and paid an amount of Rs.51,730/- towards premium through the opposite parties agent having code No.11010857 at Rajahmundry. The policy was issued by the 2nd opposite party herein. The complainant’s late husband was an employee in the cadre of operations executive in HPCL, Rajahmundry and keeping good health. The policy from the opposite parties was obtained by the complainant’s late husband on 19.01.2006 after medically examined by their panel doctor of the opposite parties. The complainant’s husband was died on 31.01.2006. The complainants herein sent claim towards the death benefits of deceased life assured to the opposite parties during the month of February 2006, after considerable delay the opposite parties repudiated the claim of the complainants on 16.06.2006 alleging that the deceased life assured did not disclosed his health conditions before issuing the policy and treated the policy as void. The cause of the death of the DLA has no nexus with that of the three existing decease i.e Diabetes. The repudiation of the claim is not legally valid and purely invented by the opposite parties for the purpose of avoiding their genuine liability. The 1st complainant addressed a letter dt 08.07.2006 to the opposite parties and the same was replied. Than the complainant approached Parishkruthi and got issued a notice dt 20.08.2006 and received reply dt 07.09.2006 with false allegations. The repudiation of the claim was intentional and to avoid the liability, which amounts to deficiency of service on the part of the opposite parties. Hence, this complaint.
3. The 1st and 2nd opposite parties filed their written version.
The brief contention of the 1st and 2nd opposite parties are that the main and material allegation in the complaint are not true and correct and the complaint is not maintainable either in law or on facts. It is submitted that the policy was issued by the 2nd opposite party on an application submitted by the Deceased Life Assured on 23.11.2005 for a face value of Rs.4,76,000/-. The application for insurance cover clearly provided that after submission of the application and before the issue of policy if there is any change in general health, occupation, financial position the DLA would have to communicate the same in writing to Met Life. Upon analyzing the risk cover Met Life reverted to the DLA and requested to him to give a counter offer to which the DLA did on 10.01.2006. There upon, Met Life accepted the counter offer and issued Met Smart Policy bearing No.1200600158255 dt 20.01.2006 for a face value of Rs.3,30,000/-. It is true that the DLA paid a premium amount of Rs.51,730/-. Further, it is pertinent to note that in response to a specific query raised in the application for insurance as follows:
“So far as you know, have you ever had or been told you had or been treated for any disorder, disease or disturbance of The Kidney, Bladder or genital organs such an inflammation, stone, tumor, sugar, albumin or blood/pus in the urine?”The DLA answered this in the negative.
The DLA was referred to a medical examiner on 13.12.2005 who examined the DLA and medical questions were asked to DLA, whose answers were recorded by the medical examiner in the medical report. During the examination it was revealed that DLA suffered from Diabetes. In fact, during the medical examination to specific questions pertaining to the Gastro Intestinal System, the DLA once again answered in the negative. Unfortunately the DLA expired on 31.01.2006 and the cause of death reported as Upper GI Bleed and Hepatitis A. Upon receiving the claim intimation on 20.02.2006 this opposite parties communicated to the complainants on 23.03.2006 asking certain documents and the same were furnished by the 1st complainant. After examination of the said documents and investigation it was found that the DLA suffered from Ailments like Haematemesis, Cirrhosis of Liver and Upper Gastro Intestinal Tract Bleed before the issuance of the policy and the same was suppressed by the DLA while obtaining policy from this opposite parties. In fact, the DLA even under gone treatment for Cirrhosis of Liver and Upper GI Tract Bleed for one and half months before his death. Further, the symptoms suffered by the DLA at the time of his death clearly shows that the DLA was suffering from the symptoms even much before his 1st application of 23.11.2005, since the symptoms were a medical indication of an advance stage of lever decease and the material changes in the health were not disclosed by the DLA either at the time of counter offer or any time before issuance of the policy.
It is true that the opposite parties herein received an appeal dt 08.07.2006 from the complainants and same was submitted before the appropriate committee which applied independent mind to the facts and circumstances of the case and decided to uphold the decision taken earlier and the decision was communicated to the claimants on 10.08.2006. It is further denied that the Met Life never responded to the legal notice got issued by the complainants. A contract of Insurance is a contract UBERIMA FIDES and there must be complete good faith on the part of the assured. The assured is under a solemn obligation to make full disclosure of all material facts relevant for the insurer to take into account while deciding whether the proposal should be accepted or not. The DLA in the instance case suppressed and misrepresented the vital facts about his health which would have influenced Met Life’s decision to grant insurance cover. The opposite parties therefore submit that the complaint be dismissed by granting them exemplary costs.
4. Heard both sides. The opposite parties filed their written arguments.
5. Points to be considered in this case are that;
1. Whether there is any deficiency in service on the part of the opposite parties?
2. Whether the complainants is entitled for the claim amounts and other
reliefs asked for? If so, to what extent?
6. Exs.A.1 to A.5 are marked on behalf of the complainant and Exs.B.1 to B.12 were
marked for the 1st and 2nd opposite parties.
7. Admitted facts in this case are that the complainant’s late husband by name G Venkata Rao obtained Ex.A.1 Life insurance policy with a coverage of Rs.3,30,000/- from the opposite parties on payment of Rs.51,688/- as installment premium which includes Rs.14,768/- towards extra premium and the date of commencement of the said policy is from 19.1.2006 to 13.5.2006/-. The deceased life assured was issued life insurance policy after medical examination by the panel doctor of the opposite parties. The complainant’s husband was died on 31.1.2006. The claim of the present complainants on the life of deceased life assured was repudiated under Ex.B.11 letter Dt.16.6.2006 by the opposite parties.
8.POINT NO.1: The case of the complainant is that though her late husband obtained life insurance policy from the opposite party Met life insurance Company after medical examination, vide policy No.1200600158255 under Met Smart plan for Rs.3,30,000/- on payment of Rs.51,730/- as premium which included extra premium amount, but the opposite parties repudiated the complainants claim for the death benefits on deceased life assured with an allegation that the DLA did not disclosed his health condition, hence they treated it as the policy is void.
Whereas, the opposite parties contended that the DLA applied for insurance coverage on 23.11.2005 and in the application itself it clearly provided that if after the submission of the application for coverage and before the issuance of policy, if there was any change in general health, occupation, financial position the DLA has to communicate the same to the insurance company. Upon analyzing the risk cover Met Life reverted to the DLA and requested to give a counter offer that the DLA did on 10.1.2006. Thereupon, this opposite parties issued policy on 20.1.2006 for face value of Rs.3,30,000/-. It is further submitted that in response to a specific query i.e “So far as you know, have you ever had or been told you had or been treated for any disorder, disease or disturbance of the Kidney, Bladder or genital organs such an inflammation, stone, tumor, sugar, albumin or blood/pus in the urine?” the DLA answered this in the negative. Further it is submitted that the DLA was referred to panel doctor for medical examination on 13.12.2005 and during examination the DLA’s answers were recorded by the doctor. At the time of this medical examination it was revealed that DLA suffered from diabetes and to specific questions pertaining to the Gastro Intestinal system the DLA answered in the negative. Unfortunately the DLA was expired on 31.1.2006 and the cause of the death was reported as Upper GI bleed and Hepatitis. The claim intimation was received on 20.2.2006 and on submission of documents by the complainant in reply to this opposite parties letter Dt.23.3.2006, upon examination of the said documents and investigation it was revealed that DLA suffered from ailments like Haematemesis, Cirrhosis of Liver and Upper Gastro Intestinal Tract Bleed which he suppressed at the time of obtaining policy. It is submitted that in fact the DLA undergone treatment for the above said ailments one and half months before his death. Further, the symptoms suffered by the DLA clearly shows that he was suffering from the ailments even much before his application i.e on 23.11.2005, since the symptoms were a medical indication of advanced stage of liver disease and suppression of this facts are material for the assessment of risk.
As per the insurance terms of the application the DLA was required to inform any changes in his health between the date of the application and issuance of policy. The DLA submitted his application on 23.11.2005 and accepted by the DLA on 6.1.2006 and the policy was issued on 19.1.2006. But the DLA undergone treatment for Cirrhosis of liver and GI Track bleed from 19.12.2005 to 26.12.2005 and the DLA suppressed this fact which gravely impacted the under writers decision. Hence, the claim was repudiated by this opposite parties and even the repudiation was upheld by the appropriate committee on 8.7.2006 which was communicated to the complainant on 10.8.2006. So, the present case on hand is a crystal clear case of MISREPRESENTATION, FRAUD AND SUPPRESSION OF MATERIAL FACTS and a deliberate non disclosure by the diseased life assured is nothing but with a mallifide intention.
On perusal of the entire record it was found that the complainant obtained Life insurance policy from the opposite parties after undergoing medical examination by their panel doctor and was charged extra premium of Rs.14,768/- along with base policy premium of Rs.36,920/- and this extra premium was charged because the DLA was a diabetic. As per Ex.B.3 Medical certificate it was found that the deceased life assured maintained good health and he complained for the first time on 18.12.2005 of Hematemesis of sudden unrest and after initial treatment he was referred to Dr A Srinivasa Rao for further evaluation and treatment by the family doctor. It was found in Ex.B.2 discharge summery given by Dr A Srinivas Rao, Gastroenterologist who treated the DLA from 19.12.2005 to 26.12.2005 diagnosed cirrhosis of liver with GI Bleed – Non B, Non C stated and that the DLA underwent Sclerotheraphy for bleeding varices, bleeding was stopped and the general condition was improved. The doctor further certified that the DLA was discharged on 26.12.2005 after satisfactory improvement. So, it is evident that the DLA diagnosed for the ailments only on 19.12.2005 and was discharged on 26.12.2005 after treatment as his general condition was improved from the said ailments.
As per Ex.B.6 death summery said to be issued by one Dr Sukanya, Registrar, without hospital name, the DLA was treated from 24.1.2006 to 31.1.2006 in their hospital and the illness was mentioned as Haepatitis-B, Decompensated Cirrhosis and the cause of death was upper GI bleed? Post EST Ulcer Bleed. As per this during the treatment as Post EVL bleeding subsided and sensorium also improved with colloids and albumin. Three days after admission he was shifted out of ICU where he remained stable, but started accumulating ascites, with oliguria. On 30.1.2006 the DLA had a sudden episode of transient hypotension from which he recovered, but again developed hypertension and was shifted to ICU where he developed 1 episodes of Bradycardia from which he was revived intubated, ventilated and put on ionotropes. Afterwards the deceased remained extremely unstable Hemodynamically and had another cardiac arrest from which he could not be revived despite prolonged CPR and declared dead on 31.1.2006.
Further, we found from Ex.B.7 questionnaire regarding treatment details of DLA, that certificate was issued by an hospital administrator of Global Hospitals, Hyderabad that the DLA was admitted in their hospital with G I bleeding and he was under drowsiness and restless and the DLA suffering from Cirrhosis of liver from one and half months as per the statement of DLA at the time of admission. This questionnaire was not supported by any authenticated medical record and there is no affidavit filed by the administrator. The genuineness of this certificate is very much doubtful as this certificate was signed by the Hospital Administrator by name Dr S Sunil Kumar who did not treat the DLA and this certificate sans official seal of the hospital. Even, if we take this certificate into consideration the DLA suffered from the diseases prior to one and half months of his death i.e mid December, 2005, the DLA was might not aware of the symptoms during the time of his medical examination by the panel doctor on 13.12.2005. Further, it was also evident from Ex.B.2 and B.3 medical certificates that for the first time the DLA was treated for the diseases on 19.12.2005 only, so, the diseases were not preexisting diseases. It is further observed that the opposite parties alleged that the DLA did not inform them about his changed health condition, but as per Ex.B.2 certificate issued by the Gastroenterologist that after treatment the DLA’s general condition was improved and as such he was discharged. So, it is evident that the DLA’s health condition was normalized after treatment and there is no need to inform the same to the opposite parties. Even as per Ex.B.5 statement by S Sriram Naik, neighbour of DLA, the DLA used to maintain good health. It is further observed that the DLA paid the premium amount of Rs.51,688/- including extra premium of Rs.14,768/- along with his application dt.23.11.2005 vide Ex.A2 application and further there is no evidence with regard to Medical examination done on dt.13.12.2005 by panel doctor and found the DLA as Diabetic. But , by this date the DLA had already paid extra premium ,How could it possible ?
Hence, we are in the considered opinion that the DLA suffered with the said diseases only after his medical examination and he was not known about the symptoms of the said diseases during the time of submission of application for life insurance policy to the opposite parties. “ As per the medical science the diagnosis of Cirrhosis is usually based on the presence of a risk factor for cirrhosis, such as alcohol use or obesity, and is confirmed by physical examination, blood tests, and imaging. The doctor will ask about the person’s medical history and symptoms and perform a thorough physical examination to observe for clinical signs of the disease. For example, on abdominal examination, the liver may feel hard or enlarged with signs of ascites. The doctor will order blood tests that may be helpful in evaluating the liver and increasing the suspicion of cirrhosis.
It is further noted that cirrhosis is a condition in which the liver slowly deteriorates and malfunctions due to chronic injury. Many people with cirrhosis have no symptoms in the early stages of the disease.
As the disease progresses, symptoms may include weakness, fatigue, loss of appetite, nausea, vomiting, wait loss, abdominal pain and bloating, itching and spiderlite blood vessels on the skin. As the liver function deteriorates one or more complications may develop and in some people complications may be the first signs of the disease” (Source:Wikepedia). Hence, it is clear that in the present case the DLA was not aware of the symptoms if any and further he was physically examined by the panel doctor of the opposite parties and even the doctor could not find any problem on abdominal examination of DLA and so, the doctor did not advise further tests.
It is well settled that in case of suppression of material facts the insured must undergone treatment for a longer period as an in-patient or got operated within the period of 5 years prior to obtaining the policy and the insurer must prove this by adducing evidence through Medical records pertaining to the treatment given by the doctor to the insured. Further, as per the decision reported in AIR 2008 (NOC), 955 NCDRC, between National Insurance Company Vs Raj Narayan wherein it was held; “that every person suffers from symptoms of any disease without knowledge of the same – as insured unaware of disease at the time of making policy – Insurance Company liable to assured amount”.
With the discussion held supra we are in the considered opinion that the DLA was treated for the above said diseases on 19.12.2005 to 26.12.2005 for the first time and recovered. Again after one month he was admitted for treatment of the said diseases and while undergoing treatment he had cardiac arrest from which he could not be revived despite prolonged CPR and died on 31.1.2006. So, it is evident that the claim for death benefits of the DLA was repudiated in a routine and mechanical manner by the opposite parties as the DLA was died within a short period after obtaining policy. The opposite parties herein completely failed to prove their case with any constructive proof that the DLA had the above said diseases prior to obtaining life insurance policy from Met life on his application Dt.23.11.2005 which is nothing but deficiency of service on the part of the opposite parties. Under these circumstances the opposite parties are certainly liable to pay the claim amount to the complainants herein. Further, it is observed that as per Ex.B.11 Dt.16.6.2006 the opposite parties herein refunded an amount of Rs.48,801/- to the complainants, but the same was not stated either in the complaint or in the version to the reasons best known to the opposite parties. If this amount of Rs.48,801/- was refunded to the complainant, the same may be deducted from the claim amount and the balance to be paid to the complainants.
9.POINT NO.2: In the result, the complaint is allowed directing the opposite parties to pay an amount of Rs.3,30,000/- (Rupees three lakhs thirty thousand only) with interest @9%P.A from the date of filing complaint i.e 24.1.2007 till realization. We further direct the opposite parties to pay Rs.2,000/- (Rupees two thousand only) towards costs of this complaint.