Judgment:
Oral Order ( R. Lakshminarsimha Rao, Member)
Opposite parties are the appellants.
Aggrieved by the order of the District Forum-II, Vijayawada in C.C.No.38 of 2007, the appellants have filed the appeal contending that the District Forum erred in partially allowing the complaint in spite of the fact that the husband of the respondent suppressed material facts at the time of obtaining the policy and that any peculiarity of the facts of the case would be borne by hasty happening of the evidence.
The husband of the respondent during his life time obtained insurance policy bearing No.10397860 commencing with effect from 29.10.2005. The husband of the respondent submitted proposal on 13.10.2005 by paying annual premium of Rs.50,000/- through cheque bearing No.505901. The proposal was accepted with the terms and conditions mentioned therein. The insured had also paid additional single premium of Rs.50,000/- in advance through cheque bearing No.505909 dated 3.11.2005. The premium was accepted by the appellants. On 1.1.2006 the insured died due to Posterior Dirculation Stroke while undergoing treatment in Help Hospital, Vijayawada. Subsequent to the death of her husband, the respondent had lodged a claim with the fifth appellant. The appellants no.1 to 5 refused to pay the policy benefits to the respondent on the ground that her husband had not disclosed that he was suffering from hypertension in the proposal form. The respondent had submitted that at the time of submitting proposal form of her husband, the appellants had scrutinized the information given therein as also that they had got examined him through their panel doctor. It was submitted that only after satisfying themselves with the information furnished in the proposal form, the appellants had accepted the proposal and issued HDFC Unit Link Young Star Plan Policy. Further it was submitted by the respondent that her husband had not suffered from hypertension at any point of time. It is her version that on 23.12.2005 about two months after the issuance of the insurance policy, her husband was admitted to the Help Hospital where he died of Posterior Dirculation Stroke. Upon repudiation of her claim, the respondent had approached the District Forum by filing complaint contending that her husband had never suffered from hypertension as also the repudiation on that ground was arbitrary in the light of examination of her husband by the panel doctors of the appellants at the time of issuance of the insurance policy.
The appellants had resisted the claim of the respondent contending that there was abundance of medical evidence which points out that the deceased, husband of the respondent at the time of taking the policy stated gross falsehood and submitted inaccurate and incorrect statement with an intention to mislead the appellants and obtained benefit to which he would not have been normally entitled to, had he made a frank and honest disclosure of all the material particulars of the ailment he was suffering from. The payment of two premiums on 29.10.2005 and 3.11.2005 is admitted. It was submitted that the insured died on 1.1.2006 due to Posterior Circulation Stroke which was incorrectly mentioned by the respondent as Posterior Dirculation Stroke. The payment of single premium in advance would raise any amount of suspicion which necessitated the appellants get the claim investigated. It was submitted that at the time of obtaining the insurance policy, the deceased disclosed that he was suffering from diabetes for last 10 years and that he was under regular treatment of Dr.T.Rajyalakhsmi. Accepting and treating the information furnished by the deceased as true, complete and correct, the appellants rated up the premium payable by the policy holder by 125% in view of history of diabetes for a sum assured of Rs.2,50,000/- with the date of commencement of the policy on 29.10.2005. The insured died within two months from the date of issuance of the insurance policy. On 2.2.2006 the respondent had submitted her claim along with necessary papers which revealed that the insured died due to Posterior Circulatory Stroke with cardio respiratory arrest. The investigation revealed that the deceased was suffering from hypertension since more than a year and he was under the treatment of his family doctor Dr.T.Rajya Lakshmi. The doctor had issued certificate dated 24.3.2006 that the deceased was a known diabetic and known hypertensive as also that he was advised Atenolal 50mg for controlling hypertension.
In the proposal dated 13.10.2005 the deceased had mentioned that his family doctor was Dr.T.Rajya Lakshmi and he deliberately suppressed the fact that he was suffering from hypertension and was under regular treatment thereof. The documents obtained from the Help Hospital on 23.12.2005 would establish that he died on 1.1.2006 and that he was a known patient of hypertension for more than a year thereto.
The District Forum has allowed the complaint with a direction to the appellants the premium collected an amount of Rs.50,000/- + Rs.50,000/- a total sum of Rs.one lakh along with interest @ 9% per annum and costs.
The point for consideration is whether the repudiation of the claim by the appellants is justified?
The husband of the respondent during his life time had obtained insurance policy bearing No.10397860 from the appellants with the commencement of the insurance policy w.e.f., 29.10.2005 and duration of the policy was about seven years on payment of annual premium of Rs.50,000/-. It is not in dispute that the respondent was appointed by her husband as his nominee in the insurance policy. The sum assured under the insurance policy is Rs.2,50,000/-. On 1.1.2006 the husband of the respondent died in Help Hospital, Vijayawada due to Posterior Circulatory Stroke. The appellants had repudiated the claim of the respondent that her husband had suppressed the material fact in regard to his health that he was suffering from hypertension at the time of filling up the proposal form and obtaining insurance policy. The appellants had relied upon the certificate issued by Dr.T.Rajyalakshmi to contend that the deceased suffered from hypertension in addition to the diabetes. The deceased had specifically mentioned in the proposal Ex.B2 that he was a diabetic and was under the treatment of Dr.T.Rajayalakshmi. It is the contention of the appellants that the deceased has only mentioned about diabetes in the proposal form and he had intentionally omitted to mention about the blood pressure i.e., hypertension that he was suffering from.
A perusal of Ex.B9 copy of certificate dated 24.3.2006 issued by Dr.T.Rajya Lakshmi show that the deceased was known diabetic and known hypertensive and he was suffering from hypertension for about one year prior to the date of issue of Ex.B9. The out patient card Ex.B10 and doctor notes Ex.B11 issued by Help Hospital, Vijayawada would show that the deceased was known hypertensive for about one year. Ex.B10 was issued on 23.12.2005 and Ex.B9 was issued on 24.3.2006. Thus it is to be seen the omission to state hypertension that the deceased suffered from, is whether a material fact which ought to have known the appellants at the time of issuing the insurance policy. Admittedly, the deceased insured had specifically mentioned in the proposal form that he was a known diabetic and he was taking treatment for the disease thereof.
In the proposal form Ex.B2, the deceased had stated that he was hospitalized and also had undergone surgery during the last five years prior to the date of submitting Ex.B2. He had given answer in positive to the question whether he was suffering from diabetes and in regard to other problems such as high B.P., respiratory disease, Tuberculosis etc., he had given the answer negative. However, a questionnaire was said to have been filled up by him inview of the answer (yes) as was furnished by him to the question whether he was a diabetic. It is interesting to see that the appellants have not filed questionnaire that was submitted by the deceased insured at the time of filling up of the proposal. The deceased insured had stated in proposal that he was diabetic for the past 10 years and the diabetes said to have been diagnosed in the year 1995. He had stated that initially he was treated by Dr.Y.Sadasiva Rao and at the relevant time i.e., at the time of submitting the proposal form he was under the treatment of Dr.T.Rajyalakshmi. It is pertinent to note that he had mentioned the name of the tab. Glynase MF (5 mg.). In this backdrop it is to be seen that whether hypertension was as was contended by the appellants a material fact to mislead them to issue the insurance policy.
It is common knowledge that a person suffering from diabetes over a decade would not be at the risk of hypertension. Just merely ticking in negative to the question whether he was suffering form hypertension, tuberculosis, cancer etc., cannot be construed as material fact and omission of the disease stating or giving reply to the question under clause no.6 of the proposal in any manner can be said to be a material fact so as to mislead the appellant as to the question of rating the risk of the deceased insured. The doctor notes issued by Help Hospital, Vijayawada would establish that the cause of death of the deceased was due to Posterior Circulatory Stroke which the appellants had failed to establish had any nexus with the hypertension.
The deceased was a retired employee i.e., lecturer. He had specifically mentioned in the proposal that his date of birth was 14.8.1947. It is also an admitted fact that he was a diabetic and he had given an answer in positive to the question whether he was suffering from any illness or taken any medicines or pills or drugs. A fact is said to be material in the given situation provided it has not been within the knowledge of the insurance company. An elderly and aged man is risk prone by hypertension and in view of his age as also due to the debilitating disease, it cannot be said that he was not hypertensive. The disclosure of diabetes that the deceased suffered from itself is an ample circumstance to show that he was with hypertension. It cannot be said that it is not within the knowledge of the appellant that an aged man as the deceased was hypertensive. To constitute suppression of the material fact, it is not sufficient to state that the deceased has suppressed the fact that he was suffering from hypertension at the time of submission of proposal. Had the deceased was entertaining an idea of suppressing the fact that he was suffering from hypertension he would not have disclosed that he was a diabetic and was under the treatment of Dr.Sadasiva Rao at the initial stage of the disease and subsequently under the treatment of Dr.T.Rajyalakshmi. Therefore, the disclosure of diabetes by the deceased had the implication of the imputed knowledge of the fact that he was also suffering from hypertension and as such the appellants cannot contend that the deceased omitted to state that he was hypertensive is a material fact to have bearing upon decision making as to the question of issuing the insurance policy. It is not the case of the appellants that very omission of the hypertension would have affected issuing the insurance policy. It is their contention that at the most the rating they have fixed would have been different had the fact of the disease being hypertensive was brought to their knowledge. As aforesaid, the imputed knowledge that the deceased was diabetic and hypertensive as well estop the appellant from contending that it was a material fact that the deceased ignored to state in the proposal in regard to the hypertension that he was suffered from.
In view of the aforesaid discussion we are of the opinion that mere omission to state that the deceased was hypertensive in spite of the fact that he had categorically stated that he was diabetic and was under the treatment of doctors over a period of decade prior to the date of submitting the proposal to the appellants. Therefore, we do not see any reason to interfere with the order passed by the District forum for the aforesaid reasons though not upon the reasons whereof the District forum had come to the conclusion.
In the result the appeal is dismissed confirming the order of the District Forum with costs of Rs.2,000/-