Back
STATE CONSUMER DISPUTE REDRESSAL COMMISSION, ODISHA
Dr. D.P. Choudhury, President, Dr. P.K. Prusty, Member and Miss S.L. Pattnaik, Member
Divisional Manager, SBI Life
Insurance Company Limited – Appellant
versus
Minati Behera – Respondent
First Appeal No.160/2015
Decided on 22.7.2022
Counsel for the Parties:
For the Appellant:Mr. A.K. Mohanty, Advocate
For the Respondent: None
IMPORTANT POINTS
1. Pre-existing Disease - It is for the appellant to prove the pre-existing disease & suppression of material facts.
2. pre-existing diseases - Contract of Insurance is based upon the cardinal principle of Uberrimae fidei which means that the proposer is bound to disclose all relevant facts within his knowledge including his pre-existing diseases.
Headnote:
Consumer Protection Act, 1986 – Section 15 [Consumer Protection Act, 2019 – S.41] – Appeal Against order of District Commission – Services – Banking and Insurance – Repudiation of Claim - Suppression of material Fact - “pre-existing illness” – It is for the appellant to prove the pre-existing disease & suppression of material facts - The investigation by the insurer indicated that the insured was suffering from a pre-existing disease & that fact which were in the knowledge of the proposer had not been disclosed. This brings the ground for repudiation – In the face of documentary evidences, it can be stated that there has been suppression of material facts regarding the health of the proposer prior to proposal made for the insurance policy - The impugned order is set aside and the appeal stands allowed. [Paras 10 to 15]
The proposer when attended the hospital as an outpatient was duly registered by the hospital authority by putting the number and the date with stamp. It is observed from the copy of the treatment book that there is a remark on 20.07.1999 by the treating doctor at page 80 of the record that the proposer was a known diabetic and medicines for diabetes was being prescribed regularly since then. Fasting Blood Sugar (FBS) of the proposer was being monitored at regular intervals and was being recorded in the treatment book from 04.02.2000 for which medicines for diabetes were prescribed. It was observed that the values of FBS was remaining always at a higher side, some time as high as 292mg/dl from February 2000.
Result: Appeal allowed
ORDER
Dr. P.K. Prusty, Member—This appeal has been filed under Section 15 of erstwhile Consumer Protection Act 1986 (hereinafter called the Act) by Deputy Manager, SBI Life Insurance Co Ltd Vs. Minati Behera against the order dt. 23-02-2015 passed by District Consumer Dispute Redressal Forum, Jharsuguda (in short District Forum) passed in C.C. No. 80/2013. Parties to this appeal shall be referred to with reference to their respective status before the District forum.
2. The factual matrix leading to this case of the complainant is that a proposal for obtaining an insurance policy of S.B.I Life Shield was submitted to the appellant by husband of the Complainant, late Sushant Ku Behera vide form No 162775811 dt. 14-12-2009. The proposal form contained questions pertaining to the health & medical history of the proposer & required a specific disclosure under item 8(iii) on whether the proposer during last 10 years had undergone or advised to undergo hospitalisation or an operation or any investigation or tests or medical treatment. The proposer answered the queries in the negative, indicating thereby that he had not undergone any medical treatment or hospitalisation & was not suffering from any ailment or disease. The declaration under item 8 (xiii) of the proposal form was query in regard to whether the proposer has diabetes or ever suffered or treated or have been advised to undergo investigation for Diabetes which was also answered as negative. Acting on the basis of proposal submitted by the proposer, a policy bearing No. 16015999103 was issued by the appellant / O.P Insurance Co on 06-01-2010 for a sum assured of Rs. 3,00,000/- with one time premium of Rs. 6407/-.
3. On 30-11-2010, the insured Sushant Kumar Behera died, following which a claim was lodged on the insurer. The death occurred within a period of 10 months 24 days from the commencement of the policy resulting in early claim. As per Section 45 of Insurance Act, 1938, the claim was the subject matter of investigation. During course of which, the hospital treatment record of Late Sushant Kumar Behera from Central Hospital was obtained by the insurer. The records revealed, according to the insurer, that the deceased was suffering from Diabetes Mellitus type-II. Copy of the health report has been placed in the record. The investigation report indicates that the deceased had been suffering from chronic diabetes. It was repudiated by the OP stating that the policy holder has suppressed his pre-existing diseases. Challenging the repudiation as deficiency in service on the part of the appellant/OP Insurer, complaint was filed before the District Forum, Jharsuguda.
4. Per contra, the OP filed written version stating that they had issued the policy in favour of late Sushant Kumar Behera who died on 30-11-2010 leaving complainant as nominee and also averred that the policy holder has suppressed his pre-existing disease regarding Diabetes Mellitus -II. They had obtained the hospital records (medical treatment Book) of Sri Sushant Kumar Behera from Central Hospital of the Valley colliery during the course of investigation as the deceased being employee of coal mines was issued with the Medical Treatment Book and found that the deceased has pre-existing disease namely diabetes Mellitus-II. So, they repudiated the claim.
5. After hearing both the parties, the learned District forum passed the following order:—
xxx xxx xxx
“We hereby direct the O.P insurance company to settle the claim of the complainant with interest from the date of claim. Further the O.P is also directed to pay a sum of Rs. 10,000/- (Rupees ten thousand) only towards harassment, mental agony including cost of the case to the Complainant. All the above stated orders are to be carried out within one month from the date of receipt of copy of this order failing which interest @ 10% per annum will be charged on the awarded amount to the O.P till its realization.”
6. Learned Counsel for the appellant submitted tha
