Mohit Kohli vs Aviva Life Insurance Company India Pvt. Ltd. And anr

Challenge in this Revision Petition, under Section 21(b) of the Consumer Protection Act, 1986 (for short “the Act”), is to order dated 1.4.2014 in Appeal No. 170 of 2011 passed by the State Consumer Disputes Redressal Commission, Delhi (for short “the State Commission”). By its impugned order, the State Commission concurred with the finding of the District Forum, which had dismissed the Complaint. 2. The brief facts as set out in the Complaint are that the Complainant’s father late Shri Rajeshwar Kohli took a Life Insurance cum Saving Policy namely “SAVE GUARD” for a sum of Rs. 3,00,000/- by paying premium of Rs. 30,000/-, for the period from 20.2.2006 to 20.2.2020 for a term of 15 years. At the time of taking of the policy, the life assured was 49 years old, hale and hearty and had disclosed to the agent the minor ailment he was suffering from, but the agent stated that these problems could be ignored. The second renewal premium was paid by the life assured on 20.2.2007 and thereafter the insured suddenly died at home. A claim was made by the Complainant and Insurance Company repudiated it on 27.2.2008 on the basis of Dr. Manju Jerath’s certificate dated 20.12.2007 that the insured was suffering from Cardiac disease. The Complainant averred that the said doctor is a Homeopathic Physician and that the life assured was never medically examined prior to the issuance of the Policy and it is only after three years of issuance of the Policy and after accepting the second premium, that the Opposite Party had repudiated the claim. The Save Guard is an investment opportunity as well as life insurance without requiring the proposal to undergo any medical examination. When the brochure of the Opposite Parties had stated that no medical examination is necessary, it is pleaded by the Complainant that repudiation on the basis of a Medical Certificate issued by the Homeopathic Physician is not justified. Hence, the Complaint seeking direction to the Opposite parties to pay a sum assured of Rs. 3 lakhs with interest, expenses, compensation, costs and also NAV on Rs. 60,000/- (two instalments paid) approximately Rs.70,796/-, totalling to Rs. 5,40,746/-. 3. The Opposite Parties filed their written version before the District Forum admitting to the issuance of the Policy and averred that as per the discharge summary issued by Escorts Heart Institute & Research Centre and also the Medical certificate of Dr. Manju Jerath dated 25.2.2008, the policy holder was suffering from Cardiomyopathy (heart muscle disease), which was diagnosed in October 2001. The Cardiomyopathy is the deterioration of the functioning of the myocardium and risk of sudden cardiac death. The medical literature states that the patient diagnosed with this disorder die within a period of 2-3 years after their symptoms begin. The medical condition of the deceased insured was well within his knowledge and was not disclosed deliberately at the time of signing the Proposal Form. The Opposite Parties pleaded that this is against the principles of ubrerrima fide and also against the provisions of Section 45 of the Insurance Act, 1938. At the time of submitting the Proposal Form, the life assured declared as follows: “ I/We declare that I/we have answered the question in the proposal form after being explained by the advisor of the Aviva Life Insurance Company India Ltd. (i.e. the OP) and have fully understood the nature of the questions and the importance of disclosing all material information while answering such questions. I/We further declare that the answers given by me/us to all the questions in the proposal form and the information given to the Medical examiner or the Respondent as to state of health and habits of life to be insured are true and complete in all and every respect and that I/we have not withheld any material information or suppressed any material information or withheld any material fact. I/We also undertake that in case of any mis-statement or suppression of material information the Respondent has a right to repudiate any claim against the policy. I/We undertake to notify the Respondent of any change in the state of health of the life to be insured or as to my/his/her occupation subsequent to signing of the proposal and before the acceptance of risk by the Respondent. I/We also certify that I/We have read and understood the Benefits illustrations and Exclusion Sheet as published by the Respondent that was handed over to me/us along with this proposal form”. 4. The Opposite Parties submitted that the salient features of the Policy were explained by the Agent and that the repudiation is justified as the Complainant had answered ‘No’ to question No. 12 (a) in the Proposal Form when it was asked whether they had any heart condition/ a stroke/ hypertension/ paralysis/ cancer etc. The Insurance Policy was issued in 2006 and the Policy holder died in the year 2007 due to cardiac arrest. The suppression of CHF- myocarditis, which is the initial stage of cardiomyopathy, is proved by discharge summary issued by the Escorts Hospital and, therefore, it can be concluded that the life assured had wilfully suppressed the material facts prior to the issuance of the Policy. 5. The District Forum, based on the evidence adduced, dismissed the Complaint, but observed that the Complainant would be entitled to the investment benefits from the Respondents, permissible under the Policy. 6. Aggrieved by the said Order, the Complainant preferred an Appeal before the State Commission which concurred with the finding of the District Forum observed as follows:- “We have very carefully gone through the evidence on record and the finding recorded by the Ld. District Forum. The Ld. District Forum has observed that copy of discharge summary of Escort Heart Institute & Research Centre was available on record, according to which the assured was admitted in that Hospital on 26.10.2001 and was discharged on 04.11.2001.It was diagnosed a case of “Dialated Cardiomyopathy/LV dysfunctions and severe Myocarditis”, coronary angiography was done in Escort Hospital on 03.11.2001.Thus it was evident that assured had developed heart problem since 2001, he was hospitalized and angiography was done. At the time of filling the proposal form, he suppressed material facts regarding his health and answered the question in negative regarding his health and maintained that he was keeping good health. It was a material fact which was not disclosed by him at the time of taking of insurance policy and in the relevant column in the proposal forum he denied to have had any heart condition, stroke, hypertension etc. Thus it was a case of deliberate concealment of material facts having bearing on the contract of insurance. The respondents were therefore justified in repudiating the claim on the ground that material facts were suppressed by the assured at the time of taking the insurance policy. Moreover, cause of death of the deceased was cardiac arrest due to “Cardiomyopathy” i.e. the complainant died due to his “heart muscle decease” which deteriorated the functions of the mycocardium. Thus, there was nexus between the cause of death and the ailment by which the life assured was suffering since 2001”. 7. Dis-satisfied with this order, the Complainant preferred this Revision Petition. 8. Heard both the sides at length. The learned counsel for the Revision Petitioner submitted that Coronary Angiography Report of Escorts Heart Institute and Research Centre dated 3.11.2001 showed normal results; that the certificate given by Dr. Manju Jerath cannot be relied upon as she is a Homeopathic Physician; that the policyholder never signed the Proposal Form but that it was signed only by the agent. He submits that the declaration by the person filling in the form was never signed by the policyholder and was in fact left blank. The terms and conditions of the Policy were never supplied to him, the life assured was 49 years old and was hale and hearty and leading normal life and invested Rs. 30,000/- for a sum assured or Rs. 3 lakhs. The counsel submitted that linking the death with the hospitalisation of the policyholder in the year 2001, i.e. after about 6 years and now terming it a non - disclosure is against the very purpose of the policy which is risk coverage. The Policy commenced from 20.2.2006 had itself dispensed with medical examination of the insured. The death took place on 20.12.2007 and the claim was raised on 5.2.2008, which was repudiated on 27.2.2008 after the expiry of the statutory period of two years on 20.2.2008. 9. The issuance of the Policy, period of coverage and the premium paid is not in dispute. The brief point that falls for consideration is whether the life assured had suppressed his medical condition prior to the issuance of the Policy? 10. The repudiation is based on two documents; (i) Certificate issued by Dr. Manju Jerath dated 25.2.2008; & (ii) the discharge summary issued by the Escorts Heart Institute & Research Centre dated 4.11.2001 reads as under:- “Dr. Manju Jerath B.H.M.S. (Delhi) PGD.H.H.M. Clinic 21-A, Pocket - B, Hari Nagar, New Delhi-64 Tel:25126741 Timing: Morning 10.00 AM to 1.00 P.M. Evening 5.30PM to 8.30 PM Res: 27A, Pocket B, Hari Nagar, New Delhi - 110064 Tel:25132847 Aviva LIC India Ltd., With reference to letter dated 21st Feb., 2008, addressed to Mr. Kohli, I would like to submit that late Mr. Rajeshwar Kohli was a well compensated case of Dialted cardiomyopil. This was diagnosed in October, 2001. Since then patient had been on regular treatment with no complications or any hospital admissions. He was consulting at EHI as an OPD patient after his admission and diagnosis in October, 2001. I have been treating him for all his trivial illnesses as a family physician. Sd/- /25.2.2008 Dr. Manju Jerath B.H.M.S. (DLI) Homoeopathic Physician Regd. No. 2089”. 11. The discharge summary reads as follows:

Escorts Okhla Road, New Delhi-110 025, INDIA

Heart Institute Phones : 6825000, 6825001

Research Centre Fax: 6825013 e-mail ehirc@vsnl.com

Discharge Summary

Name of the patient: Mr. Rajeshwar Kohli

Age: 45 Yrs.

Sex: Male

Regn. No. 166662

IPD No. 10094

Date of Admission: 26.10.2001

Date of discharge: 4.11.2001

Diagnosis Dilated Cardiomyopathy Lv Dysfunction &Ndash; Severe Myocarditis Procedure(S) Coronary Angiography done on 3.11.2001 Resume of History Mr. Rajeshwar Kohli, a 45 years old gentleman is normotensive, nondiabetic, non - smoker and has no family history of ischaemic heart disease. He was admitted to Maharaja Agarsen Hospital on 19.10.2001 with complaints of dyspnoea on exertion for the last 10-12 days. There is no history of orthopnoea/PND/chest pain/syncope/sweating. He was diagnosed to have CHF - myocarditis and LVEF 15% and was managed with IV Lasix, Cardace and Carca. There he also had Runs of NSVT and is presently on tab Cardarone. There is no history of fever/sore throat preceding the illness. He was admitted to this hospital for evaluation and stabilisation. On admission, his pulse was 96/min., and BP was 116/68mmHg. There was no pallor, no cyanosis, no clubbing, no oedema. JVP was not raised and lungs were clear. Precordial auscultation and other systemic examination was unremarkable. Course in the Hospital The patient was stabilised with diuretics and cardarone and underwent. Coronary Angiography on 3.11.2001. The procedure was uncomplicated and well tolerated. His subsequent stay in the hospital was uneventful”. 12. The afore-mentioned discharge summary shows that the diagnosis is Dilated Cardiomyopathy, which is dated 4.11.2001, six years prior to the issuance of the Policy. It is clearly stated that the life assured had a severe LV Dysfunction and Myocarditis. He was admitted on 26.2.2010 and Coronary Angiography was done on 3.11.2001 and he was discharged on 4.11.2001. This discharge summary clearly specifies that the life assured was indeed suffering from Cardiomyopathy. 13. In addition to this, the Insurance Company has also relied on the certificate issued by Dr. Manju Jerath, who, though a Homeopathic Physician, has certified that she was treating the life assured and that he was a known case of Cardiomyopathy. It is an admitted fact that it was this Doctor who has issued the last Medical Attendance Report. 14. The contention of the Revision Petitioner that the Angiography was done on 3.11.2001 showed normal result and therefore, it cannot be construed that the life assured had Cardiomyopathy, is unsustainable as seen from the record the Policy was taken in the year 2006 on the proposal dated 7.2.2006 and this Angiography was done on 3.11.2001 and was never disclosed. The reasons as to why this Coronary Angiography was necessitated has also not been stated. The other contention of the Revision Petitioner that the brochure does not ask for any medical examination prior to the issuance of Save Guard Policy and therefore, the Insurance Company cannot repudiate on the ground of suppression of material facts regarding health, also cannot be sustained as the Proposal Form did have questions regarding the health condition which was not disclosed by the Petitioner/Complainant. 15. For all the aforementioned reasons, we do not see any illegality or infirmity in the orders of the Fora below which have dismissed the Complaint but observed that the Insurance Company should pay the investment benefits as stipulated in the Policy. 16. Keeping in view our limited revisional jurisdiction as laid down by the Hon’ble Apex Court in Rubi (Chandra) Dutta v. United India Insurance Co. Ltd. II (2010) CPJ 19 (SC), I do not see any substantial reasons to interfere with the well - considered and concurrent orders of the Fora below. 17. Hence this Revision Petition fails and is dismissed accordingly. No order as to costs. Revision Petition Dismissed.