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Rajwati Devi v/s The Manager Max New York Life Insurance Co. Ltd. & Another

    First Appeal No. 795 of 2010

    Decided On, 07 May 2014

    At, Delhi State Consumer Disputes Redressal Commission New Delhi

    By, MEMBER


Judgment Text

S.A. Saddiqui, Member (Judicial):

1) This appeal has been filed under Section 15 of C.P.Act, 1986 against order dated 3.9.2010 passed by Ld. DCDRF (East), Saini Enclave, Delhi – 92 in complaint case No.475/2009.

Facts leading to the filing of the appeal are noted below :

2) Appellant’s son namely Amrit Lal has taken a whole life insurance cover policy bearing No.327164968 for a sum of Rs.2,34,511/- for the period 29.8.2007 to 28.8.2008 and paid premium of Rs.5000/- (appellant is the mother and nominee of Sh. Amrit Lal). Unfortunately, during the subsistence of the policy Amrit Lal died on 2.5.2008. Information of the death of the insured was given to the respondent Insurance Company through Smt. Poonam Sharma, Respondent No.2 on 3.5.2008. Insurance claim was duly filed by appellant/nominee. Respondent No.1 through its letter dated 8.5.2008 demanded original policy documents, original death certificate, claimant’s statement – form ‘A’, Photo I-D, attending Physician’s statement – form ‘C’, patient’s admission sheet and discharge summary and Hospital Treatment Certificate – form ‘D’. The required documents were sent to the insurance company but the claim amount was not paid and therefore complainant was compelled to file complaint under section 12 of the Act before the Consumer Court, Saini Enclave, East Delhi.

3. The complaint was admitted and notice was issued to Ops/respondents. OP-2 didn’t appear and proceedings were ex-parte against her. However OP-2 appeared and filed written statement, therefore complainant filed rejoinder. Parties led evidence. Ld. District Forum upon evaluation of the evidence on record, partly allowed the complaint and directed the OP-1 (insurance company) to refund the premium amount of Rs.5000/- alongwith compensation (Rs.5000) and cost of Rs.3000/-. The complainant was not satisfied with the impugned order and preferred this appeal inter-alia on the following main grounds besides the others :

i) that the Hon’ble District Forum did not apply its judicial mind while passing the impugned order dated 3.9.2010.

ii) The Ld. District Forum miserably failed to appreciate the facts of the case in as much as the deceased/insured was not guilty of suppression of any material fact.

iii) That the Ld. District Forum failed to appreciate that insured did not die from any of the disease mentioned by the OP in its written statement.

iv) that the insured died while the insurance policy was alive and the factum of death was duly communicated to the insurance company and all necessary documents were also despatched alongwith insurance claim. But the insurance company failed to allow the just insurance claim of the complainant and was thus guilty of deficiency in service which was also recorded by the District Forum in its impugned order. The impugned order dated 3.9.2010, therefore, suffers from various irregularities and illegalities. The appeal therefore, deserves to be allowed and impugned order be set aside.

4. OP/respondent filed reply stating therein that respondent through its letter dated 8.5.2008 demanded some further documents from the appellant, over and above documents already submitted for refund of the claim. But the appellant did not provide those documents and therefore respondent was compelled to close the claim till required documents (additional documents) were received.

5. It was further submitted by the respondent that it received form ‘D’ on 20.11.2009 duly signed by Dr. P.N.Pandey, Consultant Neurosurgery, Lok Nayak Hospital, New Delhi. It was clearly mentioned in this document that DLA was a old case of Tibercular Meningitis with Obstructive Hyderocyphalus and had suffered from Pulmonary TB in the past. This document further revealed that DLA was admitted in Lok Nayak Hospital on 9.4.2008 and was discharged on 24.4.2008 and was an old case of pulmonary TB. It has also stated in his reply that insured suppressed material facts while taking this insurance policy. In proposal form he was asked to answer whether he has ever been diagnosed with Respiratory disorder, shortness of breath, bronchitis, asthma, tuberculosis persistent cough or any other respiratory conditions to which he clearly replied in ‘No’. Thus the insured was guilty of suppressing the material fact with the insurance company and the insurance company was within its rights to dismiss the claim. There was no deficiency on the part of the insurance company.

6. We have heard Ld. Counsel for both the sides and carefully evaluated the record.

7. It is a well settled principal of law that a contract of insurance is based on ‘Doctrine of Uberrimae Fidei’. There must be utmost good faith on the part of the insured. This imposes a duty and an obligation of the assured to make a full disclosure of material facts which would affect the mind of the assurer whether to accept the risk or not and on what terms. A false answer or a non-disclosure or concealment of a material fact will avoid the policy.

8. Our attention was drawn towards annexure R-4, R-5, R-6 filed by respondent alongwith its reply. These documents reveal that additional documents were required but were not submitted by the appellant and therefore the case was closed till required documents were received. At last the insurance company received form ‘D’ on 20.11.08 duly signed by Dr. P.N.Pandey from Lok Nayak Jai Prakash Narain Hospital. It was then revealed that DLA was an old case of Tibercular Meningitis with Obstructive Hyderocyphalus and had suffered from Pulmonary TB in the past. This document further revealed that DLA was admitted in the hospital on 9.4.08 and was discharged on 24.4.08. While filling proposal form (photocopy of which was available on record) the insured replied in negative regarding several ailments including T.B. etc. It was, therefore, proved that he was suffering from Tibercular Meningitis with Obstructive Hyderocyphalus and had suffered from Pulmonary TB in the past but did not disclosed his ailment and suppressed material fact regarding his health. Therefore, the deceased/insured was guilty of suppression of material facts at the time of taking the policy and did not follow the ‘Doctrine of Uberrimae Fidei’ on which a contract of insurance is based. Thus we do not find any deficiency of service on the part of the insurance company while rejecting the insurance claim.

9. The main contention of the appellant counsel is that insured did not die from the ailments alleged by the insurance company but there was nothing substantial to rebut the allegation of the insurance company that deceased was guilty of suppressing the material facts regarding his health at the time of taking his policy. There was also no rebuttal regarding non-supply o

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f additional documents demanded by insurance company through letter dated 8.5.2008 and therefore the appeal was liable to be dismissed. However, we have taken note of the fact that appeal has been filed by the complainant against the impugned order dated 3.9.2010. The OP-1/Insurance Company did not prefer any appeal and only prayed for dismissal of the appeal in its reply. Therefore, the complainant shall be at liberty to move for execution of the impugned order dated 3.9.2010 passed by District Forum, Saini Enclave, Delhi. 10. Let a copy of the judgement be provided to the parties free of cost as per rules. A copy of the judgement shall also be placed on the appeal file and copy of the judgement will be sent to the District Forum concerned for compliance.