This is an application u/s.12 of the C.P. Act, 1986.

          Complainant by filing this complaint submitted that complainant’s mother Tapati Banerjee was a policy holder of the OP being Policy No.495368583 and during her lifetime she paid the premium as per schedule period but unfortunately complainant’s mother died intested on 07-01-2013 leaving behind the complainant and her father as her legal heirs and representatives and accordingly complainant submitted a claim letter on 20-03-2013 and the OP duly received said claim letter from the complainant and after a long period on 04-07-2013 OP by sending a letter requesting the complainant to submit all documents as per demand of the OP.   Accordingly, complainant gave a reply on 26-07-2013 informing the OP that she already submitted all documents and that letter was also received by the OP.

          On 28-10-2013 OP illegally rejected the claim of the complainant.

          That on 12-12-2013 complainant sent an Advocate letter requested the OP to pay actual amount to the complainant and letter was sent by registered post with A/D dated 12-12-2013 and on receipt of the said letter OP asked the complainant to appeal before higher authority. 

          As per advice of the OP complainant on 25-01-2014 complainant applied to the higher authority of the OP which was duly received by the OP and then OP sent reply of the aforesaid letter on 10-02-2014 and refused to accept the claim of that complainant.  against that on 30-04-2014 complainant’s Advocate sent a reminder that was duly received by the OP and on 15-06-2014 refused the claim of the complainant and advised to pray before the higher authority.

          OPs did not give any reasonable explanation for refusal of the prayer of the complainant and fact remains by that way, they are trying to harass the complainant in such a manner and for which complainant has prayed for redressal and directing the OP to release the said amount against the policy.

          On the other hand, OPs by filing written statement submitted that the contract of Insurance is based on utmost good faith and the life to be insured is under solemn obligation to truly and correctly answer the questions/interrogation in the proposal for enabling the insurer to come to a correct conclusion in accepting the risk.

          It is specifically submitted that only after paying the first premium, the life assured Tapati Banerjee expired within a very short period of the commencement of the said policy and the OP as per its rules and guidelines had initiated an investigation with regard to the health condition of the life assured prior to taking of the policy and was provided with the copies of the treatment paper of the life assured by Paramount Nursing Home Pvt. Ltd., wherein Tapati Banerjee was admitted on 19-11-2010 with the history of chest infection, hypokalaemia, hypertension, anaemia and liver dysfunction and the life assured was discharged from the said Nursing Home on 20-11-2010 and it is also crystal clear that the life assured was under the treatment of Dr. P.K. Sen for quite a long period but this fact was suppressed and not disclosed in the proposal form by the deceased life assured at the time of taking the said policy and at the same time the discharge certificate of the Paramount Nursing Home reveals that there are series of prescription prescribed for the treatment of the said insured.

          It is also clear from the case history sheet of the Health Point, a multi-speciality hospital in respect of Smt. Tapati Banerjee that is that deceased life assured was admitted on 05-12-2012 with the history of hypertension, chronic kidney disease, MR/TR and the case history sheet of the said nursing home will speak the truth that she had been suffering from which may cause death at any time.  Moreover, at the time of admission of the said insured or life assured herself reported to the doctor about her past history of DM, CKD, MR, TR and therefore, it goes without saying that the deceased life assured had full knowledge about her pre-existing diseases but that was not disclosed in the proposal form.

          Moreover, in the claim form complainant has submitted that life assured was under treatment of doctor for last three years but fact remains the life assured completely suppressed her previous sufferings/hospitalization and material fact and did not also disclose that fact in the proposal form which is the basis of the contract and at the time of taking out the policy she was suffering from HTN, Anaemia, Liver dysfunction and had consulted with medical specialist and took treatment in the different hospital before taking out the policy in question.  So, the declaration as given by the deceased life assured which is the part of the proposal form submitted by the deceased life assured serving as a warranty clause against the risk to be covered against that undertaking that if any untrue and false treatment is made in the proposal form the contract shall be null and void and moneys which shall have been paid in respect of the policy shall stand forfeited to the OP.

          It is to be mentioned that after rejection or the refusing of the claim of the complainant, complainant preferred an appeal before the ZOCRC (Zonal Office Claim Review Committee where a retired Ld. Judge is one of the members) and he had also of the opinion that there was suppression of material fact at the time of taking the policy and as such the repudiation as was made was upheld.  So, there was no negligence or deficiency on the part of the OP and repudiation of the complainant by the OP was within the ambit of the insurance contract and for which the present complaint is completely false and fabricated and further submitted that entire complaint is vexatious and for which the same should be dismissed.

Decision with Reasons

With meticulous care we have studied the complaint and the written statement and fact remains Tapati Banerjee is the insured and she submitted application form for purchasing said policy.  But in the application form she did not state about her health condition, previous hospitalization, previous treatment and about her any pre-existing disease at the time of purchasing the said policy and no doubt as per said policy Antara Banerjee is the nominee of deceased Tapati Banerjee and on the date of taking the policy she was aged about 53 years as her date of birth was 12-01-1959 and in respect of the personal history she stated that her health condition is good and all other columns is noted ‘no’ and about details of any previous diseases she mentioned ‘Nil’ and considering that declaration of the life assured Tapati Banerjee the same was accepted and policy document was issued.  Now, the question is whether repudiation as made by the OP is illegal and whether there was any pre-existing disease of the life assured for which she subsequently died due to said disease.  No doubt from the discharge certificate of the Tapati Banerjee issued by the Paramount Nursing Home dated 22-11-2010 it is proved that said life assured was admitted to said Nursing Home on 19-11-2010 with a history of chest infection, hypokalaemia, hypertension, anaemia and liver dysfunction.

          Further complainant herself made a statement at the time of filing claim application that her mother was suffering from illness having her no good health since 05-09-2012 but from the complaint it is clear that the policy was purchased with effect from 19-03-2012 and she died after lapse of 9 months and 18 days from the taking of the policy i.e. on 07-01-2013.  No doubt in this regard moot question is whether Tapati Banerjee the life insured had been suffering from several type of pre-existing diseases which may cause death or not but in this regard on careful scrutiny of the documents produced by the OPs which are not challenged by the complainant it is clear that on several dates life insured Tapati Banerjee had been treated under Dr. P.K. Sen on 06-08-2010, 28-10-2010, 09-11-2010, 29-11-2010, 24-12-2010, 28-01-2011, 02-03-2011, 22-08-2011, 29-08-2011, 27-10-2011, 29-10-2011 and 13-07-2012 and in fact after considering those medical papers it is clear that the lady Tapati Banerjee had been suffering from various illness practically with a history of DM, CKD, MR and TR and truth is that on several occasions she had been admitted to Nursing Home and Hospital for treatment but all these pre-existing diseases were suppressed by the life insured Tapati Banerjee at the time of filing that application form for purchasing the present policy which is evident from the proposal form for insurance of won life and no doubt that was done with her knowledge but noted about complainant’s health status good but truth is that her health status was completely bad and present history of health as given by the life insured was false and fabricated.  When that is the fact then invariably for suppressing the position of the health of the life insured on the date of taking the policy for suppressing that health status of the life insured the present policy is no doubt void and non-disclosure of actual state of affairs of health of the complainant’s mother she is not legally entitled to any benefit on her death.

          No doubt after considering the entire material as produced by the OP in respect of the continuous treatment of life assured during her life time and subsequent to purchasing the present policy we are convinced that deceased life assured had full knowledge of her life at the time of taking the policy but purposely she did not disclose the same in the proposal form and for which as per terms and condition of the policy it is proved that deceased life assured had full knowledge of her life at the time of taking the policy but purposely she did not disclose the same in the proposal form and for which as per terms and condition of the policy it is proved that deceased life assured practiced fraud upon LICI by giving declaration as noted by the life assured which is a part of the proposal form but that declaration is completely false, fabricated and untrue.  So, as per terms and conditions of the policy the contract shall stand null and void and all moneys in respect of the policy shall forfeit to the Corporation and in view of the above position and findings the repudiation as made by the OP can easily be upheld.

          Fact remains the complainant preferred review before the Review Committee but they also after considering the veracity of the claim of the complainant rejected the same and repudiation of the OP was confirmed.  But after proper study of other material documents it is found actually said policy was for 12 year and Tapati Banerjee’s husband was a retired person and annual premium was Rs.1,500/-.  So, we may consider whether the complainant is entitled to get back that amount which is single premium amount as paid by her mother but considering the judgment based in Civil Appeal 2776 of 2002 (Satwant Kaur Sandhu vs. New India Assurance Company) passed by Hon’ble Supreme Court we are convinced to hold that in the present case complainant is not entitled to any relief in view of the fact it is a contract of insurance falling in the category of contract 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 of the information on the subject which is within his knowledge and it is not for the proposer to determine whether the information sought for is material for the purpose of the policy or not but of course, obligation to disclose extends only to facts which are known to the applicant and not to what he ought to have known and considering this theorization of law and present facts and circumstances, we are convinced that suppression as made by the complainant’s mother was not a mistake but intentionally she suppressed it when the underwriter is received and for which the policy is void and truth is that material fact regarding her health was not disclosed for which invariably we are coming to such conclusion that statement made by the life insured in the proposal form as to the state of her health is palpably untrue to his knowledge and there is clear suppression of material fact in regard to the health of the life insured and therefore, the insurer was fully justified for repudiation of the insurance contract.

          In the light of the above observations we do not find any substance in respect of the contention of the complainant and no reliance can be made or placed upon the allegation of the complainant against the OP.

          Apart from that at no stage complainant has challenged that insured has never been treated under Dr. P.K. Sen as per document produced by the OP.  So, it is clear that entire complaint is not based on marit.

In the result, the complaint fails.

Hence,

Ordered

That the case be and the same is dismissed on contest against the OPs without any cost.