After hearing the learned counsel for respondent , Sh. Kamal Mehta, this revision petition was dismissed in limine for the reasons to be recorded separately. 2. The reasons are as follows :- (i) By its order dated 20.10.2009, the Haryana State Consumer Disputes Redressal Commission, Panchkula (in short, ‘the State Commission’) allowed the appeal of the respondent (Life Insurance Corporation) against the order dated 11.10.2002 passed by the District Consumer Disputes Redressal Forum, Faridabad (in short, ‘the District Forum’). The District Forum had allowed the complaint of the petitioner holding the opposite party deficient in service in repudiating the claim for reimbursement of the expenditure that he had incurred on a surgery for coronary artery bypass graft (CABG). The State Commission allowed the appeal and set aside the order of District Forum by observing as under :- “Before dealing with the factual position available on record of the present case, the proposition of broad law on this fact needs to be noticed. It is well settled law that the contract of insurance is a contract uberrima fides and there must be complete good faith on the part of the life assured at the time of submitting proposal form for obtaining the policy and the assured is under a solemn obligation to make full disclosure of material facts with regard to his/her state of health because the same are relevant for the insurer to decide as to whether the insurance policy is to be issued to the proposer or not? In the present case, the onus to prove that the complainant had made a false statement and suppressed the material facts at the time of submitting the proposal form lies upon the appellant-opposite party. During the course of arguments, learned counsel for the appellant-opposite party has justified the repudiation of complainant’s claim while relying upon the history of treatment obtained by the opposite party during the investigation for settling the claim of the complainant. Learned counsel drew our attention towards the certificate Annexure A-5 issued by Medical Superintendent, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, the relevant part of which is reproduced as under :- “Mr. Subhash Bansal, 43 yrs old male is a known case of Hypertension Diabetes Mellitus and bronchial asthma. He experienced sudden onset of breathlessness on 22.09.97. He was treated as acute LV Failure. ECG was normal but later revealed T wave inversion in leads V4-6. He had similar attack 7-8 years back and was treated as Asthma. He has positive History of IHD”. It cannot be disputed that the history of the patient is recorded in the hospital at the time of admission of the patient which is disclosed by the patient himself and in case the patient is unconscious, then on the statement of his attendants/family members. In view of the certificate issued by Medical Superintendent, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, it is evident that the complainant was admitted in the said hospital on 26.9.1997 and he was suffering from Hypertension Diabetes Mellitus and bronchial asthma for the last 7-8 years. The Medi-claim insurance policy was taken by the complainant on 17.1.1996. Thus, it is proved on record that the complainant was having full knowledge of his illness on the date of submitting proposal form for obtaining the insurance policy and he intentionally and deliberately concealed true and material information with regard to his state of health and committed fraud with the company. Reliance is placed on the case law cited in Mithoo Lal V Life Insurance Corporation of India, AIR 1962 Supreme Court 814, wherein it has been held that :- “Contract of life insurance entered into as a result of fraudulent suppression of material facts by policy holder. Policy is vitiated and person holding assignment of policy cannot claim benefit of contract……”. In case Life Insurance Corporation of India Ltd. & Anr. I (1996) CPJ 115 (NC), it has been held :- “Suppression of Fact”- Deceased had taken an insurance policy – died after three months of taking the policy – insurance company. Repudiated all liabilities on account of deceased having withheld correct information of his health – State Commission rejected the claim but directed the insurance company to refund the premium – Hence, appeal – “Whether the complainant is entitled for the refund of the premium? – (No)”. The Hon’ble National Commission in case of Life Insurance Corporation of India Versus Smt. Mintu Kalita, III (2002) CPJ 10 (NC) has held that :- “Repudiation of claim – Insured suffering from cancer, took treatment in hospital not disclosed – Claim allowed by both lower Forums – Hence revision – Incorrect information regarding health, age and income – Insurance contract invalid ab initio – No deficiency in service – Repudiation justified – Order of lower Forums set aside”. The facts and circumstances of the present case are fully attracted to the authoritative pronouncements cited above”. (ii) Despite the strenuous efforts of the learned counsel for the petitioner and his reliance on a medical certificate issued in favour of the petitioner, I am afraid the petition cannot succeed. As rightly observed by the State Commission, a contract of insurance is primarily one of uberrima fide, i.e., utmost good faith on the part of the assured. This doctrine and its implications, in terms of disclosure of material facts by a person seeking either a policy of life insurance or a non-life insurance (mediclaim as in this case), have been authoritatively expounded in a recent judgment of the Apex court in case of Satwant Kaur Sandhu v New India Assurance Company Limited [(2009) 8 SCC 316], the Apex court has in particular, observed as under :- “18. A mediclaim policy is a non-life insurance policy meant to assure the policy-holder in respect of certain expenses pertaining to injury, accidents or hospitalisations. Nonetheless, it is a contract of insurance falling in the category of contract uberrima fide, meaning a contract of utmost good faith on the part of the assured. Thus, it needs little emphasis that when an information on a specific aspect is asked for in the proposal form, an assured is under a solemn obligation to make a true and full disclosure on the information on the subject which is within his knowledge. It is not for the proposer to determine whether the information sought for is material for the purpose of the policy or not. Of course, the obligation to disclose extends only to facts which are known to the applicant and not to what he ought to have known. The obligation to disclose necessarily depends upon the knowledge one possesses. His opinion of the materiality of that knowledge is of no moment. (See Joel v Law Union & Crown Insurance Co.)”. 22. The term “material fact” is not defined in the Act and, therefore, it has been understood and explained by the courts in general terms to mean as 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’ ”. (iii) In view of this exposition of the principle of uberrima fide and what constitutes ‘material facts’ in the context of a policy of insurance, there is no doubt that, in this case, the petitioner (in obtaining the mediclaim policy in question) failed the most essential test of utmost good faith on his part inasmuch as he chose not to disclose the status of his health at the time of seeking the said claim policy. Hence, the impugned order of the State Commission is fully justified and does not call for any interference under the provisions of section 21(b) of Consumer Protection Act, 1986. 3. Revision petition is dismissed.
......................ANUPAM DASGUPTAPRESIDING MEMBER | |