Order No. 21 dt. 08/09/2016
The case of the complainant in brief is that the complainant filed this case with the allegation against the o.p. for non payment of death claim. The complainant stated that the insured person died on 6.2.12. The nominee of the insured person applied for death claim but o.p. declined. The complainant stated that the complainant’s husband purchased a life insurance policy in the month of July 2010 for which premium was paid to the tune ofrs.15,000/- per annum and the sum assured Rs.15 lakhs. The policy continued for two years and unfortunately the policy holder expired. Whenever the claim was made the o.p. informed that since the insured person suppressed the fact of disease of diabetes at the time of application for policy the claim of the complainant was denied. In view of the said fact the complainant prayed for assured amount of Rs.1,50,000/- and compensation of Rs.50,000/- and cost of the proceeding.
The o.p. contested the case by filing w/v and denied all the material allegations of the complaint. It was stated that that Pranab Sanyal applied for life insurance policy and he filled an application form and in the application form he stated in the column making queries whether the proposer had any disease of diabetes, thyroid disorder or any hormone disorder, to its reply he replied ‘no’. In question no.5 it was asked whether in the last 5 years he attended any doctor or any other medical facility for investigation or diagnostic tests, such as x-ray, USG, citiscan, biopsy, ECG, blood or urine test etc, to its answer, he replied ‘no’. On the basis of the said fact o.p. stated that the life assured suppressed the information and after the death of the life assured on 6.2.12 an enquiry was made by o.p. wherefrom it was evident that the cause of death was related to diabetes mellitus history and he was suffering from the said disease since 2005. Since the complainant’s husband suppressed the material fact therefore the claim of the complainant was denied. The o.p. agreed to pay Rs.15,522/- and the said amount was transferred in the account of the complainant through NEFT. On the basis of the said fact o.p. prayed for dismissal of the case.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant’s husband had the insurance policy.
- Whether the insured suppressed his illness.
- Whether the complainant will be entitled to get the relief as prayed for.
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. lawyer for the complainant submitted that the complainant being widow of the insured policy holder claimed the sum assured which was denied, though the policy was valid at the time of death of her husband. It was argued by ld. lawyer for the complainant that complainant’s husband had no illness therefore he did not disclose the disease of diabetes and other ailments and if such diseases can be found afterwards for which the policy holder cannot be held responsible.
Ld. lawyer for the o.p. argued that the policy holder was specifically asked some questions regarding whether he was suffering from any illness of diabetes, thyroids etc. to which he answered ‘no’ and he also stated that he was never treated for any of such illness and he never attended any doctor or availed of any medical facility for investigation or diagnostic tests, such as x-ray, USG, citiscan etc. But after the death of policy holder an enquiry was made from the side of o.p. and from the death certificate of the policy holder it appears that he died on 6.2.12 due to cardio respiratory failure in a case of diabetic nephropathy and HTN heart failure i.e. within 1 year 6 months and 6 days of insurance policy. After scrutinizing the medical papers of the said policy holder it was found that he was under treatment for diabetes mellitus since prior to applying for the insurance policy and he did not disclose such information. Accordingly, the claim of the complainant was denied but an amount of Rs.15,522/- was paid in the account of the complainant through NEFT.
Considering the submissions of the respective parties it appears that the complainant’s husband had an insurance policy and the policy was valid at the time of death of the said policy holder. It is also an admitted fact that the policy holder during the time of filling in the form for obtaining the policy suppressed his illness and subsequently within 1 year 6 months and 6 days he died. Therefore, on considering the materials on record we hold that the fact of illness of the policy holder was not disclosed and as such, on the basis of judgment passed by Hon’ble National Commission as reported in II (2012) CPJ 272 (NC) we hold that the deceased had not disclosed the fact of his suffering from acute diabetes and other ailments and therefore we hold that the complainant will not be entitled to get the sum assured as claimed by her owing to suppression of illness in the form for opening the policy and as a result of which we hold that the o.p. after the claim made by the complainant rightly paid the amount of Rs.15,522/-. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.120/2013 is dismissed on contest without cost against the o.p.
Supply certified copy of this order to the parties free of cost.
