C.F. CASE No. : CC/36/2013
COMPLAINANT : Haripada Dey,
S/o Late Sitanath Dey,
Adarshapara, Gobarkuli,
P.O. Dhubulia T.B. Hospital
P.S. Dhubulia, Dist. Nadia
OPPOSITE PARTIES/OPs : 1) Senior Div. Manager
Life Insurance Corporation of India,
Kolkata Suburban Div. Office,
Jeevan Prabha, DD-5, Sector -1,
Salt Lake City, Kol-64.
2) Branch Manager,
Life Insurance Corporation of India,
Kalyani Branch, Jeevanjyoti,
Central Park, B-Block, Kalyani,
Dist Nadia , PIN - 741235.
PRESENT : SHRI PRADIP KUMAR BANDYOPADHYAY, PRESIDENT
: SMT REETA ROYCHAUDHURY MALAKAR, MEMBER
: SHRI SHYAMAL KUMAR GHOSH, MEMBER
DATE OF DELIVERY
OF JUDGMENT : 17th June, 2014
: J U D G M E N T :
This is an application U/S 12 of Consumer Protection Act 1986 filed by the complainant praying for relief as mentioned in his complaint.
The brief facts of the case are that wife of complainant, viz., Nanibala Dey has obtained a LIC policy bearing no – 426960690 from the opposite party No. 2 for the sum assured of Rs. 1,00,000/-. The said policy was started on and from 12/11/2008 and quarterly premium of Rs.2,482/- has been paid by the complainant. The complainant was the nominee of the said policy. The said policy was continued upto November 2010 without any default. The said Nanibala Dey died on 07/03/2011. The complainant has submitted claim form in the office of Insurance Company for getting death benefit of his deceased wife. But the office of opposite party No. 1 by the letter dated 31/12/2012 repudiated the said claim on the ground of mis-statement and wrong material information , i.e., suppression of material fact). Hence, the case with the prayer mentioned in the relevant portion of his complaint.
The opposite parties Nos. 1 & 2 both have filed written version stating, inter alia, that every policy is based upon utmost good faith which is one of the most important feature. But before obtaining the said policy Nanibala Dey submitted false information which comes within the purview of suppression of material fact and the said event goes against the basic feature of utmost good faith. The policy holder died on 07/03/2011 due to cardio respiratory failure. The matter has been sent to op No. 1 for settlement of the above claim. But after enquiry it was found that the DLA i.e., Nanibala Dey was a patient of dilated cardiomyopathy since 2007. It should be necessary to provide correct information of her disease in the proposal form but intentionally she has failed to provide the correct information. Thereafter, the claimants has approached before the office of ZOCRC for reconsideration of the said claim but the said office upheld the decision of repudiation which has already been conveyed by the letter dated 16/04/2013. This case is purely the case relating to suppression of material fact from the end of policy holder, so the petition filed by the complainant is liable to rejected with cost.
Now this Forum is to consider the following points-
1 ) Whether the complainant can be termed to be a consumer as per Provisions of C P Act 1986.
2 ) Whether there is any gross negligence or deficiency in service on the part of ops.
3) Whether the complainant is entitled to get any relief as prayed for or not.
REASOND DECISIONS
The records give indication that the complainant in substantiating his claim submitted certain documents. The ops also submitted several documents in respect of their defence. Perused the all documents including complaint, written version etc. and also perused written argument filed by the complainant on 11/04/2014.and written argument filed by the ops on 04/06/2014. Hd the ld. Counsels at length.
Point No. 1
In the instant case Nanibala Dey since deceased obtained a LIC policy bearing no – 426960690 on payment of premium of Rs 2482/-(qtr) against the sum assured of Rs.1,00,000/-. The commencement of said policy, i.e., DOC was 12/11/2008 which is clearly revealed from the premium receipt bearing No. 3680049. As per proposal form dt 12/11/2008 it is also clear that the present complainant, viz, Sri Haripada Dey has figured as a nominee of the assured. As per certificate of death, it is also fact that Nanibala expired on 07/03/2011 at TB Hospital P.O. and P.S. – Dhubulia, Nadia. After death of Nanibala, her husband i.e. the present complainant may approach before the proper forum for getting his relief mentioned in the complaint. So in view of the status of the complainant and his relationship with the respective OPs , has been found to be a consumer in terms of the provisions of Sec 2(1)(d)(ii) of the C P Act 1986 for the purpose of this proceeding. Point No. 1 is thus disposed of.
Point Nos. 2 and 3
In the instant case the moot question is that whether there is any suppression of any material facts on behalf of the complainant or not. The ld counsel for the complainant has argued that the policy is not to be called in question on the ground of misstatement after two years. On the other hand, the ld. counsel for OPs has also argued that the insurance is a kind of contract between the parties which is based upon utmost good faith. In the life insurance contracts also, every material fact must be disclosed. But in the instant case, the insured since deceased has failed to do it. Sec-45 of Insurance Act, 1938 provides that no policy of life insurance shall, after expiry of 2 years from the date on which it was effected, be called in question by an insurer on the ground that a statement made in the proposal for insurance or in any report of a medical officer, or referee, or friend of the insured or in any other document leading to the issue of the policy, was inaccurate or false, unless the insurer shows that the followings-
- the statement must be on a material matter, or it suppresses facts which it was material to disclose,
- the suppression must be fraudulently made by the policy holder , and
- the policy holder must have known that it was false or it suppressed facts which it was material to disclose .So we can say that where more than 2 years have elapsed from the date on which the policy was originally effected , the LIC can repudiate the claim of policy only if it is shown that all the three conditions mentioned above enumerated in the second part of Sec-45 are satisfied
In the instant case ld counsel for the complainant has referred 2012(1) CPR 391 (NC) LIC Vs. Smt Sudesh wherein Hon'ble National Commission has held that the appellant / L.I.C. of India has relied entirely on the record of treatment of the period 20/03/1997 to 25/03/1997 for repudiation of claim. Ld counsel for appellant LIC of India could not point to any other evidence produced before the state commission which could show that the deceased suffered from any of all of these aliments at the time when the proposal for insurance was made on 23/02/1996. The question of disentitlement under the insurance policy on the ground of concealment / suppression of information , would have arisen in this case only if there was evidence to show that the insured had undergone hospitalization / treatment for any disease in near proximity of the time when insurance policy was obtained and had chosen not to disclose it .The ld counsel for complainant has also cited another case law 2012 (1) CPR 282 (NC) LIC Vs. Smt Chanagoni Upendra wherein national commission has held that the grant of assistance under Apathbandhu Scheme to widow of life assured by itself cannot be sufficient proof of declaring that statement made by life assured was false.
On the other hand, the ld counsel for the ops has also cited 111(2010) CPJ 358 (NC) Dineshbhai chandarana and another Vs. LIC wherein Hon'ble National commission has held that non-disclosure of details of last policy by deceased is a material fact in the proposal form for last policy not a bonafide inadvertence. The contract of life insurance based upon the principle of uberrimae fidie on part of life assured and L.I.C. is well within its right to repudiate claim under the last policy. There is no deficiency in service .
In IV (2009) CPJ 8 (SC) Satwant Kaur Sandhu Vs. New India Assurance Co. ltd the Apex court held that 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 of 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.
The ld counsel for ops has also cited another reference i.e., 111(2013) CPJ 684 (NC) Kapil Sharma Vs. LIC of India, wherein the Hon'ble National Commission has held that the contract of insurance is based on the doctrine of utmost good faith and life assured was under an obligation to disclose each and every aspect with respect to his health at the time of submitting proposal form. Insured had not disclosed fact of being alcoholic for last 15 to 20 yrs and suffering from cirrhosis for last one year and had not disclosed fact of remaining on leave on medical grounds for about 3 and ½ months and in such circumstances, on account of suppression of material facts regarding health, respondent / L.I.C. has not committed any error in repudiating claim filed by the petitioner.
Upon careful perusal of the above case laws / references and other relevant documentary evidence we try to describe whether there is any suppression of material facts or not from the end of complainant .It is admitted fact that Nanibala since deceased has obtained L.I.C. policy bearing No. 426960690 with the ops having sum assured of Rs. 1,00,000/- on payment of premium of Rs. 2,482/- (qtr) started on and from 12/11/2008. It is also admitted that Haripada Dey is a nominee of the said policy and Nanibala expired on 07/03/2011.
The original bed head ticket clearly reveals that Nanibala took admission in Gandhi Memorial Hospital, Kalyani, Nadia (ICCU-3) at 9-15 AM on 29/11/2007 for treatment of DCM and she was discharged from the said hospital on 14/12/2007. So it is clear that she stayed at the said hospital for 16 days which is very much material factors that should have been disclosed in the proposal form as per our view as it is the basic sense that any patient who takes admission at ICCU in any hospital / nursing home, the said patient is surely be treated as a serious patient .
Now we come to the law point. The commencement of the said policy was 12/11/2008 and Nanibala expired on 07/03/2011. So the difference between the two days is more than 2 years, yet as per our views on the basis of Sec – 45 of Insurance Act 1938 the OPs/L.I.C. has exclusive right to repudiate the policy on the ground that the policy holder clearly knew that she took admission at ICCU-3 in Gandhi Memorial hospital, Kalyani, Nadia before opening of the said policy but she i.e., policy holder Nanibala Dey intentionally/fraudulently has suppressed the said material fact in her proposal form. There is a clear, strong and sufficient evidence to show that the insured had undergone hospitalization/ treatment for disease (DCM) before opening of the said policy and disclosure of the said event is very much vital in the proposal form by which the insurance company is able to fix up the correct/actual premium amount. But the policy holder in the instant case submitted in the proposal form that she bears a good health and is not suffering from any disease or there is no question of medical consultation for last 5 years etc. which are very much wrong submission from the end of policy holder in the proposal form.
Actually the insurance is a contract upon speculation. The man who desires to take an insurance policy, must disclose to the under writer/ Insurer all the material facts / circumstances because the insurer knows nothing and the assured knows everything . The contract of insurance is of utmost good faith i.e. uberrimae fidei. The special facts lie commonly in the knowledge of the insured and the insurer trusts the insured’s representations. Suppression of such material facts is fraud and therefore the policy is void. In the instant case the insured / policy holder was clearly aware about her illness / medical treatment and she also took leave on several occasions on Medical ground before opening of policy but she has failed to disclose it .Thus the second part of Sec – 45 of Insurance Act 1938 is clearly established by OPs. So repudiation of claim of the complainant by OPs / Insurance Co. is just and proper. There is no deficiency in service on the part of OPs and the complainant is not entitled to get any relief as prayed for. So the point nos. 2 & 3 are thus decided on the basis of above observation. So the case fails.
Hence,
Ordered,
That the case No. CC/36/2013 be and same is dismissed on contest against the OPs without cost.
Let the free copy of this order be supplied to the parties free of cost.
