DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL)

MAHARANA PARTAP BUS TERMINAL: 5^th  FLOOR.

KASHMERE GATE DELHI.

No. DF / Central/ 2015

Gunisha Kohli (minor) Daughter

Of Late Sh. Sanjay Kohli

Through her mother,

The natural guardian Ms. Kavita Kohli,

House No. 52 A, Pocket B,

Vikas Puri Extension , New Delhi-110018

Delhi-110053                                                                                 ..........Complainant

Versus

ICICI Prudential Life Insurance Company Ltd Through its

Vice President Videocon Tower E-1 Block, Jhandewalan Extension,

New Delhi

                                      ..........Respondent/OP

BEFORE

SH. RAKESH KAPOOR, PRESIDENT

SH. S. N. SHUKLA, MEMBER

ORDER

Per Sh. RakeshKapoor, President

Sanjay Kohli  , the deceased father of the complainant had purchased one “ICICI PRU SMART NEW LINKED REGUALR PREMIUM” policy from the OP in order to secure the education of his daughter.  The policy was purchased on 5.12.2009 and bore no. 13001637. The father of the complainant died on account of a heart attack on 5.1.2011.  A claim was lodged in respect of the said policy which has been repudiated by the OP.  The complainant has alleged that this act of the OP was illegal and unwarranted.  Hence, the complaint.

The OP has contested the complaint and has filed a reply. It has claimed that the complaint is false, frivolous and is a gross misuse of the process of law. It has claimed that the complaint is without any merits and is liable to be dismissed.  Paras 5 ,6 and 9  of the preliminary objections of the reply are relevant and are being reproduced as under:-

5. That without prejudice to the above submission, the OP disputes and denies its liability to pay any compensation or claim amount to the complainant as alleged.  It is stated that the policy is a legal contract between the policy holder and insurance company and the parties to the said contract are bound by its terms and conditions.  The extract are bound by its terms and conditions.  The extract of relevant clause which defines freelook period is under:

FREELOOK PERIOD

   “ A period of 15 days is available to you to review the policy. If you do not find the policy suitable this policy document must be returned to the company within 15 days from the date you have received the same.”

 In the present complaint, the complainant has approached the OP after the expiry of freelook period i.e. after 15 days from the receipt of the policy documents. The policy documents of the policies in dispute were dispatched by the OP on 9.12.2009 and the same was received by the complainant admittedly. The complainant retained the policy and never complained about the discrepancies in the policy as such it was assumed that the complainant has received the documents and is also satisified with the terms and conditions of the policy. Thus, the present complaint is liable to be dismissed.

6. That it is submitted that the policy is a legal contract between the policy holder and insurance company and the parties to the said contract are bound by its terms and conditions. The extract of the relevant clause of the proposal form is as under

20.Are you presently in good health. Please submit previous medical report (if any) as receipt of these reports helps us in faster assessment of the health of the life to be assured

A. Yes

23. Have you ever consulted any doctor or are  you currently undergoing/ have undergone any tests, investigations, awaiting result of any test or investigation or have you ever been advised to undergo any tests, investigations or surgery or been hospitalized for general check up, observation treatment or surgery?

A. No

23.  (i) Did you have any ailment/ injury/ accident requiring treatment medication for more than a week?

A. No

23 (h) Have you ever suffered or are suffering from any of the following

1. Diabetes/ High Blood Sugar
2. High/ Low Blood Pressure

1. No

In the present case, during the claim investigation it was revealed that the life assured was a known case of Diabetes Mellitus with insulin dependency and Hypertension since 4-5 years i.e. prior to issuance of the subject policy. Had the past medical history been disclosed by the life assured the subject policy would not have been issued to the complainant in the same lines. That if this fact was known to the company then the company would have asked for medicals and would have probably charged an extra premium under the policy. Thus, the claim of the complainant was rightly repudiated by the OP as such the present complainant is liable to be dismissed.

9. That the present complaint is not maintainable. It is stated that the contract of insurance is based on foundation of utmost good faith i.e. principle of uberrimafides. The proposer/ life sassured has to maintain and observe a complete good faith in entering into a insurance contract with the insurer. The life assured is under solemn obligation to make full, complete, true and correct discloser of the material facts which may be relevant for the insurer to take into account while decideing whether the proposal should be accepted. If the life assured/ proposer fails to disclose the true and correct material facts to the insurer then the policy obtained by the life assured/ proposer stand vitiated and the life assured or any person claiming under him is not entitled for any benefits under the said policy. In the present case, the life assured has concealed his past medical history from the OP while purchasing the subject policy as such the present complaint is liable to be dismissed.

 The OP has contested the complaint on merits and has reiterated that the  deceased insured had made a misstatement about the state of his health and , therefore, the claim lodged by the complainant has been rightly repudiated by it. 

We have heard arguments advanced at the bar and have perused the record.

 In United India Insurance Co. Ltd. Vs. M.K. Corporation,III(1996)CPJ8(SC),the Hon’ble Supreme Court held as under :-

“It is a fundamental principle of Insurance Law that utmost good faith must be observed by the contracting parties.  Good faith forbids either party from concealing (non disclosure) what he privately knows, to draw the other into a bargain, from his ignorance of that fact and his believing the contrary.  Just as the insured has a duty to disclose, ”Similarly, it is the duty of the insurers and their agents to disclose all material facts within their knowledge since obligation of good faith applies to them equally with the assured.

The duty of good faith is a continuing nature.  After the completion of the contract, no material alteration can be made in its terms except by mutual consent.

 The learned counsel for the OP has taken us through the proposal form, a copy of which has been placed on record. It has been pointed  out that the insured had been  specifically asked at the time of entering into the contract as to whether he was suffering from diabetes and high blood pressure to which he had replied in the negative. He had further denied that he had suffered from any ailment which had required him medication/ treatment for more than a week.  He had also denied that he had even consulted any doctor or had undergone any investigation and had claimed to be in good health . The learned counsel has then taken us through the medical record of M/s Jeevan Jyoti Clinic and Nursing Home in respect of the deceased who had remained admitted there  from 20.11.2010 to 28.11.2010. The medical record shows that the deceased was a known case of diabetes and was on insulin for the last five years.   He was  also a known case of hypertension i.e. High Blood Pressure for the last two to three years.  The learned counsel  has forcefully contended that the deceased had made a misstatement about his health at the stage of issuing of the policy. Therefore, the OP was justified in repudiating the claim. We have considered the contention of the learned counsel with which we tend to agree. The medical record of the  OP placed on the file shows that he was taking insulin for the last five years for the treatment of diabetes. He was also a known case of hypertension for the last two to three years. It is, therefore, clear that the deceased had made a misstatement in the proposal form about the state of his  health which had vitiated the contract entered into between the parties. We , therefore, are of the considered opinion that there is no deficiency in service on the part of the OP as it was justified in repudiating the claim lodged with it in accordance of the terms and condiotns of the policy of insurance purchased by the deceased. Accordingly, we see no merits in this case which is hereby dismissed.

     Copy of the order be made available to parties free of cost as per law.

File be consigned to R/R.

Announced in open sitting of the Forum on_____________

    ( S N SHUKLA )                   ( RAKESH KAPOOR )

          MEMBER                      PRESIDENT