(Passed on 11/04/2023) Per Mr. Atul D. Alsi, Hon’ble President - The complainant filed a complaint case against arbitrarily repudiation of insurance claim for the sum assured of Rs. 5,00,000/- for the reason of suppression of material fact in respect of treatment of pre-existing decease and thereby claiming sum assured under the policy along with compensation.
- The story in short are as under.
- The complainant is a nominee of wife Vinita D. Jain who is insured under insurance policy bearing No. 337526904 by paying yearly premium of Rs. 50,000/- for the sum assured of Rs. 5,00,000/-. The wife of complainant is died on 11/9/2018 at Pant Hospital, Chandrapur. The complainant had filed insurance claim with relevant documents with the OP having claim bearing No. 1819011461 but the OP has arbitrarily repudiated the insurance claim for the reason of the insured had suppressed the information in respect of existing and treatment for diabetes mellitus, Hypertension, BP, Chronic thyroid and kidney disease after detailed investigation was carried by the OP. Hence, claim is repudiated by issuing letter dated 1/3/2019 and refunded Rs. 45,709/- towards collection of premium as full and final settlement of claim. The repudiation of insurance claim thus amounts of deficiency in service. Therefore, the complaint is filed.
- The OP Nos. 1 and 2 filed reply and denied allegation against it and submitted that as per policy terms and condition, the insured at the time of taking policy was required to state the information in respect of pre-existing disease or treatments. The insured, in this case, had suppressed that she was under treatment for diabetes mellitus, Hypertension, BP, Chronic thyroid and kidney disease of Dr. Ajay Gandhi at Gandhi Nursing Home, Chandrapur and Dr.Nitin Shinde at Nagpur as per investigation, carried by OP. Therefore, the rejection of claim does not amounts to deficiency in service.
- The counsel for complainant argued that the policy was issued after medical examination from OP and there is no nexus of diabetes or hypertension with cause of death of insured. Therefore, rejection of claim thus amounts to deficiency in service. The counsel for complainant relied on judgment of LIC Vs. Appollo in Nilam Chopra Vs. LIC, NCDRC, New Delhi in 4461/2012, holding that the decease does not have any co relation with cause of death, it cannot be suppression of any information relating to pre-existing decease or no direct relation to cause of death which would not completely disentitle the claimant for the claim.
- The counsel for OP Nos. 1 and 2 argued that after investigation, it was found that the insured was under treatment for disease of hypertension and diabetes, thyroid and kidney disease which was not disclosed in prop osal form at the time of purchase of policy. Therefore, for the reason of suppression of material fact, the insurance claim of complainant has been repudiated as per terms and condition of the policy. Therefore, there is no negligence on the part of OP Nos. 1 and 2. The counsel for OP Nos. 1 and 2 relied on judgment as per judgment in Civil Appeal No. 5322/2007 in P.J. Chacko andAnr. Vs. Chairman, Life Insurance Corporation of India &Ors. holding that a deliberate wrong answer given by insured having great bearing on contract of insurance. Hence policy may be repudiated.
REASONING - The insured purchased the policy from OP No. 1 as Bajaj Allianz life future Wealth Gain bearing No. 0337526904 for the period from 1/9/2017 to 31/08/2027 by yearly premium of Rs. 50,000/- for the term of 10 years for the sum assured of Rs. 5,00,000/- the complainant’s insurance claim came to be repudiated by OP No. 1 for the reason that deceased had suppressed the treatment for diabetes and hypertension and kidney decease since 2015. As per death certificate issued from Pant Hospital dated 11/9/2018, the cause of death of patient was Cardio respiratory arrest and the treatment which the deceased had taken for diabetes, hypertension and thyroid has no nexus with cause of death of insured moreover the OP Nos. 1 and 2 has not filed any evidence of expert with affidavit that the previous treatment has nexus that cause of death of insured with appropriate evidence. Therefore, the complainant is entitled for the sum assured of Rs. 5,00,000/- excluding the amount received Rs. 50,000/- that is 4,50,000/- along with compensation for mental torture amounted to Rs. 10,000/- with cost of litigation Rs. 5,000/- as per following order.
ORDER - The complaint is partly allowed.
- The OP nos. 1 and 2 shall pay to the complainant sum assured of Rs. 4,50,000/- of policy bearing No. 33752690.
- The OP Nos. 1 and 2 shall pay to the complainant Rs. 10,000 for mental harassment and Rs. 5,000/- for cost of litigation.
- Copy of order be furnished to both parties, free of cost.
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