This complaint case is filed by one Sri Dinabandhu Mitra against HDFC Standard Life Insurance Co. Ltd., praying for a direction upon the OPs to pay the assured sum of Rs. 1,97,836/- along with interest and litigation cost.

In nutshell, case of the Complainant, is that, his son, Deepam Mitra, since deceased, took a life insurance policy from the OPs on 31-03-2012, being Policy No. 15096259.  As per the terms and conditions of the policy, the policyholder paid his first premium on 31-03-2012, and thereafter, paid second and third premiums within the prescribed time.  The policyholder got admitted at CMRI on 08-09-2014 with abdominal pain and died on 11-10-2014 due to decompensated CLD and hepato renal syndrome as per death certificate issued by the said hospital.  The Complainant, being beneficiary nominee of the said policy, intimated the death of the policyholder to the Insurer and staked insurance claim on 03-11-2014.  Subsequently, the Insurer, vide its letter dated 17-12-2014 declined to accept the said death claim holding that the policyholder provided wrong information with regard to Sec. D of 2A and 3 where the policyholder was asked medical questions on his own life.  The Complainant further requested the OPs through letter dated 08-01-2015 to review their decision, but to no avail.  Hence, this case.

This case is duly contested by the OPs by filing WV, wherein they denied all the material allegations of the complaint.  It is further stated that on receipt of a duly filled up proposal form and premium amount, the OPs, considering the information given by the DLA as true and correct, issued the subject policy bearing no. 15096259.  In the proposal form, the DLA was asked various questions related to his employment and health. The proposal form, being the foundation of the insurance contract, the Insured was supposed to give correct answers in respect of all questions given in the proposal form.  The OPs received claim intimation from the Complainant on 10-11-2014, thereby intimating that the life assured died on 11-10-2014.  After receipt of death claim, the OPs vide a letter dated 11-11-2014 called upon the Complainant to furnish certain documents, including past medical records of diagnosis and treatment taken by the DLA in his lifetime.  Accordingly, the Complainant furnished certain medical prescriptions of the LA which revealed pre existing disease suffered by the DLA.  The same was, however, not disclosed at proposal stage.  It revealed that the LA was suffering from Hepato Splenomegalysis prior to the issuance of the subject policy.  Based on the information received, OPs repudiated the claim of the Complainant vide its letter dated 17-12-2014 on the ground that DLA suppressed the facts related to his health.  Accordingly, they prayed for dismissal of the claim.

Point for determination is whether the Complainant is entitled to the reliefs sought for by him, or not.

Decision with reasons

The present dispute revolves over repudiation of Complainant’s claim by the OP Insurer on account of non-disclosure of past ailments by the Insured, since deceased.  In order to buttress such contention, OPs furnished photocopies of some treatment sheets dated 26-03-2012, 30-03-2012 and 29-05-2012, issued by Dr. Sabyasachi Pattnaik, CMRI Hospital. It appears from the noting on the prescription dated 26-03-2012 that the USG report dated 23-03-2012 detected that the patient was having Hepato Splenomegalysis (enlarged spleen).

Taking a high moral ground, the OPs squarely blamed the deceased Insured for not coming clean about his past ailment.  No doubt, it was obligatory on the part of the Insured/Complainant’s son, since deceased, to disclose all his past ailments without any cover up. However, the burning question remains, is it proper to always hold one guilty of mala fide intention simply on the basis of information mentioned in the proposal form.

 It is an open secret that proposal forms are filled up by the agents of insurance companies, who often impress upon the incumbents to put their signatures on the dotted line without bothering to explain the implications of contends of proposal forms.  In fact, a comparison of the handwriting – the manner in which the proposal form was signed vis-à-vis various particulars filled up in the proposal form - fairly gives the impression that the proposal form was not filled up by Complainant’s son. No affidavit is filed from the side of the concerned agent to clarify that the proposal form was filled up by the proposer himself and not him.  In such circumstances, we cannot conclusively hold that the proposer answered in the negative when asked about his past medical history. Who knows, whether the concerned agent, in the interests of his business, put (√) mark in the negative column, or not.  We afraid, for want of sufficient evidence to prove otherwise, we do not deem it proper to hold the Complainant guilty of any wrongdoing. 

Further, we have to keep in mind that every applicant is subjected to stringent medical checkup by the panel doctor of the Insurance Company. In such circumstances, we find it quite baffling that the concerned doctor of the OP Insurer did not notice any abnormality with the applicant during his physical check up.  It appears from the photocopies of prescriptions on record that Complainant’s son had to rush to the concerned doctor in quick successions - USG and various other tests were done on 23-03-2012, which is a clear testimony of the fact that he was treated by a doctor who prescribed said tests on or before 23-03-2012.  Besides this, the patient (Complainant’s son) also visited the concerned doctor on 26-03-2012, 30-03-2012 and 29-05-2012.  It further transpires from the prescriptions that the patient was suffering from severe pain and various other complications.  It is hard not to wonder how the poor state of health of Complainant’s son, since deceased, escaped the attention of the panel doctor of the Insurer, who examined him and declared physically fit.  When a human being suffers from any serious ailment, inherent symptoms are bound to surface on the appearance of the person. 

In our considered view, therefore, the OP Insurer cannot escape the liability of settling Complainant’s claim for the palpable gross negligence on the part of its own panel doctor. 

In its own interest, it is of paramount importance for the Insurer to satisfy itself about the sound health of the incumbent policyholder.  Issuance of an insurance policy signifies the fact that the Insurer has done so on being fully satisfied about the bona fide of declarations of the applicant as mentioned in the proposal form, particularly in respect of health condition of the applicant.  After issuing an insurance policy, in case of detection of any discrepancy in respect of the information furnished in the proposal form, it cannot abruptly pass the entire responsibility of such discrepancy upon the declarant, conveniently forgetting the negligent acts of its authorized agent/empanelled doctor. We cannot be oblivious of the fact that the Insured did not die overnight after taking the policy, but during the long three years since coming under the shelter of the insurance policy in question, he paid an amount of Rs. 91,395/- as premium to the OP Insurer. 

In the light of our foregoing discussion, we are of view that the OPs must settle Complainant’s claim.

Hence,

O R D E R E D

that CC/68/2015 be and the same is allowed in part on contest against the OPs.  The OPs are directed to pay Rs. 1,97,836/- within two months of this order, i.d., they would be liable to pay interest @ 10% p.a. over the aforesaid amount after expiry of two months till full and final payment is made.