CONSUMER DISPUTES REDRESSAL COMMISSION – X
GOVERNMENT OF N.C.T. OF DELHI
Udyog Sadan, C – 22 & 23, Institutional Area
(Behind Qutub Hotel)
New Delhi – 110016
Case No.110/2018
MR. MANOJ KUMAR MEHRA
S/o LATE SHRI JEEVAN LAL,
RESIDENT OF 21, PUSHPA MARKET, LAJPATNAGAR-II …..COMPLAINANT
Vs.
HDFC ERGO GENERAL INSURANCE Co. LTD.,
EROS CORPORATE TOWER, GROUND FLOOR,
OPPOSITE NEHRU PLACE METRO STATION
NEHRU PLACE, NEW DELHI – 110019
THROUGH ITS MANAGER: .…..OPPOSITE PARTY
Date of Institution-15.05.2018
Date of Order- 26.09.2022
O R D E R
MONIKA SRIVASTAVA – PRESIDENT
The complainant has filed the present complaint seeking payment of Rs.5,89,890/- i.e the bill amount paid by the complainant towards his wife's illness. Along with this, the complainant is also seeking a compensation of Rs.5,00,000/- for causing mental agony, pain harassment and Rs.25,000/- as litigation expenses
- It is stated by the complainant that he had insurance policy, Health Suraksha policy bearing no. 2952201502935 00000/1 and Sarv Suraksha policy-personal accident bearing number 2952201050293500000/2 for a sum of Rs. 3,00,000/- and Rs.10,00,000/- respectively for which a total premium of Rs. 22,208/- was paid and the said policies were valid for the period 24.04.2015 to 23.04.2017.
- It is stated by the complainant that under the above policies the complainant, his wife and 2 daughters were insured. Unfortunately his wife, Smt. Anjali Mehra expired on 27.03.2017 in Max hospital, Saket.
- It is stated by the complainant that on the demise of his wife the complainant filed claim for getting death/medical claim and submitted bill amounting to Rs.5,89,890/- in the month of April 2017 along with all requisite documents.
- It is stated by the complainant that even after waiting for one year he did not receive any response from the OP and therefore got a legal notice issued to them dated 03.04.2018 which has been duly served on them.
- In the reply, OP has taken preliminary objections and stated that the claim of the complainant was repudiated for non-disclosure of material fact. It is stated by them that the complainant while taking the policy did not disclose that his wife is a known case of progressive systemic sclerosis, hypothyroidism and hypertension.
- It is stated by the OP that in the contract of insurance principle of good faith is the code that requires contracting parties to act honestly and not to mislead or withhold information essential to the insurance contract from one another. It is stated that both the parties to the insurance contract must disclose all facts material to the risk voluntarily to each other in any breach of this duty renders the contract voidable at the option of the aggrieved party.
- It is stated by the OP that when the claim was launched before the OP on 12.04.2017, the claim was verified and during verification the OP came across the past discharge summary of the wife of the complainant dated 19.12.2014 wherein it was clearly mentioned in the past history
‘progressive systemic sclerosis since 2000 and is on homeOPathic medication, hypothyroidism and is on tab Thyronorm 25 mg once a day and HTN, is on medication.’
It was also revealed from the death summary of the complainant’s wife that she was diagnosed with
‘metastatic progressive adenocarcinoma lung carcinoma (EFGR/ALK).’
It is stated that perusal of the medical documents showed that the ailment suffered before the policy inception and the ailment has diagnosed had relation and this fact was never disclosed at the time of procurement of policy.
The OP has also relied on medical studies where in it has been observed that a person having progressive systemic sclerosis are more prone to lung cancer …… several reports have also demonstrated an increased risk of malignancy cancer in patients with SSc.
- It is stated that there is no deficiency of service or unfair trade practice on the part of the OP as alleged by the complainant.
- It is stated that the insurance is based upon the principle of utmost good faith and the person proposing for insurance cover is supposed to disclose all the pre-existing diseases at the time of taking the insurance cover. The act of non- disclosing of pre-existing disease by the complainant amounts to non-disclosure of material facts and thus the claim of the complainant was rightly repudiated.
- It is stated had the complainant disclosed the said ailment suffered by his wife at the time of availing the first insurance policy, the OP would have issued the policy with certain conditions attached to it.
- The OP has placed reliance on the judgment of the Hon’ble Supreme Court in Satwant Kaur Sandhu vs New India Assurance Co. Ltd. reported in (2009) 8 SCC 316 wherein it was held
the term material fact…. means any fact which would influence the judgment of a prudent insurer in fixing the premium or determining whether he would like to accept the risk. Any fact which goes to the root of the contract of insurance and has a bearing on the risk involved would be ‘material’.
- The OP has also placed reliance on the decision of the Hon’ble National Commission in Smt. Phoola Devi vs Life Insurance Corporation of India Revision Petition No. 2271/ 2011 decided on 29.08.2016 where in it was held that the OP rightly repudiated the claim on the ground of suppression of material information about his health condition by the insured.
- In their rejoinder, the complainant has merely denied all that has been stated by the OP and has reiterated what has been stated by him in his complaint. It is stated by the complainant that he was never put any query regarding his wife's health and neither was his wife suffering from any disease at the time of procurement of the policy.
- Both the parties have filed the evidence affidavit as well as written arguments which are on record. The Commission has carefully gone through all the documents and material on record. It is clear from the documents filed on record by the OP that the wife of the complainant was suffering from systemic sclerosis prior to the inception of the policy, which fact was never disclosed to the OP at the time of taking of the policy.
The OP has also placed on record, the transcripts of the telephonic conversation between the agent of the OP and the complainant where in categorically, the agent of the OP had questioned the complaint regarding any illness in the family relating to him or his wife and the complainant, replied in negative. The complainant was also informed by the agent that in case the information is found to be false, the claim under policy may be rejected.
The documents which have been filed by the OP pertaining to the illness of the complainant’s wife for the year 2014, goes to lucidly indicate that the wife of the complainant was suffering from some diseases at the time of procurement of the policies from the OP. As has been held by the Hon’ble Supreme Court in Satwant Kaur Sandhu since there is non-disclosure of material facts, the claim of the complainant has been rightly repudiated.
The complaint is dismissed with no order as to costs. File be consigned to the record room after providing copy of the order to the parties as per rules.
Order be uploaded on the website.
(Dr. RAJENDER DHAR) (RASHMI BANSAL) (MONIKA SRIVASTAVA)
MEMBER MEMBER PRESIDENT
