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Judgment
Since copy of the repudiation letter filed in the revision petition was not complete, a complete copy of the said document has been taken on record. I have heard the learned counsel for the petitioners.
No one has appeared in this matter for the complainant, despite her service. Late Molleti Eswara Rao, husband of the complainant took two life insurance policies from the petitioner company on 31.03.2010. He having died due to Jaundice on 21.09.2010, a claim under the aforesaid policies was submitted on 27.12.2010. The claim however, was repudiated vide letter dated 26.05.2011 which, to the extent it is relevant, reads as under:
"On investigation and from medical documents, we understand that late Mr. Molleti Eswara Rao was diagnosed for renal failure during February 2010 and was under treatment.
Late Mr. Molleti Eswara Rao submitted proposal for insurance on 31/03/2010 the relevant questions in the proposal form and answers provided by him are reproduced below:
Question 29: 'Are you currently taking any medication or drugs, other than minor conditions, (eg. cold and flu), either prescribed by a doctor, or have you suffered from any illness, disorder, disability or injury during the past 5 years which has required any form of medical or specialized examination (including chest x rays, gynecological investigations, pap smear or blood tests), consultation, hospitalization or sugery?'
Answer: No
Question 31: 'Do you suffer from any medical ailments eg: diabetes, high blood pressure, cancer, respiratory disease (including asthma), kidney or liver disease, stroke, any blood disorder, heart problems, hepatitis or Tuberculosis, psychiatric disorder, depression, HIV, AIDS or a related infection?'
Answer: No
Late Mr. Molleti Eswara Rao submitted proposal for insurance on 31/03/2010 the relevant questions in the proposal form and answers provided by him are reproduced below:
Question 29: 'Are you currently taking any medication or drugs, other than minor conditions, (eg. cold and flu), either prescribed by a doctor, or have you suffered from any illness, disorder, disability or injury during the past 5 years which has required any form of medical or specialized examination (including chest x rays, gynecological investigations, pap smear or blood tests), consultation, hospitalization or sugery?'
Answer: No
Question 31: 'Have you ever in the past suffered or presently suffering from any medical ailments such as: disorder of the heart, chest pain in high blood pressure stroke, asthma, any respiratory problems, cancer of tumour, lump of any kind of diabetes, hepatitis, disorder or stones in urinary tract or kidneys, blood disorders (including anemia), mental or psychiatric conditions, Tuberculosis, disease of brain or nervous system, fits (epilepsy), AIDS or tested positive for HIV?'
Ans: No
The non-disclosure renal disease was material to the issuance of the policy and ought to have been disclosed in the proposal form. By not doing so, the proponent had misled us to grant his insurance cover in the policy schedule.
In the light of the above facts and the irrefutable evidence we hold that we were provided with false and inaccurate answers, we are constrained to repudiate the claim under the policy in terms of Section 45 of the Insurance Act 1938. According to our policy conditions, all claim benefit shall cease and all monies that have been paid will be forfeited to us. We are pleased to inform you that the fund balance of Rs.4458.95/- is being paid. Our branch officials will personally hand over the cheque to you."
Being aggrieved from the repudiation of the claim, the complainant approached the concerned District Forum by way of a consumer complaint. The complaint was resisted by the petitioner primarily on the grounds on which the claim had been repudiated.
The District Forum having dismissed the complaint, the complainant approached the concerned State Commission by way of an appeal. Vide impugned order dated 13.07.2017, the State Commission allowed the appeal filed by the complainant and directed the petitioner to pay a sum of Rs.1,00,000/- under one policy and a sum of Rs.4,00,000/- under the other policy, alongwith compensation quantified at Rs.50,000/- and the cost of litigation quantified at Rs.10,000/-. Being aggrieved from the order of the State Commission, the petitioner is before this Commission by way of this revision petition. As would be seen from the repudiation letter, the case of the petitioner in nutshell is that late husband of the complainant was suffering from Acute Renal Failure since February 2010 and this material fact was concealed by him while obtaining the insurance policies on 31.03.2010. In order to prove the alleged concealment, the petitioner relied upon a Discharge Summary purporting to be issued by King George Hospital, Jagdamba Junction, Vizag.
As far as the above referred discharge summary, one Molleti Eswara Rao was suffering from Acute Renal Failure. He was admitted on 26.02.2010 and discharged on 23.03.2010. If the aforesaid document is correct, it is evident that the deceased insured was suffering from a life threatening disease but the said life threatening disease was concealed by him while taking the insurance policies about eight days after his discharge from the hospital. However, the petitioner company neither examined the author of the discharge summary nor did it examine any official from King George Hospital to prove the aforesaid documents. In my view, the petitioner company must necessarily be given an opportunity to prove the aforesaid discharge summary preferably by summoning the author of the said discharge summary from King George Hospital and in case the author of the discharge summary is not available any more with the aforesaid hospital, some other doctor/official of the hospital conversant with the signature of the author of the discharge summary, alongwith the relevant record relating to the admission, treatment and discharge of deceased husband of the complainant.
The impugned order is therefore, set aside subject to payment of Rs.25,000/- as cost to the complainant and the consumer complaint is remitted back to the concerned District Forum to decide the same afresh after giving an opportunity to the petitioner to prove the above referred discharge summary dated 23.03.2010 issued by King George Hospital, Jagdamba Junction, Vizag. The complainant of course, will also be entitled to lead such evidence as may be desired by her in order to rebut the evidence which the petitioner may produce to prove the said discharge summary.
The parties are directed to appear before the concerned District Forum on 07.01.2019. The cost to the complainant shall be paid within four weeks from today.
The revision petition stands disposed of.