Birla sun life
This is a discussion on Birla sun life within the Insurance forums, part of the Financial Services category; Case No. FA-09/358 (Arising from the order dated 19-02-2009 passed in complaint No. OC-203/06 by the District Consumer Redressal Forum ...
- 01-21-2010, 10:50 AM #1Senior Member
- Join Date
- Jan 2010
Birla sun life
Case No. FA-09/358
(Arising from the order dated 19-02-2009 passed in complaint No. OC-203/06 by the District Consumer Redressal Forum – VI, K.G. Marg, New Delhi)
M/S BIRLA SUNLIFE INSURANCE CO. LTD - APPELLANT
New Delhi – 110001
SMT RICHA GOEL - RESPONDENT
W/o late Shri Ashok Goel,
R/O BT – 47, Shalimar Bagh,
Delhi - 110088
JUSTICE BARKAT ALI ZAIDI - President
SHRI M.L. SAHNI - Member
1. Whether reporters of local newspapers be allowed to see the judgment?
2. To be referred to the Reporter or not?
SHRI M.L. SAHNI (ORAL)
1. M/s Birla Sunlife Insurance Co. Ltd. (hereinafter referred to as appellant) have filed this appeal against the order dated 19-02-2009 passed by the District Consumer Redressal Forum, New Delhi whereby the appellant/OP have been directed to pay a sum of Rs. 4,59,368/- being the entire insurance amount of Rs. Five lakhs minus the refunded premium of Rs. 40,632/-. The Ld. Forum has also awarded compensation of Rs. One lakh against the appellant on account of deficiency in service and for mental agony and harassment caused to the complainant (hereinafter referred to as respondent).
2. Facts giving rise to this appeal, precisely stated, are that Shri Ashok Goel, deceased-husband of the respondent took an insurance policy on his life for an amount of Rs. Five lakhs from the appellant. The application form of the policy was filled in by the deceased on 28-02-2005 and he was subjected to medical examination conducted by the medical officer of the appellant. The appellant thereafter issued policy charging premium of Rs. 40,632/- which was paid by the deceased on 28-02-2005. Unfortunately, the said Shri Ashok Goel, husband of the respondent died on 20-07-2005 and the respondent informed the appellant of his death. She also submitted claim form alongwith requisite documents but the appellant repudiated the claim on the ground that the deceased had been suffering from pre existing diseases. The respondent then filed complaint before the District Forum praying for direction to the OP/Appellant for disbursement of claim amount of Rs. Five lakhs with compensation after setting off the premium amount of Rs. 40,632/- already refunded by the appellant.
3. When the appellant appeared in response to the notice issued by the District Forum, they pleaded that the claim of the respondent was repudiated because the deceased, husband of the respondent had suppressed material facts regarding to his health in the application form while applying for insurance on 28-02-2005.
4. After the parties filed their evidence before the District Forum, the matter was heard and decided against the appellants as stated above relying upon the view held by this Commission in various decisions on the point of pre-existing diseases. The Ld. Forum came to the conclusion that the appellant by returning premium on the policy paid by the deceased-husband of the respondent was nothing but a ploy to defeat the claim of the respondent. According to the Ld. District Forum, the appellant should not have done so after they had once accepted the premium and issued the policy which could be revoked, because the liability was continuous. According to the Ld. Forum returning of the premium after the death of the insured does not absolve the appellant of their liability to pay the insurance amount to the nominee of the insured who in this case is his wife the respondent.
5. We have heard the Ld. Counsel appearing on behalf of the appellant and have carefully gone through the grounds of the appeal.
6. It is submitted on behalf of the appellant that the impugned order is contrary to the settled principles of Law because Section 2 (1)(d) of the Insurance Regulatory and Development Authority (Protection of Policy Holder’s Interests Regulations, 2002) provides:
“Proposal form means a form to be filled-in by the proposer for insurance, furnishing all material information required by the insurer in respect of a risk, in order to enable the insurer to decide whether to accept or decline, to undertake the risk and in the event of acceptance of the risk to determine the rates, terms and conditions of a cover to be granted. Also “Material” for the purpose of these regulations shall mean and include all important, essential and relevant information in the context of Underwriting the risk to be covered by the Insurer. Further, Section 11 of the aforesaid Act, states that the Policyholder shall furnish all information that is sought from him by the insurer and also any other information which the insurer considers as having a bearing on the risk to enable the latter to assess properly the risk sought to be covered by a policy. Thus it is evident that the Act also imposes a duty upon the Policyholder to disclose all the material facts to the insurer to enable them to assess the risk to be undertaken”.
7. It is further submitted that insurance is done on the basis of doctrine of ‘Uberrima Fidei’ and there was no reason for the Appellant to verify the correct facts stated in the Application. To this extent it can be said that material facts were not disclosed by the Life assured, and, therefore, the appellant was entitled to repudiate the claim”.
8. Denying the allegations of the respondent made in her complaint before the District Forum that the application for taking the insurance policy was filled-in by the agent of the appellant and that policy was issued after the medical panel of the appellant thoroughly examined the deceased and found him in perfect health condition, they submitted that the medical examination of the deceased was done in routine manner on the basis of the information provided by the deceased and at the time of test, he had concealed vital information about his previous medical history i.e. suffering from hypertension and Ischaemic Heart disease and angiography and therefore the decision of the appellants had been influenced while issuing the policy. Since the vital information has been concealed about his pre existing disease for the last five years and his having undergone angiography in 1998 was nothing but suppression of “material facts” on the record about his health. The appellants, therefore, repudiated the claim of the respondent vide their letter dated 05-10-2005 and also refunded the premium amount vide cheque no. 589817 dated 03-10-2005 which was encashed by the respondent.
9. Since it is an admitted fact by the appellant that before issuing the policy the deceased has been subjected to medical examination by their medical officer or panel of medical experts who found the deceased in perfect health, they cannot be allowed to take the plea now after the death of the husband of the respondent that he had concealed the pre-existing diseases; or that he was guilty of suppression of material fact. If so, what was the purpose of subjecting him to medical examination? Their plea of pre medical check up was influenced by the wrong information supplied does not absolve them of their liability. The purpose of medical check up before issuing insurance policy is always to ensure that the person whom they are issuing the life insurance policy suffers from no disease whatsoever a disease as per the opinion already formed by this Commission means a serious derangement of health and chronic deep-seated disease for which a person is frequently suffering and for which the insured has frequently been hospitalized or operated upon in the near proximity of time of obtaining the insurance policy. As per the appellant’s own case the deceased had been suffering from hyper tension and Ishcaemic heart disease for the last five years and undergone angiography on 09-11-1998. The policy was issued on 28-02-2005 after accepting the premium of Rs. 40,632/-. The angiography had been done on 09—11-1998. By the no stretch of reasoning can it be said in the close proximity to the date of the policy. The diseases like hyper tension and heart problems from which the deceased was allegedly suffering do not require frequent hospitalization. Nor these could be called derangement or chronic deep-seated diseases.
10. The Ld. District Forum has rightly held that the claim of the respondent could not have been repudiated by taking the plea of such diseases mentioned in the discharge summary of the deceased-insured by invoking “exclusion clause” or on the ground of “non-disclosure of pre existing diseases”. There was no concealment or no hospitalization or operation for the Omission to mention of diseases like hyper tension and ischaemic heart disease, modern-life-diseases in the proposal form cannot be considered as concealment of material facts to disentitle the insurer of his/her rightful claim for which a hefty amount has been charged as premium by the appellant.
11. This Commission has observed in similar matters in past that if the insurer concealed the facts that he is having pain in chest or worries but has never been diagnosed for any serious ailment requiring surgery and sudden hospitalization for the said purpose does not defeat his rightful claim on the ground of non-disclosure of material facts while applying for the insurance policy.
12. As a result of the above discussion, we find that there is no merit in the appeal which is liable to be dismissed at the admission stage.
13. We, therefore dismissed the appeal in limine.
14. Bank Guarantee/FDR, if any, be returned to the appellant after completion of due formalities.
15. A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to Record Room.
16. Announced on 23rd November 2009.
- By admin in forum InsuranceReplies: 9Last Post: 05-13-2013, 12:44 AM
- By kallappabk in forum Life InsuranceReplies: 11Last Post: 05-06-2013, 02:57 PM
- By mbaanilkumar patel in forum Life InsuranceReplies: 25Last Post: 03-20-2013, 11:56 PM
- By Gaurav Rastogi in forum Life InsuranceReplies: 3Last Post: 05-11-2010, 01:15 PM