USHA VORA vs New India Assurance Co.Ltd.

THIS is a complainant''s appeal against the order dated 12.8.1996 passed in Case No. 122/1996 by the District Consumer Disputes Redressal Forum, Raipur (for short the ''District Forum'').

FACTS giving rise to this appeal are thus : Late Shantilal Vora submitted a claim form duly filled on 19.2.1993 for taking a Medi Claim Hospitalisation and Domiciliary Hospitalisation Benefit Policy for himself, for his wife and two daughters and one son. After accepting the proposal the policy No. 48-450308-01934 was issued. The deceased was covered for medi claim in Scheme A Category of table of benefits-I. The complainant alleged that the deceased felt for the first time discomfort on 17.1.1994. On 2.9.1993 the deceased came to know that he was suffering from Colonic Carcinoma "Colon Cancer" and, therefore, he took his treatment at Bombay where he incurred expenses of Rs. 1,09,575/- in Medical Research Centre, New Wing of Bombay Hospital Trust and accordingly lodged the claim with all documents of treatment receipts, vouchers etc. The opposite party vide registered letter dated 19.1.1995 after scrutinising the material repudiated the claim stating that in the proposal form the deceased misled and concealed the facts which were primarily necessary for consideration before issuance of policy. Therefore, for mis-representation and suppression of the material facts the policy was null and void right from the inception and the claim preferred by him stands repudiated. The deceased died on 2.1.1995 because of the cancer. The complainant as the widow of the deceased filed a complaint to claim the amount under medi claim alleging deficiency in service. The complaint was resisted on the ground that the deceased in the proposal form in the personal statement of the medical history and health of the proposer insured person suppressed in answer to query No. 13(b) that he was not suffering from diabetes, hyper tension, chest pain and angina. The District Forum after appreciation of evidence produced by the complainant of Dr. Ashish Malhotra, Dr. Suresh Chourasiya, Dr. G.P. Gupta and Dr. P.S. Deshpande and treatment prescriptions Exs. D-1, D-2 and D-3 recorded a finding that the deceased was suffering from high blood pressure since last 10 years. He was examined by Dr. Ashish Malhotra who advised ECG, as he was suffering from Hypertrophic Cardiomyopathy and hyper tension, which is evident from Ex. D-1, Ex. D-2 is the report of Dr. Desh Pande who examined the deceased on 19.8.1992 and diagnosed the deceased a patient of angina and whose high blood pressure on that day was 160/90 and edema in the legs. After appreciation of evidence on record, the District Forum recorded a finding of the deceased was a cardiac patient who at the time of the filling of the proposal form in answer to query No. 13 suppressed the correct and material information and on mis-representation obtained the policy. Therefore, even the deceased died of cancer but that would be of no help as the policy was void from inception, therefore, the claim was rightly repudiated, hence, dismissed the complaint. Mr. Rajesh Bhawanani, learned Counsel for the appellant submitted that there was no nexus with the cause of the death of the alleged suppression of material information about the health condition of the deceased. Therefore, the repudiation of the claim was unjustified. Counsel cited decisions of National Commission in Life Insurance Corporation of India v. Sanjeev Mahendra Lal Shah, II (1998) CPJ 45 (NC), and B. Chinamma v. Divisional Officer, LIC, (1998) CCJ 663.

Mr. R.C. Sobhani, learned Counsel for the respondent submitted that the ailments which the deceased suffered were serious and ought to have been disclosed in the proposal form. That information was material from the view point of the Insurance Company and not with the view point of the assured, which he thinks to be not material. If the correct answers would have been given about the ailment which the deceased was suffering, the Insurance Company would have considered whether medi claim policy is to be issued, if yes, on what rate of the premium. The repudiation of the claim in the circumstance was justified. Counsel cited the decisions of Punjab State Consumer Disputes Redressal Commission in case of Smt. Kuldip Kaur v. LIC of India & Anr., III (1993) CPJ 1747=1993 (3) CPR 455 (Punjab SCDRC), and Rajasthan State Consumer Disputes Redressal Commission in case of Murli Devi Agrawal v. Chairman, LIC & Ors., III (1993) CPJ 1427.

IT is well settled that the contracts of insurance, including the contract of life insurance are uberrimae fidei. They are found upon utmost good faith. If one party fails to observe this utmost good faith, the contract may be avoided by the other. Therefore, the obligation is cast upon both the parties to deal fairly and honestly in equal degrees. In these contracts, the contracting parties are placed under a special duty towards each other not merely to refrain from the active mis-representation, but to make full disclosures of all material facts within their knowledge. The ailments which the deceased was suffering were not casual ailment or simple disorder, but, were serious. Patient had to take regular treatment and care. True, the deceased died of cancer and the medi claim cover related to the expenses of treatment of cancer, but the fact remains that the deceased suppressed the material facts in relation to his health condition and the answers given to query Nos. 13(a), (b), (c), (d) were incorrect and false to the knowledge of the proposer deceased. If the correct answers would have been given the opposite party would have taken into consideration whether the medi claim policy has to be issued or not and if yes, at what rate of premium. In view of the above, we are of the opinion that the District Forum rightly found that there was no deficiency in service as the decision of repudiation the claim by the insurer was after taking into consideration all related facts and circumstances on good faith as the policy was void from inception which was obtained by suppression of material facts.

IN the result, the appeal fails and is dismissed with no order as to costs. Appeal dismissed.