Date of Filing : 05/05/2015
Order No. 21 dt. 15/03/2018
The case of the complainant in brief is that the complainant’s wife Smt. Varsha Kripalini had applied for insurance with o.p. no.1 on 21.2.10 and on the basis of such application a life insurance policy was issued to her on 23.12.10. The complainant was appointed as nominee under the said policy. The said policy having a term of 10 years required the payment of quarterly premium of Rs.13,017/- and sum assured was of Rs.5 lakhs and in case of death of life assured before maturity of the policy, the insurer company shall have to pay twice the basis sum assured along with the guaranteed additions accrued till the date of the policy holder’s death, to the nominee of the policy holder. The policy holder Smt. Varsha Kripalini paid all quarterly premiums. The wife of the complainant was absolutely fit and she enjoyed the good health at the time of inception of the policy, but in the later part of the year 2011 she felt discomfort and consulted Dr. Bani Kumar Mitra who advised her to undergo certain medical tests wherefrom it was revealed that she was a diabetic suffering from fibrosis / adenomyosis of the uterus. She was admitted to RSV Hospital, Kolkata and she was discharged on 4.11.11. After discharge the complainant noticed that the health condition of the patient did not improve and she was admitted to Tata Memorial Hospital, Mumbai where she was diagnosed with endometrial cancer. She was administered chemotherapy and thereafter she returned to Kolkata and admitted to Belle Vue Clinic on 22.8.12 and she expired on 2.9.12. On the basis of the said fact the complainant intimated the fact of death of his wife and claimed the amount as per the terms of the said policy, but o.ps. repudiated the claim of the complainant for which the complainant filed this case praying for direction upon the o.ps. for releasing the amount of Rs.10 lakhs which is twice the basic sum assured and a further sum oif Rs.12,500/- which is value of the accrued guaranteed addition as well as compensation of Rs.7 lakhs and litigation cost of Rs.50,000/-.
The o.p. no.1 contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that the law of insurance is governed by the legal doctrine “Uberrima fides” meaning “utmost good faith”. This means that all parties to an insurance contract must deal in good faith, making a full declaration of all material facts in the insurance proposal. However, in the instant case, there are inherent misrepresentation and suppression of material facts and the insured has intentionally made misrepresentations and false statement at the time of getting the insurance cover. The deceased life assured suppressed the relevant fact at the time of issuance of policy that she was suffering from cerebro vascular accident on 15.6.04 and diabetes mellitus (DM) on insulin and hypertension on 25.4.08. The deceased policy holder had grossly mis-stated / suppressed that she was not suffering from any disease, to get the insurance cover. Whereas in reality she was suffering from above mentioned diseases which is reveled from hospital discharge summary that DLA was admitted at Woodland Hospital which confirms that she was admitted on 15.6.04 – 4.7.04 and was treated for cerebro vascular accident and the discharge summary confirms diagnosis of DM and HT. hence the policy was void ab-initio. Since the complainant suppressed the material fact and as per Sec 45 of the Insurance Act wherein it was stated that policy not to be called in question on ground of mis-statement after 2 years. No policy of life insurance effected before the commencement of this Act shall after the expiry of 2 years. Admittedly the life assured suppressed the material fact of her undergoing treatment of cerebro vascular accident on 15.6.04 and she was suffering from AM and HT since 25.4.08 and the policy holder ought to have mentioned in the proposal form. On the basis of the said fact o.p. no.1 also relied on some decisions and stated that the repudiation made by o.ps. was justified and the complainant will not be entitled to get any relief as prayed for.
In spite of receipt of notice the o.p. no.2 did not contest this case by filing w/v and as such, the case has proceeded ex parte against them.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant’s wife was the policy holder?
- Whether the policy holder suppressed the materials fact of her previous illness at the time of obtaining the policy?
- Whether after demise of the policy holder the complainant will be entitled to get the claim made by him?
- Whether there was any deficiency in service on the part of o.ps.?
- Whether the complainant will be entitled to get the relief as prayed for?
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. lawyer for the complainant argued that the complainant’s wife Smt. Varsha Kripalini had applied for insurance with o.p. no.1 on 21.2.10 and on the basis of such application a life insurance policy was issued to her on 23.12.10. The complainant was appointed as nominee under the said policy. The said policy having a term of 10 years required the payment of quarterly premium of Rs.13,017/- and sum assured was of Rs.5 lakhs and in case of death of life assured before maturity of the policy, the insurer company shall have to pay twice the basis sum assured along with the guaranteed additions accrued till the date of the policy holder’s death, to the nominee of the policy holder. The policy holder Smt. Varsha Kripalini paid all quarterly premiums. The wife of the complainant was absolutely fit and she enjoyed the good health at the time of inception of the policy, but in the later part of the year 2011 she felt discomfort and consulted Dr. Bani Kumar Mitra who advised her to undergo certain medical tests wherefrom it was revealed that she was a diabetic suffering from fibrosis / adenomyosis of the uterus. She was admitted to RSV Hospital, Kolkata and she was discharged on 4.11.11. After discharge the complainant noticed that the health condition of the patient did not improve and she was admitted to Tata Memorial Hospital, Mumbai where she was diagnosed with endometrial cancer. She was administered chemotherapy and thereafter she returned to Kolkata and admitted to Belle Vue Clinic on 22.8.12 and she expired on 2.9.12. On the basis of the said fact the complainant intimated the fact of death of his wife and claimed the amount as per the terms of the said policy, but o.ps. repudiated the claim of the complainant for which the complainant filed this case praying for direction upon the o.ps. for releasing the amount of Rs.10 lakhs which is twice the basic sum assured and a further sum oif Rs.12,500/- which is value of the accrued guaranteed addition as well as compensation and litigation cost.
Ld. lawyer for the o.p. no.1 argued that the law of insurance is governed by the legal doctrine “Uberrima fides” meaning “utmost good faith”. This means that all parties to an insurance contract must deal in good faith, making a full declaration of all material facts in the insurance proposal. However, in the instant case, there are inherent misrepresentation and suppression of material facts and the insured has intentionally made misrepresentations and false statement at the time of getting the insurance cover. The deceased life assured suppressed the relevant fact at the time of issuance of policy that she was suffering from cerebro vascular accident on 15.6.04 and diabetes mellitus (DM) on insulin and hypertension on 25.4.08. The deceased policy holder had grossly mis-stated / suppressed that she was not suffering from any disease, to get the insurance cover. Whereas in reality she was suffering from above mentioned diseases which is reveled from hospital discharge summary that DLA was admitted at Woodland Hospital which confirms that she was admitted on 15.6.04 – 4.7.04 and was treated for cerebro vascular accident and the discharge summary confirms diagnosis of DM and HT. hence the policy was void ab-initio. Since the complainant suppressed the material fact and as per Sec 45 of the Insurance Act wherein it was stated that policy not to be called in question on ground of mis-statement after 2 years. No policy of life insurance effected before the commencement of this Act shall after the expiry of 2 years. Admittedly the life assured suppressed the material fact of her undergoing treatment of cerebro vascular accident on 15.6.04 and she was suffering from AM and HT since 25.4.08 and the policy holder ought to have mentioned in the proposal form. On the basis of the said fact o.p. no.1 also relied on some decisions and stated that the repudiation made by o.ps. was justified and the complainant will not be entitled to get any relief as prayed for.
Considering the submissions of the respective parties it is an admitted fact that the complainant’s wife had the policy with o.p. no.1 at the relevant point of time. It is found from the materials on record that during the subsistence of the policy the complainant’s wife underwent treatment at different hospitals viz. RSV Hospital, Tata Memorial Hospital, Belle Vue Clinic. It appears from the documents filed by the insurance company that the complainant’s wife had underwent cerebro vascular accident on 25.6.04 and diabetic mellitus on insulin and hypertension on 25.4.08. It appears from the record that at the time of applying for the policy the complainant’s wife suppressed the said fact and on the basis of good faith the policy was issued to the said life assured. It appears from the materials on record that the complainant suppressed the material fact and the law of insurance is governed by the legal doctrine “Uberrima fides” meaning “utmost good faith”. This means that all parties to an insurance contract must deal in good faith, making a full declaration of all material facts in the insurance proposal. However, in the instant case, there are inherent misrepresentation and suppression of material facts and the insured has intentionally made misrepresentations and false statement at the time of getting the insurance cover. In support of the said contention we can rely on the documents filed by o.p. insurance company in the w/v as well as evidence that the complainant had undergone several serious types of illness and by suppressing the said fact the policy was obtained by her. It appears from the record that the policy was taken in the year 2010 and within 2 years of her obtaining the policy she expired. On the basis of the facts and circumstances of the case and on the basis of the materials facts it appears that the insurance company rightly repudiated the claim of the complainant being the nominee of the said policy of his wife. In view of the facts and circumstances as stated above, we hold that the case filed by the complainant has got no merit and the complainant will not be entitled to get any relief as prayed for. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.228/2015 is dismissed on contest against the o.p. no.1 and dismissed ex parte against the o.p. no.2 without cost.
