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ANDHRA PRADESH STATE CONSUMER DISPUTES REDRESSAL COMMISSION, HYDERABAD
R. Lakshminarasimha Rao, Thota Ashok Kumar, Members
Shriram Life Insurance Co. Ltd. & Anr. - Appellants
Versus
Yedla Purushotham Reddy - Respondent
F.A. No. 553 of 2012
Decided On : 20-06-2013
Advocate Appeared:
For the Appellant :M/s. KRR Associates, Advocate.
For the Respondent:Mr. V. Narasimha Rao, Advocate.
The central legal point established in the judgment is the significance of medical records in insurance claims, the duty of the insured to disclose material facts, and the consequences of the insurer's failure to prove non-disclosure or misrepresentation of material facts under Section 45 of the Insurance Act, 1938.
Headnote:
Insurance Policy - Claim Repudiation - Medical Record - [Insurance Policy] - [Section 45 of the Insurance Act, 1938] - The court discussed the requirement of submitting medical records for insurance claims and the duty of the insured to disclose material facts at the time of taking the insurance policy. The court also considered the past medical history of the deceased and the significance of medical records in determining the validity of the claim. The decision was influenced by the interpretation of Section 45 of the Insurance Act, 1938, which deals with the consequences of the insurer's failure to prove the policyholder's non-disclosure or misrepresentation of material facts.
Fact of the Case:
The respondent sought to set aside the repudiation of his claim and obtain the sum assured under an insurance policy after the death of his wife. The appellant closed the claim on the premise that the respondent failed to submit the medical record of his wife pertaining to the treatment of epilepsy.
Finding of the Court:
The District Forum allowed the complaint, ruling that the closure of the claim for non-submission of the medical record was unjustified and amounted to deficiency in service. The court dismissed the appeal, confirming the order of the District Forum.
Issues: The main issue was whether the respondent was entitled to the benefits conferred by the insurance policy, considering the requirement of submitting medical records and the alleged non-disclosure of the insured's medical condition.
Ratio Decidendi: The court considered the past medical history of the deceased, the duty of the insured to disclose material facts, and the significance of medical records in determining the validity of the claim. The court also relied on the interpretation of Section 45 of the Insurance Act, 1938.
Final Decision: The appeal was dismissed, confirming the order of the District Forum. No separate order as to costs was issued.
ORDER :
R. Lakshminarasimha Rao, Member
The opposite party is the appellant. The respondent filed complaint seeking for setting aside the repudiation of his claim and for award of the sum assured under the insurance policy.
2. The respondent’s wife during her life-time obtained insurance policy bearing number LN071000032266 from the appellant for the period commencing from 24.2.2010 for a period of one year till 23.2.2011. The sum assured in terms of the insurance policy is Rs. 1,00,000. The insured died on 24.7.2010 at Omni Hospital, Hyderabad due to cardio-respiratory arrest. After the death of his wife, the respondent being her nominee, submitted claim along with relevant documents to the appellant and the appellant required the respondent to submit medical record of his wife relating to the treatment for epilepsy for which the respondent had given reply that he did not have any such medical record since the insured did not take any treatment. The appellant closed the claim on the premise that the respondent failed to submit the medical record of the insured whereon the respondent filed the complaint.
3. The respondent submitted that his wife was not treated for curing of epilepsy and as such he did not possess any such medical record insisted on by the appellant unreasonably and thus the repudiation of his claim is bad and unjust.
4. The appellant resisted the claim on the premise that the respondent’s wife concealed the fact that she suffered from epilepsy at the time of filling up the proposal form and through the claim form it was disclosed that she was suffering from epilepsy and the appellant requested the respondent to submit the medical record of his wife as regards treatment obtained for cure of epilepsy and as the respondent failed to submit the medical record despite giving sufficient time, the appellant closed the claim.
5. The respondent filed his affidavit and the documents Exs. A1 to A6. On behalf of the respondents, its Assistant General Manager filed his affidavit and the documents, Exs. B1 to B8.
6. The District Forum allowed the complaint on the premise that the closure of claim for non-submission of medical record of the insured is not justified and it amounts to deficiency in service on the part of the appellant-Insurance Company.
7. Feeling aggrieved by the order of the District Forum, the opposite party has filed appeal contending that basing on the information furnished in the proposal submitted by the respondent’s husband, the appellant had issued insurance policy. It is contended that the respondent submitted claim form and the appellant requested him to submit the medical record of the insured as regards the treatment for epilepsy and as there was no response from him, the appellant closed the claim. It is contended that the doctor, Pavan Kumar Reddy who treated the deceased signed the claim form which contains the information that the deceased suffered from epilepsy. The insured had not disclosed material fact at the time of taking the insurance policy.
8. The Counsel for both parties have filed written submissions.
9. The point for consideration is whether the respondent is entitled to the benefits conferred by the insurance policy?
10. The facts which have been admitted and which do not require elaborate discussion are that on 24.2.2010 the respondent Insurance Company had issued Insurance Policy for a sum assured of Rs. 1,00,000 in favour of the respondent’s wife and the insured died on 24.7.2010. The appellant had lodged claim for payment of the sum assured under the policy.
11. The appellant Insurance Company closed the claim on the premise that the respondent failed to produce medical record of his wife pertaining to the treatment of epilepsy and the insured concealed the fact that she was suffering from epilepsy while submitting the proposal. The contention of the respondent is that his wife was not treated for cure of epilepsy and as such he could not submit the medical record. The learned Counsel fo
