As per Hon’ble President. Mr. Atul Alshi.

1.                               The complainant has filed complaint against OP for repudiation of insurance claim of Rs.13,00,000/- for the reason of suppression of pre existing disease and thereby claiming insurance amount, Rs.5,00,000/- about compensation and cost.  The complaint’s complaint in short as under-

2.               The complainant’s husband Shri Kakasaheb Gyanba More was a Clerk at Public Health Institute of Government of India at Nagpur and availed Housing loan of Rs.12,00,000/- from India Shelter Finance Corporation Limited, Gurgaon, Haryana on 18.03.2016. The complainant was principal borrower and her husband was co-borrower and guarantor and mortgaging the property of husband as collateral security as per loan application No. AP-0673270. For security of loan amount the insurance policy has been issued under Policy No. GLP3042573 in favour of complainant’s husband after necessary medical tests and made enquiry about past medical history. In the first week of November, 2018, the complainant’s husband got infected with dengue and therefore he was admitted to Suretech Hospital & Research Centre Limited, Dhantoli, Nagpur on 03.11.2018 and undergoing treatment of dengue. The complainant husband died on 13.11.2018 in the hospital due to Cardiac arrest. The complainant submitted the insurance claim with relevant documents, but the OP insurance company has rejected the insurance claim for the reason of “Non disclosure of history of brain abscess with craniotomy done in 2017 in Membership cum declaration of good health Form”. The complainant further submitted in complaint that her husband has disclosed and provided all details about minor surgical procedure of craniotomy which he has undergone in May 2017 alongwith treatment papers to the branch office of OP. After necessary test and medical examination and previous history submitted in proposal form of OP insurance company accepted the complainant’s husband insurance proposal. After minor surgical procedure of craniotomy the deceased had no medical complication and he lives normal and healthy life like other person. The deceased has not suffering any serious problem of health. There is no suppression of any pre existing disease. The complainant’s husband has been died due to dengue with other medical complications. The repudiation of insurance claim on the ground of concealment of non disclosure of pre existing disease is negligence of service on the part of OP and therefore, the complainant is liable to compensate.

3.               The OP filed reply and denied allegations and admitted insurance policy. According death summary of deceased the insurer has past history of Occipital abscess, history of Acute inflammatory Craniotomy and treatment undergone prior to issuance of the insurance policy. Therefore, the insurer had obtained policy by misrepresentation and the insurance contract based on rocky foundation of utmost good faith. The suppression of facts violates the fundamental principle of “Uberrimafides” thereby voilating the contract of Insurance. The insured disclosed the information sought in a truthful manner, the OP would not have issued the subject policy to the complainant’s husband, as per the judgement Satwant Kaur Sandhu Vs. New Assurance Co. Ltd. (2009 (9) Suprement Court 488). The dispute on question of law and therefore it cannot be decided under summary proceedings. The complainant does not raise any consumer disputes therefore liable to dismiss with cost. At the time of securing insurance policy his past history and also answer negative declaration. Therefore, it is breach of section 45 of Insurance Act, 1938. The Insurance Regulatory And Development Authority of India imposes duty upon policy holder to disclose material facts to insurer to enable them to assess the risk. The suppression of material fact the breach of contract of good faith and material fact therefore, repudiation of insurance claim on the misrepresentation and does not amount deficiency of service therefore the compliant liable to dismiss with cost.  

4.               The counsel for the complainant argues that the deceased submitted all information at the time of proposal alongwith treatment papers and after medical examination. The policy holder disclosed the minor surgical procedure of craniotomy which undergone in May 2017 which has no nexus dengue therefore rejection of insurance claim on the ground of suppression of material is deficiency service.

5.               The counsel for OP argued that suppression of pre existing disease treatment in declaration form does amounts to breach of trust and principle of utmost good faith upon which contract of insurance based on. Therefore rejection of insurance claim does not amounts deficiency of service.

6.               Both the parties argued the case on merit at length. After hearing of case the following points arose for consideration.

1. Whether the complainant is consumer ?                Yes.
2. Whether there is deficiency in service                             on the part of OP?                                  Yes.    3)  What order ?                          As per final order.

                             REASONING

7.               Point No. 1 to 3 - The complainant and her husband Shri Kakasaheb Gyanba More availed Housing loan of Rs.12,00,000/- from India Shelter Finance Corporation Limited, Gurgaon, Haryana on 18.03.2016. The complainant was principal borrower and her husband was co-borrower and guarantor and mortgaging deceased plot as collateral security for repayment of the said loan. At that time, complainant’s husband took the insurance cover for the housing loan. The OP insurance company has issued policy No. GLP3042573 on 28.02.2018. In the first week of November, 2018 the complainant’s husband got infected by dengue and admitted Suretech Hospital & Research Centre Limited, Dhantoli, Nagpur for treatment of dengue but sudden he suffered cardiac arrest during course of treatment and died on 13.11.2018. The complainant’s insurance claim rejected by OP for the reason suppression of pre-existing medical treatment for minor surgical procedure of craniotomy which undergone in May 2017. The insurer at the time of purchase of policy has examined by doctor of OP and thereafter issued insurance policy. The OP has failed to file expert evidence of doctor that minor surgical procedure of craniotomy in May 2017 has nexus the death of insurer. As per death certificate of Suretech Hospital & Research Centre Limited the cause of death the sudden cardiac arrest and dengue. The insurer got infected with dengue therefore he came to be admitted to Suretech Hospital on 03.11.2018. Therefore, non submission of information of minor surgical procedure for craniotomy declarations form of good health does not amounts suppression of material facts and therefore there is no breach of insurance policy as a whole. Hence, Complainant entitled for the insurance claim under the policy for the sum assured of Rs.13,00,000/- alongwith compensation and cost.

                       ORDER

1.       The complaint is partly allowed.
2.      The OP No. 1 & 2 is hereby directed to pay insurance claim of Rs.13,00,000/-  to the complainant.
3. The OP No.1 & 2 is further directed to pay compensation of Rs.25,000/- for mental agony and Rs.10,000/- towards litigation cost to the complainant.
4. The OP shall comply with above order within 45 days from date of receipt of order copy.
5. Copy of the order shall be supplied to all the parties free of cost.