Sri Shyamal Gupta, Member

The complaint case bearing no. CC/94/2013 since been allowed by the Ld. District Forum, Uttar Dinajpur vide its order dated 21-01-2016, aggrieved with such decision, this Appeal is moved by Tata AIA Life Insurance Co. Ltd.

The dispute cropped up over repudiation of the insurance claim of the Respondent No. 1.

Parties were heard and documents on record gone through minutely.

The insurance policy was taken by the husband of the Respondent No. 1, since deceased, in the month of February, 2009 and the policyholder died on 11-11-2009.

The policyholder died of heart failure in a case of dilated cardiomyopathy with lower respiratory tract infection. 

The allegation against the deceased policyholder was that he suppressed his past medical history while submitting the proposal form. 

In support of such contention, the Appellants furnished several treatment papers.

From one of such medical papers, viz., Outpatient Summary, issued by the Department of Cardiology, Sri Sathya Sai Institute of Higher Medical Services, Bangalore dated 19-10-2006, it transpires that the policyholder, since deceased, was found to be suffering from DCM, severe MR, severe LV dysfunction, MOD PAH. 

It may not be out of the place to mention here that DCM or dilated cardiomyopathy is a medical condition when the heart's ability to pump blood is lessened because its main pumping chamber, the left ventricle, is enlarged and weakened and MR (Mitral regurgitation) is defined as an abnormal reversal of blood flow from the left ventricle (LV) to the left atrium (LA).  Left ventricular systolic dysfunction is a condition that often leads to heart failure.  MOD stands for multi organ damage. Having pulmonary arterial hypertension (PAH) means that one has high blood pressure in the arteries that go from one’s heart to one’s lungs.

It is indeed surprising that the policyholder, since deceased, made no disclosure about such extreme condition of his health in the proposal form.

Needless to say, it is obligatory on the part of a prospective policyholder to make candid disclosure about his health condition in order to enable the Insurance Company evaluate the associated risk factors prior to issuance of the policy. 

By making false declaration, the policyholder, since deceased, contravened policy conditions rendering the policy void ab initio in the eye of law.

As the policyholder died of his pre-existing health condition, the instant claim was rightly repudiated by the Appellants. 

In view of this, setting aside the impugned order, we allow the Appeal.