(Passed on 27/07/2022)

Passed by Shri Atul D. Alsi, Hon’ble President 

1.         Complainant is the nominee  of   legal heirs of  deceased  husband  Goyal Ashok Rakshel who had insured himself  under Insurance Policy  bearing  No. 979749254 under plan of  841/24/15 on 09/08/2017 for the sum assured  of Rs. 4,00,000/-. The complainant’s husband died on 25/03/2019 and filed insurance claim with O.P. but O.P. repudiated the claim for the reason of suppression of material facts in proposal form at the time of purchasing of policy. The complainant’s claim was rejected by O.P. on 19/07/2019. The complainant further submitted  in complaint  that  the deceased  was not suffering  from any ailment  nor under medical treatment  for the given period  in proposal  nor any record  of hospital is filed  by O.P. by rejecting  the claim.  Hence, there is no suppression of material facts in respect of health condition. Therefore, the rejection of the claim, thus amount to deficiency in service.

2.         O.P. filed reply and admitted the insurance policy of the complainant for the sum assured of Rs. 4,00,000/- purchased  on 09/08/2017.  The insured had died within three years from inception of policy. Hence matter is investigated and it was found that the deceased was alcoholic and under medical treatment for heart at Christanand Hospital, Brahmapuri, District Chandrapur from 2010 to 2018.  Therefore, insured had submitted  false information  to question No. 11(a) for the consultation  of doctor  for the period  of 5 years  and question No. 11(d) suffering  from any  ailments  pertaining to Liver , Stomach, Heart, Lungs, Kidney, Brain or Nervous system and question No. 11(g) for denial of  alcoholic drinks, narcotics , any other  drugs and tobacco in any form.  The treatment papers of Christanand Hospital, Brahmapuri proves that the deceased was under treatment for ailment before purchasing of the policy.  Therefore, the deceased submitted false information.  The insurance claim is based on utmost good faith. The  deceased  had submitted  false information  in respect of state of health .Therefore, the rejection  of claim  does not  amount  to  deficiency  in service.

3.         Counsel for the  complainant  argued  that the deceased  had submitted  true and correct information  in proposal form for  the  last five years to the agent at the time of  purchasing  the policy.  The documents filed by the O.P. in respect of treatment papers are not certified copies   and false documents. Therefore, the rejection of claim thus amount to deficiency in service.

4.         Mr. Khati, counsel for the  O.P. argued that  the O.P.  has filed treatment  papers  from year 2010  to 2018 from Christanand Hospital, Brahmapuri on record  as per list of documents  dated 17/12/2019. Therefore, the information supplied by the deceased at the time of purchasing of policy in respect of state of health is suppression of material facts. Therefore, due to breach of utmost  good faith, the claim is repudiated.  The counsel for the O.P. has relied on judgment  passed by the  Hon’ble Supreme Court of India  by Hon’ble Justice D.K. Jain and R.M. Lodha on 10/07/2009 in  Satwant Kaur Sandhu Vs. New India  Assurance Company Ltd. holding that  the material  fact is not defined in Act- In general  terms it means as any fact which would  influence judgment of a prudent insurer in fixing premium or determining  whether he would like to accept the  risk. In another judgment  of Hon’ble Supreme Court of India in the case of  P.C. Chacko Vs. chairman, Life Insurance  Corporation of India,  reported in 2007 LawSuit (SC) 1251 holding  that proposal  can be  repudiated if fraudulent act discovered after two years  from the policy.  Therefore, rejection of claim does not amount to deficiency in service.

REASONING

5.         The deceased had insured with the O.P. under the insurance policy  bearing No. 979749254 from 09/08/2017. The insured was died on 25/03/2019 within three years from purchasing of policy. Hence,  the matter is  investigated  and the insured  claim has been repudiated  for the suppression  of material facts in respect of  medical treatment at about state of health  vide  repudiation  letter dated 19/07/2019.

6.         The O.P. failed to file original papers  of treatment  of deceased  or certified  copies  to prove  his contention  by  leading  evidence  on affidavit of treating  doctor for the deceased  and treatment was given  to prove  the contention  about  suppression of material facts. Hence,  the contention of the O.P. cannot be accepted  and proved mere filing  of Xerox copies  of treatment papers  are not sufficient. The defence  shall be proved  by the reliable  evidence. Therefore,  the repudiation of the insurance claim of the  complainant  thus amount to  deficiency  in service and complainant   is entitled  for  insurance claim of sum assured  of Rs. 4,00,000/-  under the  insurance policy  along with interest  at the rate of 6% p.a. from the date of  judgment  till its  realization  along with  cost of litigation Rs. 10,000/- as per  following  order. 

ORDER

i.          Complaint is partly allowed.

ii.          The complainant  is entitled  to receive  the sum assured  for  Rs. 4,00,000/- under  the Insurance Policy  bearing  No. 979749254 along with interest at the rate of  6% p.a. from the  date of judgment  till its realization  with cost of Rs. 10,000/- towards  litigation.

iii.         Copy of order be furnished to both the parties , free of cost.