Smt. Bandana Roy, President
The fact of the complainant’s case, in short, is that the husband of the complainant namely Ratan Chandra Maity had an policy with the OP in the name of LIC’s Bima Gold (Golden Jubilee Policy) vide policy no. 437326100, the date of commencement being 15.03.2006 and date of maturity on 15.03.2026 for an amount of Rs.210000/-. The complainant being the legally married wife was the nominee of the said policy. During the continuance of the said policy the husband of the complainant suffered an ailment namely, Acute Pancreatitis with Multiorgan Failure alongwith other ailments for which he was admitted to CMRI, Kolkata, but on 25.09.2007 he died. After the death of her husband, the complainant duly applied for death claim for her deceased husband before the OP and she supplied all relevant documents and papers as per demand of the OP in due course of time.
However, after expiry of long period, OP did not give any information to the complainant regarding the said death claim and the complainant applied vide a letter under the provisions of the Right to Information Act on 09.09.20111 before the OP and his higher authority. In response to the said application under RTI Act, on 30.09.2011 the OP informed the complainant that the claim has been repudiated on 24.09.2011. Thereafter, complainant visited the office of the OP several times and requested OP to pay her claim, but the OP paid no heed. The complainant sent a legal notice to the OP through her ld. Lawyer and on 01.02.2016, the said notice was forwarded to the higher authority of the OP but none replied the complainant. Finding no other alternative, the complainant filed this case.
The OP contested the case by filing written version wherein OP denied all material allegations made by the complainant. The OP stated that the date of commencement of the policy was 15.03.2006 and the policy holder died on 25.09.2007. From the Discharge Certificate of Mediland Nursing Home dtd. 22.03.2016, the deceased life assured Ratan Chandra Maity was admitted in the said Nursing Home during the period from 16.03.2006 to 22.03.2006 for the treatment of Acute Pancreatitis. Existence of Acute Focal Pancreatitis was confirmed by the sonoscan report dtd. 18.03.2006. The OP also stated that from the Claim Form B completed by Dr. Debasis Paul of CMRI, Kolkata it was confirmed that the primary cause of death of the deceased was Acute Pancreatitis and secondary cause was Multiorgan Failure. It was also mentioned in the said report that Pancreatitis was diagnosed two years back. OP argued that from the case history form of CMRI, Kolkata it was understood that DLA was known Alchoholic since last 8 years. The OP claimed that in their repudiation letter dtd. 24.09.2011 it was clearly mentioned that DLA did not disclose the material information at the time of affecting the policy and gave a false reply to the specific questions. The policy was taken on 15.03.2006 and policy holder died on 25.09.2007, i.e. after one year seven months from commencement and so Sec. 45 of the Insurance Act 1938 is very much applicable.
The OP argued that as per forfeiture clause under para 5 of the policy bond, in case of untrue or incorrect statement or disclosure of material information, the policy will be void and all claims to any benefit in virtue thereof shall cease and any payment in consequence hereof shall belong to the Corporation. The OP prayed for dismissal of the instant case as the complainant suffered no loss or mental agony for such honest mistake.
Point for consideration
Whether the complainant is entitled to get any relief, as prayed for?
Decision with reason
We have heard the submission of ld. Lawyers of both sides. We have also perused the documents in support of their contentions. Admittedly, deceased took a policy on 15.03.2006 and died on 25.09.2007. It appears from the Discharge Certificate of Mediland Nursing Home that the deceased Ratan Chandra Maity was admitted in the Nursing Home for the period from 16.03.2006 to 22.03.2006 for the treatment of Acute Pancreatitis. From the Claim Form B, it appears that the cause of death was Acute Pancreatitis and secondary cause was Multiorgan Failure. It is mentioned that Pancreatitis was diagnosed two years back. From the case history of CMRI, Kolkata, it appears that the deceased was alchoholic. According to the ld. Lawyer of the OP the deceased gave false reply to the specific questions while taking the policy, as follows:
Questions | Answer ‘Yes’ or ‘No’ |
During the last five years did you consult a medical practitioner for any ailment requiring treatment for more than a week? | NO |
Have you ever been admitted to any hospital or nursing home for general checkup observation treatment or operation? | NO |
Are you suffering from or have you ever suffered from ailments pertaining to Liver, Stomach, Heart, Lungs, Kidney, Brain or Nervous System? | NO |
Do you use or have you ever used Alchoholic drinks and Narcotics? | NO |
What has been your usual state of health | GOOD |
According to the ld. Lawyer for the OP, policy was taken on 15.03.2006 and death took place on 25.09.2007 where Section 45 of the Insurance Act is applicable.
Ld. Lawyer for the OP submits that according to clause 5 of the Policy Bond if it found that if the insured make any untrue statement, the policy will be void.
According to the clause 5:
‘Forfeiture in certain events: In case of premiums shall not be duly paid or in case any condition herein contained or endorsed hereon shall be contravened or in case it is found that any untrue or incorrect statement is contained in the proposal, personal statement, declaration and connected documents or any material information is withheld, then and in every such case but subject to the provisions of Sec.45 of the Insurance Act, 1938, wherever applicable this policy shall be void and all claims to any benefit in virtue hereof shall belong to the Corporation’.
Deceased signed in the Declaration. Declaration says:
“the person whose life is herein before proposed to be assured do hereby declare that the foregoing statements and answers have been given by me after fully understanding the questions and the same are true and complete in every particulars and that I have not withheld any information and I do hereby agree and declare that these statements and his declaration shall be the basis of the contract of assurance between me and the Life Insurance Corporation of India and that if any untrue statement be contained therein the said contract shall be absolutely null and void and all moneys which shall have been paid in respect thereof shall stand forfeited to the Corporation.”
From the Medical Attendants’ Certificate, it appears that the deceased was suffering Pancreatitis for two years. Ld. Lawyer for the OP referred a decision reported in 2014(4) CPR 148 (NC) which says: “Consumer Protection Act, 1986-Sections 15, 17, 19 and 21-Insurance-Death claim repudiated on ground that deceased Insured had suppressed material information regarding his health at the time of taking life insurance policies-It is not for proposer to determine whether information sought for is material for the purpose of the policy or not-Obligation to disclose extends only to facts which are known to applicant and not to what he ought to have known-Answers given by Insured in proposal form were untrue to his knowledge-There was clear suppression of material facts in regard to health of Insured-Insurance Company was justified in repudiating claim of Respondent-Orders of Fora below set aside”
Ld. Lawyer for the OP further referred a decision reported in 2014(4) CPR 729 (NC) wherein it has been held that u/s 17 of The Contract Act- “if a contract is obtained by concealment of material facts, it is voidable at option of party from whom material fact has been withheld.”
We have perused the decision referred by the ld. Lawyer for the OP and also given our anxious consideration to the materials 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. The statements made in the Proposal Form were untrue and incorrect, falling foul of the condition no.5 in the Policy. We are, therefore, of the opinion that the OP was justified in repudiating the claim of the complainant. Complainant is not entitled to get any claim in this case.
Hence, it is,
ORDERED
that the consumer case being no. CC/40/2016 be and the same is dismissed on contest against the OP, but without any cost.
Let the copies of the judgement be supplied to all the parties free of cost.
