Haryana

StateCommission

A/508/2018

SANJAY KUMAR GUPTA - Complainant(s)

Versus

STAR HEALTH AND ALLIED INSURANCE CO. - Opp.Party(s)

TARUN GUPTA

18 Dec 2018

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

 

 

 

 

                                                          First Appeal No  :         508 of 2018

Date of Institution:       23.04.2018

Date of Decision :        18.12.2018

 

 

Sanjay Kumar Gupta, House No.54A, Tribune Colony, Ambala Cantt.

                                      Appellant-Complainant

 

 

Versus

 

 

 

1.      Star Health and Allied Insurance Company Limited, SCO No.257, 2^nd Floor, Sector 44-C, Chandigarh through its Branch Manager.

 

2.      Star Health and Allied Insurance Company Limited, KRM Centre, VI Floor, No.2, Harrington Road, Chatpet, Chennai-600301

 

3.      Sarabjit Lal Lamba, House No.260, Housing Board Colony, Ambala Cantt, Agent of the Insurer Company Star Health and Allied Insurance Company Limited, email smallsaving@ymail.com.

                                      Respondents-Opposite Parties

 

 

 

 

 

 

CORAM:             Mr. Ram Singh Chaudhary, Judicial Member.

                             Mrs. Manjula, Member.

         

                            

 

 

 

Argued by:          Shri Tarun Gupta, Advocate for appellant

                             Shri Satpal Dhamija, Advocate for the respondents No.1 and 2

                             (Respondent No.3 given up vide order dated 29.06.2018).

 

                              

                                                   O R D E R

 

RAM SINGH CHAUDHARY, JUDICIAL MEMBER

 

          Delay in filing the appeal is condoned for the reasons stated in the application.

2.      Sanjay Kumar Gupta-complainant (appellant herein) purchased Family Health Optima Insurance Policy from Star Health and Allied Insurance Company Limited-opposite parties No.1 & 2 (for short ‘Insurance Company’) on 29.03.2012. The policy covered the complainant, his wife Monica Gupta, daughters Ishita and Tanya and son Arjun Gupta. The period of insurance was from 29.03.2012 to 28.03.2013. The basic floater sum insured was Rs.3,00,000/-.  During the subsistence of the insurance policy, the son of complainant suffered ear problem.  The complainant got his treated from various hospitals and doctors viz. Loomba Hospital, Ambala Cantt, M.M. Institute of Medical Sciences, Mullana, Dr. Anuj Kaushal, PGI, Chandigarh, Dr. Girish Raheja, Anand Hearing, Rajeev Ultrasound, Ambala Cantt, Dr. Anupan Jindal, Mayo Hospital, Mohali, Dr. P.N. Ranjen, Dr. Gagandeep, Global Health Private Limited, Medanta Institute of Neurosciences, Gurgaon and Dayanand Medical College and Hospital, Ludhiana.  He submitted claim of Rs.1,43,345/- with the Insurance Company but the same was repudiated vide letter dated 04.01.2016 on the ground that Insured Arjun Gupta had decreased hearing left ear for four years and alopecia as observed by Medanta Hospital and Dayanand Medical College and Hospital, which was prior to the purchase of the insurance policy.  He did not disclose that he had pre-existing disease.

3.      Aggrieved of the repudiation, the complainant filed complaint under Section 12 of the Consumer Protection Act, 1986 before the District Consumer Disputes Redressal Forum, Ambala. The District Forum dismissed the complaint vide order dated 12.02.2018.

4.      Against the aforesaid, the complainant has filed the instant appeal.

5.      It is not in dispute that as per medical record drawn at Medanta, Global Health Private Limited (Annexure A-4) and Dayanand Medical College and Hospital, Arjun Gupta-insured had decreased hearing left ear for four years and alopecia, MRI shows demylenating disease. The complainant purchased the policy on 29.03.2012.  Thus, it is clear from the medical record that insured Arjun Gupta had pre-existing disease, which he did not disclose to the Insurance Company at the time of purchase of the insurance policy. It is a well settled proposition of law that a contract of insurance is based on the principle of utmost good faith – uberrimae fidei, applicable to both the parties.  The rule of non-disclosure of material facts vitiating a policy still holds the field.  The bargaining position of the parties in a contract of insurance is unequal. The insured knows all the facts, the insurer is unaware of anything which may be material to the risk. Very often, it is the insured who is the sole person who has this knowledge.  The insurer may not even have the means to find out facts which would materially affect the risk.  The law, therefore, enjoins on the insured an absolute duty to disclose correctly all material facts which are within his personal knowledge or which he ought to have known had he made reasonable inquiries.  A contract of insurance, therefore, can be repudiated for non-disclosure of “material facts.” 

6.      In Mithoo Lal V. Life Insurance Corporation of India , AIR 1962 Supreme Court 814, Hon’ble Apex Court held as under:-

“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………….”

7.      In Revision Petition No.967 of 2008, Life Insurance Corporation of India versus Smt. Neelam Sharma, decided on September 30^th, 2014, Hon’ble National Commission observed as under:-

“8.       In Satwant Kaur Sandhu vs. New India Assurance Company Ltd. (2009) 8 SCC 316, it has been observed by the Supreme Court that the expression “material fact” is to be understood in general terms to mean as any fact which would influence the judgment of a prudent Insurer, in deciding whether to accept the risk or not.  If the proposer has knowledge of such fact, he is obliged to disclose it particularly while answering questions in the proposal form.  Any inaccurate answer will entitle the Insurer to repudiate their liability because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering into a contract of insurance, which is based on the principle of utmost faith –uberrima fides.  Good faith forbids either party from non-disclosure of the facts which the party privately knows, to draw the other into a bargain, from his ignorance of that fact and his believing the contrary. (See: United India Insurance Co. Ltd. Vs. M.K.J. Corporation [(1996) 6 SCC 428].  It has also been emphasized that 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, obligation to disclose extends only to facts which are known to the applicant and not to what he ought to have known.”

“11.     Having given our anxious consideration to the material on record, we are of the opinion that the answers given by the Insured in the proposal form were untrue to his knowledge. There was clear suppression of “material facts” in regard to the health of the Insured.  It was not for the Insured to determine whether the information sought for in the aforesaid questionnaire was material for the purpose of the two policies…..”  

8.      On the aforesaid facts and law enunciated, it is proved that the person insured had pre-existing disease prior to the purchase of the insurance policy, which he concealed while obtaining the insurance policy.  Thus, the complainant had no right to claim the benefits of insurance. The District Forum has rightly dismissed the complaint and as such, the appeal is also dismissed.

 

 

 

Announced 18.12.2018

(Manjula) Member

(Ram Singh Chaudhary) Judicial Member