Passed  by  Shri  Atul D. Alsi, Hon’ble President.

1. The complainant filed present complaint against the repudiation of Health Insurance claim arbitrarly of four insurance policies for Rs.30,00,000/- for the reason of suppression of pre-existing decease and thereby claiming insurance amount with compensation.

The facts in short.

2. The complainant’s husband was insured under 4 insurance policies bearing No.501/8578A, 501/8450A, 501/8450 and 501/8578 respectively from O.P.No.1 and 2.  The insured Rafique Sattar Sheikh was infected with Covid-19 and treated about 18 days in City Hospital, Kampte, later on shifted to Indira Gandhi Government Hospital, Nagpur but unfortunately died on 9.10.2020 due to covid infection to lungs. The complaint submitted insurance claim with relevant document to O.P.No.1 and 2 but the insurance claim of complainant repudiated for the reason that the insured had history of hypertension and diabetes and Ischemic Heart Disease from last 10 years.  The death of insured due to Carona has no nexus to hypertension and diabetic and therefore rejection of claim does amount to deficiency of service and therefore present complaint is filed.
3. O.P.No.1 and 2 filed their reply and denied allegation of complainant and submitted that the complainants husband had obtained 4 policies by suppressing and misrepresentation material information regarding his health, medical history, pre-existing illness in proposal form at the time of obtaining policies. The contract of insurance is dependent upon utmost good faith and there is breach of section 45 of Insurance Act 1938.  It is a duty of insured to disclose all information in proposal form upon which the insurance company decided to accept proposal or deny.  That the respondent in accordance with terms and condition of subject policy of insurance law and no relief which travels beyond terms of subject of insurance policy can be granted and no court or commission have jurisdiction to go beyond the terms of contract.  The complainant claim is early claim category therefore after investigation the claim has been repudiated as per medical record of Indira Gandhi Medical College and hospital as insured was suffering from heart disease which is 10 years and therefore rejection of claim does not amount to deficiency of service. 
4. The counsel for complainant Advocate Mr. Sriniwas Rao argured that the agent of O.P.-1, approached to insured and told various benefits of the policies and relying on words of agent and after filing of proposal forms by agent the insured purchased the four policies.  The insured was infected for post Covid period and treated for 18 days in City Hospital later on shifted to Indira Gandhi Government Hospital, Nagpur but died on 9.10.2020. The O.P.No.1 and 2 issued policies after medical check up. Due to Covid the lungs, heart and kidney were affected.  There is no nexus of pre-existing ailment with cause of death, hence the repudiation of claim does amount to deficiency of service on the part of O.P.
5. The counsel for O.P.No.1 and 2, Advocate Mrs.Athaley argued that as per judgement in Reliance Life Insurance Co.Ltd. Vs. Rekhaben Nareshbhai Rathod, Supreme Court Cases 2019(6) page-175, held that –proposal form filled by agent and a person who affixes his signatures to a proposal contains statement which is not true, can’t ordinarily escape from consequences arising there from and the agent queerly ceases –the act-an agent- of insurer but becomes the agent of the insured.   In M/s. ICICI Prulife Towers, Vs. Lalita Jain on 10^th February, 2015 by National Consumer Commission, New Delhi, held that “Suppression of material information in the proposal, the insurance company is deprived of an opportunity to consider the proposal or reject the proposal. The O.P. has rightly repudiated the insurance claims for suppression of material facts about pre-existing deceases as per  investigation report, therefore rejection of insurance claim does not amount to deficiency of service.
3582407835169.  
3582407835170. The compliant claim repudiated vide letter dated 28.2.2021 for the policies issued in November-2018 and December-2018 for the reason of suppression of pre existing disease of hypertension diabetic and heart decease since 10 years as per repudiation letter dated 28.2.2021.  The O.P. has failed to file the evidence of doctor on affidavit that pre-existing deceased has Nexus with the death of insured due to post Covid -2019 infection.   The O.P.No.1 & 2 has failed to file the evidence on affidavit of investigator who conducted the investigation for the death occurred within 3 years from the purchase of policies.   The pre-existing disorder of insured has no nexus to the death of insured therefore as the insured died due to post Covid complications. If the insured had not been affected due to Covid he would be alive today, non discloser of pre existing ailment in proposal form does not breach the complete policy therefore the complainant is entitled for the sum assured under the 4 policies bearing No.501/8578A, 501/8450A, 501/8450 and 501/8578 respectively along with cost of litigation of Rs.10,000/- as per following order.

                                                ORDER

1. Complaint is party allowed.
2. O.P. No.1 and 2 are directed to pay the amount of sum assured under the four policies bearing No.501/8578A, 501/8450A, 501/8450 and 501/8578 respectively to the complainant.
3. O.P. No.1 and 2 are also directed to pay Rs.10,000/- towards cost of litigation to complainant.

Copy of order be furnishe`d to both parties, free of cost.