By : SMT SYEDA SHAHNUR ALI, MEMBER
The case of the complainant is claimants no. 1, 3 and 4‘s mother Sumitra Ruhidas purchased a LIC Bima Gold policy dted 08.03.2011 being No. 499594389 for a assured sum of Rs. 1,00,000/- and name of the nominees were Rajkumar Ruhidas and Shravani Ruhidas. Mother of the claimants also purchased another policy being No. 459792666 through the OP No.1 on11.11.14 for assured sum of Rs. 2,00,000/- and Rajkumar Ruhidas was the nominee. On demise of Sumitra Ruhidas, her son Rajkumar submitted all the relevant documents along with original certificate and filled up form in connection with the scheme for getting the death benefit of their mother. OP No. 2 send a letter to complainants on 11.09.2015 for submitting the treatment particulars of DLA from 11.02.12 to 11.02.15. The OP No.2 also sent a letter to Shravani Ruhidas D/O Rajkumar Ruhidas, complainant no.2 on 11.09.15 wanting the records of treatment particulars of DLA for Chronic Kidney Disease. All the medical papers were sent to the office of the OP at the time of submission of the proposal form of the policy. The OP answered that the assured had suffered from kidney disease while effecting the revival on 27.10.14. Hence, the OP repudiated the claim.
Under the above circumstances, the claimants have prayed for reliefs as mentioned in the complaint.
The OPs no 1 and 2 contested the claim application by filing joint written version. The OP admit that the life assured Sumitra Ruhidas had taken two LIC policies from Tamluk Branch. The first policy being No. 499594389 dated 08.03.11 for a sum of Rs. 1,00,000/- lapsed due to nonpayment of the premium and was revived on 11.02.15. That another policy being No. 459792666 for a sum of Rs. 2,00,000/- commenced from 11.11.14. At the time of taking the policies, it was declared that the health of the assured was good. From the treatment papers of the Tamluk District Hospital it reveals that the patient was admitted on 27.04.15 and was diagnosed as a patient of CKD (Chronic Kidney Decease) and expired on 03.05.15 due to Ranal Failure. The medical terms Chronic Denotes “A disease or condition that persists or lasts or progresses over a long period of time, with reference to disease of long duration. The OP stated further that when any kidney disease persists for more than six months then it is categorized as Chronic Kidney Disease. The life assured has intentionally suppressed the material truth of her disease in order to deceive the LIC.
The OPs have prayed for dismissal of the complaint petition.
The only point for consideration in the case is whether the complainants are entitled to get the relief or reliefs as prayed for.
Decision with Reasons.
We have carefully gone through the statements of the complainants and the written version of the OPs and also perused all the documents filed by both the parties. Admitted case is that life assured had taken two policies from Tamluk Branch of LICI. The date of commencement of the policy bearing No. 499594389 is 08.03.2011 but the policy was revived on 11.02.15. The date of commencement of another policy being No. 459792666 is 11.11.14. Admittedly the date of death of the life assured is 03.05.2015. According to the OP the assured died due to Acute Chronic Disease. According to the OP life assured was suffering from Acute Chronic Disease (CKD) and admitted at Tamluk District Hospital on 03.05.15. According to the OP the assured suppressed the material facts that she was under treatment at the time of reviving of the policy as well as on the date of commencement of the policy bearing No.459792666. We have perused the treatment sheets of the assured which shows that the patient was suffering from Chronic Kidney Disease on 27.04.2015. Documents suggests that she was suffering from kidney disease on and before 27.10.14.
Ld lawyer for the OPs submitted that in the case of Satwant Kaur Sadhu Vs. New India Assurance Ltd. (2009) 8 SCC 316 and 2013 (3) CPR 664 (SC) it has been observed there that the expression “material fact” has to be understood in general terms to mean as any fact which would influence the judgement of a prudent insurer,in deciding whether to accept the risk or not. If the proposer has knowledge of such fact, he obliged to disclose it particularly while answering questions in the proposal form. Any inaccurate answer entitled 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 information disclosing of the facts which the party from nondisclosure of the facts which the party privately knows, to draw the other into a bargaining, from his ignorance of that fat and his believing the contrary.
It appears from the proposal form on which production reliance has been placed by the ld lawyer for the OP and which were required to be replied by the insurer, were i) whether during the last five years the insured had been treated for more than a week in connection with any disease ? Answer was ‘No” ii) Whether the insured at that time admitted in any hospital for any disease treatment – the answer was “No”. iii) Whether during the last five years the insured had taken any medical leave or remained absent from office – the answer was “No” and iv) whether you at present in sound health – the answer was “Yes, good”. Undoubtedly these were material facts and being within knowledge of the insured only, she was obliged to disclose the same fairly in the proposal form issued to her for the purpose of obtaining the policy in question.
From the complainants’ documents, it suggest that complainant was suffering from disease from before taking the policy No.459792666. OP files case history vide reference from (1) KDO/LSH PF/Cons. Case , ( 2) medical advice dated 27.04.2015, annexure 3 to 8, (3) medical certificates in Form No. 04, Annexure 10 to 11, (5) reports of cross-match, annexure 12 to 13, (6) lLICI note sheets – annexure 14 and 14 A, (7) New Bima Gold policy Table 179 – annexure 15 to 19, (8)Proposal forms ,annexure 20 to 27, (9) Identity card of Sumitra Ruhidas, annexure 26 to 30, (10) Agent’s confidential report, annexure 28 and 29 (11)one transfer certificate, annexure 30, (12) LICI Jiban Raxak policy bond- annexure 31 to 35, (13) proposal form, Annexure 36 to 41, (14) claimant’s statement, annexure 42 to 43.
The ld advocate for the claimants submitted that the medical documents produced by the OP has been fraudulently collected from the hospital. But complainant failed to submit any document in support of their contention. Annexure 14 A filed by the OP shows that deceased was suffering from Kidney disease which persisted there for more than six months. Then it categorized as chronic kidney disease.
Ld lawyer for the OP referred a decision reported in 2014 (4) CPR 148 (NC) wherein it has been held “it is not for the proposer to determine whether information sought for is material for the purpose of policy or not.“ According to the ld lawyer for the OP there was clear suppression of material facts on the ground of health of the insurer. It was not for the insured to determine whether the information sought for in the said questioner was material for the purpose of two policies. According to the ld lawyer for the OP the OP rightly repudiated the claim of the complainants for the suppression of material facts. Ld lawyer for the OP also referred to another decision reported in 2015 (i) CPR 421 (NC) wherein it has been held that claim which is covered under the Exclusion Clause, cannot be settled by the Insurance Co. Another decision referred by the ld lawyer for the OP is 2016 (4) CPR 251 (NC) wherein it has been held that “ Revival of policy does not condone pre-existing disease”. Another decision of National Commission is reported in 2016 133 CPR 380 (NC) decided that claim may be repudiated on ground of suppression of pre-existing disease. Besides that, ld lawyer for the OP also referred section 45 of the Amended Insurance Act 1938 where in explanation (1) it has been said that No policy of life insurance shall be called in question on any ground whatsoever after the expiry of three years from the date of the policy i.e from the date of issuance of the policy or the date of commencement or risk or the date of revival of the policy or of the rider to the policy, whichever is later. Explanation 2 - A policy of life insurance may be called in question at any time within three years from the date of issuance of the policy or the date or the date of commencement or risk.
We have given out anxious thought over the matter. There is no doubt that the insured suppressed about her preexisting disease while taking the policy No. 459792666 dated 11.11.14 which is for a sum of Rs. 2 lakhs. But considering the facts of the case we are of the view that the complainants are entitled to get the sum assured Rs. 1 lakh against the New Bima Gold Policy dated 08.03.2011 being No. 499594389 as the same Therefore, in view of the discussion made hereinabove, we are of the view that the complainants are entitled to get part relief in this case.
Hence, it is
O R D E R E D
That the complaint case being No 214 of 2016 be and the same is in part on contest against the OPs.
The OPs are directed to pay Rs 1,00,000/- to the complainants against New Gold Bima Policy dated 08.03.2011 within one month from the date of this order failing which the OP will be liable to pay interest at the rate of 9% per annum from the date of filing of the complaint till final payment . The OPs. are also directed to pay Rs.5000/-as litigation cost to the complainant within one month from the date of this order, in default the OPs will be liable to pay Rs 150/- per diem as punitive charge which would be payable to Consumer Welfare Fund.
Let the copy of the judgment be supplied to all the parties free of costs.
