Order No. 12 dt. 02/11/2017
The case of the complainant in brief is that the complainant’s wife, Nirmala Devi Kishorepuria availed a loan facility of Rs. 1,05,43,500/- from o.p. 1 and insurance was done for collateral as special condition for such loan and Rs. 3,500/- was deducted towards credit protect premium for life coverage of said Nirmala Devi Kishorepuria. The o.p. 2 issued a membership certificate of insurance of HDFC Life Group Credit Protect Plus and the certificate of membership continued for 3 years from 07/08/2014 till 06/08/2017. During the tenure of policy coverage the wife of the complainant expired. After the death of the insured the complainant made death claim. The o.p. insurance company sought for some clarification from the complainant regarding the ailments of the insured and in reply to the said clarification the complainant informed the insurance company, o.p. 2 that due to certain ailments she was hospitalized. After considering the documents submitted by the complainant the o.p. 2 stated that the claim of the complainant cannot be accepted since the life assured was suffering from asthma, epilepsy and hyper-tension prior to the policy. Because of such denial of the complainant the complainant filed this case praying for direction upon the o.p. 2 for providing the death claim benefit to the complainant to the tune of Rs. 19,43,500/- and also prayed for compensation of Rs. 50,000/-.
The o.p. 1 has not contested the case as such the has proceeded ex-parte against the o.p. 1.
The o.p. 2 contested the case by filing w/v and denied all the material allegations of the complaint. It was stated that the agents solicits the insurance policies from the proposed customer after briefing him / her the terms and conditions of the policies. Only after being convinced and satisfied with the terms of the policy explained through the agent and the sales literature, life assured had filled and duly signed the member declaration form for issuance of a HDFC Life Group Credit Protect Plus certificate. At the time of taking policy the life assured was required to provide details of her health condition by way of questionnaires. The life assured had filled up the form suppressing certain medical conditions of her which ought to have been disclosed. After acceptance of member declaration form the policy was issued to the member. The claim form was received by the o.p. 2 on 27/07/2015 whereby certain documents were annexed including the death certificate. During the course of investigation it was found that the life assured was suffering from prior diseases like asthma, epilepsy and hyper-tension. Accordingly the death claim was not entertained. Since the life assured did not disclose any ailment no medical test was done. Each of the condition has direct and indirect relation to the death of the life assured. The life assured survived only for six months after taking the policy. The cause of death was absolutely was related to the known medical condition of the life assured which was suppressed at the time taking policy. On the basis of the said fact the o.p. insurance company prayed for dismissal of the case.
On the basis of the pleadings of the respective parties following points are to be decided :-
- Whether the complainant’s wife was insured with the o.p. 2, insurance company ?
- Whether the life assured expired during the subsistence of the said policy ?
- Whether there was suppression of any pre-existing disease at the time of obtaining policy ?
- Whether there was any deficiency in service on the part of the o.p. 2 ?
- Whether the complainant will be entitled to get the death claim benefit of his wife ?
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, Nirmala Devi Kishorepuria availed a loan facility of Rs. 1,05,43,500/- from o.p. 1 and insurance was done for collateral as special condition for such loan and Rs. 3,500/- was deducted towards credit protect premium for life coverage of said Nirmala Devi Kishorepuria. The o.p. 2 issued a membership certificate of insurance of HDFC Life Group Credit Protect Plus and the certificate of membership continued for 3 years from 07/08/2014 till 06/08/2017. During the tenure of policy coverage the wife of the complainant expired. After the death of the insured the complainant made death claim. The o.p. insurance company sought for some clarification from the complainant regarding the ailments of the insured and in reply to the said clarification the complainant informed the insurance company, o.p. 1 that due to certain ailments she was hospitalized. After considering the documents submitted by the complainant the o.p. 2 stated that the claim of the complainant cannot be accepted since the life assured was suffering from asthma, epilepsy and hyper-tension prior to the policy. Because of such denial of the complainant the complainant filed this case praying for direction upon the o.p. 2 for providing the death claim benefit to the complainant to the tune of Rs. 19,43,500/- and also prayed for compensation of Rs. 50,000/-.
Ld. Lawyer for the o.p. 2 argued that the agents solicits the insurance policies from the proposed customer after briefing him / her the terms and conditions of the policies. Only after being convinced and satisfied with the terms of the policy explained through the agent and the sales literature, life assured had filled and duly signed the member declaration form for issuance of a HDFC Life Group Credit Protect Plus certificate. At the time of taking policy the life assured was required to provide details of her health condition by way of questionnaires. The life assured had filled up the form suppressing certain medical conditions of her which ought to have been disclosed. After acceptance of member declaration form the policy was issued to the member. The claim form was received by the o.p. 2 on 27/07/2015 whereby certain documents were annexed including the death certificate. During the course of investigation it was found that the life assured was suffering from prior diseases like asthma, epilepsy and hyper-tension. Accordingly the death claim was not entertained. Since the life assured did not disclose any ailment no medical test was done. Each of the condition has direct and indirect relation to the death of the life assured. The life assured survived only for six months after taking the policy. The cause of death was absolutely was related to the known medical condition of the life assured which was suppressed at the time taking policy. On the basis of the said fact the o.p. insurance company prayed for dismissal of the case.
Considering the submissions of the respective parties it is an admitted fact that the insurance policy’s form is provided to the prospective customer and he / she is also explained by the agent the terms and conditions of the insurance policies. After being satisfied with the terms and conditions of the policy the life assured put her signature on the declaration form for issuance of a HDFC Life Group Credit Protect Plus certificate. It is the mandatory provision that the proposed applicant of the policy should answer the queries as provided in the proposal form for obtaining policy. Herein this case it is found that the life assured did not disclose any ailment and all the queries regarding previous ailment was answered in negative manner. Thereby the insurance company did not make any arrangement for medical examination. If the life assured would have disclose any ailment the o.p. 2 would not have issued the policy since no ailment was disclosed the o.p. 2 did not ask for any medical examination of the life insured. From the materials on record it is crystal clear that the life assured expired within 6 month from the date of her opening of the policy. After the demise of the life assured while the complainant submitted the death claim of the life assured an investigation was made and it was revealed that the wife of the complainant had various ailments including asthma, epilepsy and hyper-tension etc. and the death occurred due to such effect of ailments which was suppressed by the life assured at the time of obtaining policy. The o.p. 2 after getting the death claim application from the complainant made thorough investigation as well as the application form filled in by the life assured, since there was no disclosure of any ailment therefore no medical examination was arranged by the o.p., insurance company and after considering all these aspects the insurance company rightly repudiated the claim of the complainant. In view of the facts and circumstances 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, it is ordered,
that the case no. 188 of 2016 is dismissed ex-parte against o.p. 1 and o.p. 2 without any cost.
Supply certified copy of this order to the parties free of cost.
