State Consumer Disputes Redressal Commission
Harihar Yadav vs Manager , Dhfl Pramerica Life Insurance ... on 4 September, 2023
Appeal No. Harihar Yadav Order Pronounced FA/2023/38 Vs On-04.09.2023
Manager, DHFL Pramerica Life Ins. Co. Ltd. & Anr.
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miHkksDrk fookn Áfrrks"k vk;ksx] iaMjh] jk;iqj lafLFkr fnukad&25-05-2023 vafre rdZ fnukad&08-08-2023 vkns'k fnukad&04-09--2023- vihy Øekad&FA/2023/38 gfjgj ;kno firk Lo- /kus"oj jke ;kno] mez&34 o'kZ fuokl@dk;kZy;@nqdku@laLFkku dk iw.kZ irk& xzke uksfu;krkyk] nqynqyk] rglhy&nqynqyk] ftyk&t"kiqj ¼N-x-½ ¼}kjk Jh fnus"k oekZ vf/koDrk okLrs vihykFkhZ½
----------------- vihykFkhZ@ifjoknh-
fo:)
1- izca/kd@lapkyd]
Mh- ,p- ,Q- ,y- izesfjdk ykbZQ ba";ksjsal daiuh fyfe- ¼tcfd Mh-,p-,Q-,y- izesfjdk ykbZQ ba";ksjsal fyfeVsM daiuh fyfeVsM½ Ikathd`r irk ,oa lapkj irk&pkSFkh eafty] fcfYMax ua-&9] VkWoj&ch] LkkbZcj flVh] Mh- ,y- ,Q- flVh] Qsl&III, xqM+xkao 12002] gfj;k.kk] CIN : U66000HR2007PLCo52018, Tel : 0124-4697000 E-Mail : Contactrus @Pramericalife.in Website:WWW. Pramericalife.in ¼}kjk Jh vHk; dqekj frokjh] vf/koDrk okLrs mRrjoknh Ø&1½
-----------mRrjoknh Øekad&1@fo:) i{k Øekad&1-
2- izca/kd] b.Mlb.M cSad fyfeVsM] "kkWi uacj&,l- vks-&01] rhljh eafty] eSXusVks n ekWy ] th- bZ- jksM ykHkk.Mh] jk;iqj ¼N-x-½] fiu&492001 3- izca/kd] b.Mlb.M cSad fyfeVsM] ekbØks dk;kZy;&ljdkjh vLirky ds lkeus] iRFkyxkao] rglhy&iRFkyxkao] ftyk t"kiqj ¼N-x-½ ¼mRrjoknh dzekad&2 ,oa 3 ,di{kh;½
----------mRrjoknh Øekad&2 ,oa 3@fo:) i{k Øekad&2 ,oa 3- le{k% ekuuh; Jh xksiky panz "khy] lnL;-
ekuuh; Jh izeksn dqekj oekZ] lnL;-
ekuuh; Jh v"kksd dqekj ywfu;k] lnL;-
vafre rdZ esa mifLFkr& vihykFkhZ dh vksj ls Jh fnus"k oekZ] vf/koDrkA mRrjoknh Øekad&1 dh vksj ls Jh vHk; dqekj frokjh] vf/koDrkA mRrjoknh Øekad&2 ,oa 3 ,di{kh;A Dismissed Page 1 of 10 Appeal No. Harihar Yadav Order Pronounced FA/2023/38 Vs On-04.09.2023 Manager, DHFL Pramerica Life Ins. Co. Ltd. & Anr.
vkns'k ¼}kjk& izeksn dqekj oekZ] lnL;½ vihykFkhZ@ifjoknh uss ;g vihy /kkjk&41 miHkksDrk laj{k.k vf/kfu;e] 2019 ds varxZr ftyk miHkksDrk fookn izfrrks"k vk;ksx] t"kiqj ¼N-x½ ¼ftls vkxs laf{kIr esa **lacfa /kr ftyk vk;ksx** lacksf/kr fd;k tk,xk½ ds ifjokn izdj.k dzekad&lhlh@2021@24 esa ikfjr vkns"k fnukad&12-04-2023 ftlds }kjk vihykFkhZ@ifjoknh ds ifjokn dks fujLr fd;k x;k gS] ls {kqC/k gksdj izLrqr fd;k gSA 02- lacfa /kr ftyk vk;ksx ds le{k vihykFkhZ@ifjoknh dk ifjokn laf{kIr esa bl izdkj jgk gS fd vihykFkhZ@ifjoknh ds firk }kjk mRrjoknh dz-&3@fo:) i{kdkj dz-&3 }kjk fnukad&14-02-2019 dks ts- lh- ch- e"khu Ø; gsrq 23]42]257@&¼rsbZl yk[k ca;kyhl gtkj nks lkS larkou :i;s½ Qk;usal fd;k x;k Fkk ftldk 61]700@&¼bdlB gtkj lkr lkS :i;s½ izhfe;e r; fd;k x;k FkkA mDr Qk;usl a jkf"k dk mRrjoknh dz-&1@fo:) i{kdkj dz-&1 chek daiuh esa chek djk;k x;k Fkk ftldk chek ikWfylh dz-&thlh 000027013 D;w,Q 00 tkjh fd;k x;k Fkk tks fnukad&13-02-2023 rd oS/k Fkk ftlesa vihykFkhZ@ifjoknh ukfeuh FkkA vihykFkhZ@ifjoknh ds firk /kus"oj jke ;kno dh vpkud LokLF; [kjkc gksus ls mUgsa mipkj gsrq fnukad&09-03-2020 dks Hkxoku egkohj esfMdks lqij Lis"kfyVh gkWfLiVy jkaph ys x, tgka mUgksua s fnukad&09-03-2020 ls fnukad&15-03-2020 rd HkrhZ jgdj mipkj djk;k ftlesa mipkj esa 1]94]464@&¼,d yk[k pkSjkucs gtkj pkj lkS pkSalB :i;s½ O;; gqvk ftldh lwpuk mRrjoknhx.k@fo:) i{kdkjx.k dks nh xbZA vihykFkhZ@ifjoknh ds firk dk le;≤ ij Mk;fylhl vafcdkiqj] fleMsxk] ch: ,oa jkaph esa djk;k tkrk jgk vkSj fnukad&14-12-2020 dks mudh e`R;q gks Dismissed Page 2 of 10 Appeal No. Harihar Yadav Order Pronounced FA/2023/38 Vs On-04.09.2023 Manager, DHFL Pramerica Life Ins. Co. Ltd. & Anr. xbZA vihykFkhZ@ifjoknh us chek /kkjd /kus"oj jke ;kno dh e`R;q mijkar chek jkf"k izkIr djus gsrq chek nkok e`R;q izek.k&i= lfgr mRrjoknh dz-&3@fo:) i{kdkj Øekad&3 ds "kk[kk dk;kZy; esa tek fd;k rc mRrjoknhx.k@fo:) i{kdkjx.k }kjk chek jkf"k&-23]00]000@&¼rsbZl yk[k :i;s½s Hkqxrku djus dk vk"oklu fn;k x;k] fdarq fnukad&05-03-2021 dks mRrjoknh dz-&1@fo:) i{kdkj Øekad&1 }kjk i= izsf'kr dj vihykFkhZ@ifjoknh ds firk ds }kjk e/kqesg jksxh gksus dh tkudkjh iwoZ esa ugha fn;s tkus dk vk/kkj ysdj chek nkok fujLr djus dh lwpuk nh xbZA bl izdkj mRrjoknhx.k@fo:) i{kdkjx.k }kjk chek vof/k esa chek /kkjd dh e`R;q i"pkr~ chek jkf"k dk Hkqxrku u dj lsok esa deh dh xbZ gS ftlds dkj.k vihykFkhZ@ifjoknh dks ifjokn&i= izLrqr djus dh vko";drk iM+h gSA vr% ifjokn esa okafNr vuqrks'k fnyk;s tkus dk fuosnu fd;k gSA 03- lacfa /kr ftyk vk;ksx ds le{k mRrjoknh dz-&1@fo:) i{kdkj dz-&1 dh vksj ls fyf[kr dFku izLrqr dj Lohd`r rF;ksa ds vykok ifjokn ds leLr vfHkopuksa ls badkj djrs gq, ;g cpko fy;k gS fd vihykFkhZ@ifjoknh ds firk Lo- /kus"oj jke ;kno ds i{k esa Mh- ,p- ,Q- ,y- izesfjdk ykbZQ xzqi dzsfMV ykbZQ chek ikWfylh fnukad&14-02-2019 ls fnukad&23-02-2023 rd dh vof/k ds fy, 42]256@&¼ca;kyhl gtkj nks lkS NIiu :i;s½ izhfe;e izkIr dj chek jkf"k&23]00]000@&¼rsbZl yk[k :i;s½ fu/kkZfjr dj tkjh fd;k x;k FkkA vihykFkhZ@ifjoknh us >wBs vk/kkjksa ij ifjokn is"k fd;k gSA Lo- /kus"oj jke ;kno ikWfylh ysus ds iwoZ e/kqesg jksx ls ihfM+r Fkk ftls fNikdj ikWfylh izkIr fd;k Fkk] blfy, vihykFkhZ@ifjoknh dk nkok fujLr fd;k x;k gSA mRrjoknh dz-&1@fo:) i{kdkj dz-&1 us lsok esa dksbZ deh ugha fd;k gSA Dismissed Page 3 of 10 Appeal No. Harihar Yadav Order Pronounced FA/2023/38 Vs On-04.09.2023 Manager, DHFL Pramerica Life Ins. Co. Ltd. & Anr. vihykFkhZ@ifjoknh dksbZ vuqrks'k izkIr djus dk vf/kkdkjh ugha gSA vr% ifjokn fujLr fd;s tkus dk fuosnu fd;k gSA 04- lacfa /kr ftyk vk;ksx ds le{k mRrjoknh Øekad&2 ,oa 3@fo:) i{kdkj Øekad&2 ,oa 3 dh vksj ls fyf[kr dFku izLrqr dj Lohd`r rF;ksa ds vykok ifjokn ds leLr vfHkopuksa ls badkj djrs gq, ;g cpko fy;k gS fd mRrjoknh Øekad&1@fo:) i{kdkj Øekad&1 }kjk vihykFkhZ@ifjoknh ds firk /kus"oj jke ;kno ds uke ls fnukad&14-02-2019 dks izhfe;e jkf"k&42]256- 98@&¼ca;kyhl gtkj nks lkS NIiu :Ik;s vaBkucs iSl½s izkIr dj chek ikWfylh 04 o'kZ ds fy, tkjh fd;k x;k FkkA vihykFkhZ@ifjoknh us firk ds mipkj ,oa e`R;q dh lwpuk ugha nh xbZ FkhA vihykFkhZ@ifjoknh chek jkf"k mRrjoknh Øekad&1@fo:) i{kdkj Øekad&1 ls ikus dk vf/kdkjh gSA mRrjoknh Øekad&2 ,oa 3@fo:) i{kdkj Øekad&2 ,oa 3 }kjk lsok esa dksbZ deh ugha dh xbZ gSA vr% ifjokn fujLr fd;s tkus dk fuosnu fd;k gSA 05- lacfa /kr ftyk vk;ksx us vihykFkhZ@ifjoknh ds ifjokn dks fujLr fd;k gS ftlds fo:) ;g vihy gSA 06- vihykFkhZ@ifjoknh dh vksj ls milatkr gksus okys fo}ku vf/koDrk Jh fnus"k oekZ dk ;g rdZ gS fd chek/kkjd /kus"oj jke ;kno dks chek ikWfylh tkjh fnukad&14-02-2019 dks 50 o'kZ dh vk;q gks pqdk Fkk ,sls esa fdlh Hkh O;fDr dk thou chek djus ls iwoZ chek daiuh dh uSfrd o fof/kd ftEesnkjh gksrh gS fd og mldk esfMdy psdvi djok ys ftlls mlds fdlh chekjh ls xzflr gksus dh tkudkjh izkIr gks] fdarq mRrjoknhx.k@fo:) i{kdkjx.k }kjk ,slk u dj tku&cw>dj ykijokgh cjrh gSA e`rd e/kqesg o mPp jDr pki dk jksxh Fkk ftl dkj.k mldh e`R;q gqbZ gS vkSj vihykFkhZ@ifjoknh ds ifjokn Dismissed Page 4 of 10 Appeal No. Harihar Yadav Order Pronounced FA/2023/38 Vs On-04.09.2023 Manager, DHFL Pramerica Life Ins. Co. Ltd. & Anr. dks [kkfjt dj ekuuh; ftyk vk;ksx us =qfV dh gSA e/kqesg o mPp jDr pki ,d lkekU; chekjh gS ftlls gj nwljk O;fDr xzflr gSA mDr chekjh dks xaHkhj Js.kh ds varxZr ugha ekuk tkrk ftldh tkudkjh gksrs gq, Hkh mRrjoknh dz- 1@fo:) i{kdkj Øekad&1 }kjk mDr fcanq dks vk/kkj cukdj vihykFkhZ@ifjoknh ds nkok dks [kkfjt dj lsok es deh dh xbZ gSA vr% vihykFkhZ@ifjoknh dh vksj ls izLrqr vihy Lohdkj dj lacaf/kr ftyk vk;ksx }kjk ikfjr vkyksP; vkns"k vikLr dj ifjokn esa okafNr vuqrks'k fnyk;s tkus dk fuosnu fd;k gSA vihykFkhZ@ifjoknh dh vksj ls vius rdZ ds leFkZu esa Revision Petition No. 2488/2010 Deep Saraf Vs United India Insurance Co. Ltd & Ors 2015 3 CPR (NC) 208, First Appeal No. 665/2007 Branch Manager & Anr. Vs. Laxman Swaroop 2013 1 CPR (NC) 264, First Appeal No. 179/2010 New India Assurance Company Ltd. Vs. H. M. Kapoor and Anr. 2012 4 CPJ 88; 2013 1 CPR 179, New India Assurance Co. Ltd. Vs. Marari Lal Bhusri 2011 (3) CPR 500 (NC), Appeal No. FA/14/178 ICICI Prudential Life Insurance Co. Ltd Vs Vijay Krishna Aggarwal, Decided by this Commission on 08-01-2015, Appeal No. 2176/2010 Smt. Sadhna Mehra & Ors. Vs Life Insurance Corporation of India, Decided by M.P. State Consumer Commission On 04.12.2015 dk voyacu fy;k gSA 07- mRrjoknh Øekad&1@fo:) i{kdkj Øekad&1 dh vksj ls milatkr gksus okys fo}ku vf/koDrk Jh vHk; dqekj frokjh us lacaf/kr ftyk vk;ksx }kjk ikfjr vkns"k dk leFkZu djrs gq, vihykFkhZ@ifjoknh dh vihy vikLr fd;s tkus dk fuosnu fd;k gSA mRrjoknh Øekad&1@fo:) i{kdkj Øekad&1 dh vksj ls vius rdZ ds leFkZu esa Appeal No. FA/22/13 Pramerica Life Insurance Ltd. Vs Smt. Vijay Laksmi Sharma Decided by this Commission on 06.12.2022 dk voyacu fy;k gSA Dismissed Page 5 of 10 Appeal No. Harihar Yadav Order Pronounced FA/2023/38 Vs On-04.09.2023 Manager, DHFL Pramerica Life Ins. Co. Ltd. & Anr. 08- mRrjoknh Øekad&2 ,oa 3@fo:) i{kdkj Øekad&2 ,oa 3 bl vk;ksx ds le{k ,di{kh; jgs gSaA 09- geus mHk;i{k ds fo}ku vfHkHkk'kdx.k ds rdZ Jo.k fd, rFkk lacfa /kr ftyk vk;ksx }kjk ikfjr vkns"k ,oa ewy vfHkys[k dk voyksdu fd;kA 10- izdj.k esa ;g rF; vfookfnr gS fd vihykFkhZ@ifjoknh ds firk Jh ?kus"oj jke }kjk mRrjoknh dz-&3@fo:) i{kdkj dz-&3 ls fnukad&14-02-2019 dks ts- lh- ch- e"khu Ø; gsrq 23]42]257@&¼rsbZl yk[k ca;kyhl gtkj nks lkS larkou :i;s½ dk Qk;usal djk;k Fkk rFkk Qk;uasl jkf"k&23]00]000@&¼rsbZl yk[k :Ik;s½ dk mRrjoknh dz-&1@fo:) i{kdkj dz-&1 chek daiuh ls fnukad&14-02-2019 ls fnukad&13-02-2023 rd dh vof/k ds fy, chek djk;k Fkk ftldk chek ikWfylh dz-&thlh 000027013 D;w,Q00 gS ftlesa vihykFkhZ@ifjoknh gfjgj ;kno ukfeuh gS tks izn"kZ vkj&1 i`'B dzekad&129 ls izekf.kr gSA izdj.k esa ;g rF; Hkh vfookfnr gS fd vihykFkhZ@ifjoknh ds firk /kus"oj jke ;kno dh vpkud LokLF; [kjkc gksus ls mUgsa mipkj gsrq fnukad&09-03-2020 dks Hkxoku egkohj esfMdks lqij Lis"kfyVh gkWfLiVy jkaph esa HkrhZ djk;k x;k Fkk tgka mldk fnukad&15-03-2020 rd mipkj djk;k x;k ftlesa mipkj esa 1]94]464@&¼,d yk[k pkSjkucs gtkj pkj lkS pkSalB :i;s½ O;; gqvk tks nLrkost i`'B dz-&68 ls izekf.kr gSA ;g rF; Hkh vfookfnr gS fd vihykFkhZ@ifjoknh us chek /kkjd /kus"oj jke ;kno dh e`R;q mijkar chek jkf"k izkIr djus gsrq chek nkok e`R;q izek.k&i= lfgr mRrjoknhx.k@fo:) i{kdkjx.k ds le{k izLrqr fd;k ftls mRrjoknh dz-&1@fo:) i{kdkj dz-&1 chek daiuh }kjk fnukad&05-03-2021 dks fujLr dj fn;k x;k tks fd izn"kZ vkj&5 ls izekf.kr gSA Dismissed Page 6 of 10 Appeal No. Harihar Yadav Order Pronounced FA/2023/38 Vs On-04.09.2023 Manager, DHFL Pramerica Life Ins. Co. Ltd. & Anr. 11- vihykFkhZ@ifjoknh ds firk /kus"oj jke ds i{k esa Ikz"uk/khu chek ikWfylh fnukad&14-02-2019 ls fnukad&13-02-2023 rd dh vof/k ds fy, tkjh dh xbZ gS vkSj bl lac/a k esa chek /kkjd }kjk iziksty QkeZ ds lkFk fpfdRlk lac/a kh iwNs x, iz"uksa dk mRrj ugha esa fn;k x;k gS tcfd mRrjoknh dz-&1@fo:) i{kdkj dz-&1 }kjk chek /kkjd /kus"oj ;kno ds rst Mk;XuksfLVd lsaVj dh fjiksVZ ,oa MkW- vt; NkcM+k ds fizfLdzI"ku fLyi ls ;g izekf.kr gS fd chek /kkjd /kus"oj ;kno o'kZ 2017 ls e/kqesg ,oa mPp jDr pki ls ihfM+r Fkk vkSj mlds }kjk bl laca/k esa mipkj djk;k x;k gS] fdarq mDr rF; dks chek ikWfylh izkIr djrs le; iziksty QkeZ esa ugha crk;k x;k vkSj viuh chekjh ds rF;ksa dks fNikdj iz"uk/khu chek ikWfylh izkIr dh xbZ rFkk tkap ds nkSjku Hkh ;g ik;k x;k fd chek /kkjd yxHkx 15 o'kksZa ls Mk;fcVht VkbZi&Vw ls ihfM+r Fkk ftlds vk/kkj ij chek daiuh us vihykFkhZ@ifjoknh ds nkos dks fujLr fd;k gSA bl lac/a k esa chek vf/kfu;e] 1938 dh /kkjk&45 esa Hkh Li'V :Ik ls mYysf[kr gS fd iwoZ chekjh dks fNikdj ikWfylh dz; djus ij chek /kkjd dks 03 o'kZ ds Hkhrj chekjh ls xzflr gksus ij mlds bZykt esa gq, [kpZ dk Hkqxrku djus gsrq chek fgr ykHk Hkqxrku dh nsunkjh chek daiuh dh ugha gksxhA chek lafonk ije fo"okl ij vk/kkfjr gksrk gSA ikWfylh dzsrk ls ;g vis{kk dh tkrh gS fd muds }kjk chek ikWfylh ysus gsrq fn, x, izLrko esa nh xbZ tkudkjh esa fdlh egRoiw.kZ rF;ksa dks fNik;k ugha x;k gS] fdarq vihykFkhZ@ifjoknh us ikWfylh dz; djrs le; iwoZ chekjh ds egRoiw.kZ rF;ksa dks fNik;k gS] cfYd vihykFkhZ@ifjoknh }kjk ifjokn izLrqr djrs le; Hkh mDr rF; dks fNikdj ifjokn izLrqr fd;k gSA 12- Satwant Kaur Sandhu Vs. New India Assurance Co. Ltd. (2009) 8 SCC 316 esa ekuuh; loksZPp U;k;ky; us ;g izfrikfnr fd;k gS fd%& Dismissed Page 7 of 10 Appeal No. Harihar Yadav Order Pronounced FA/2023/38 Vs On-04.09.2023 Manager, DHFL Pramerica Life Ins. Co. Ltd. & Anr.
"12. There is no dispute that Section 45 of the Insurance Act, 1938 (for short "the Act"), which places restrictions on the right of the insurer to call in question a life insurance policy on the ground of mis-statement after a particular period, has no application on facts at hand, inasmuch as the said provision applies only in a case of life insurance policy. The present case relates to a mediclaim policy, which is entirely different from a life insurance policy. A mediclaim policy is a non-life insurance policy meant to assure the policy holder in respect of certain expenses pertaining to injury, accidents or hospitalizations. Nonetheless, it is a contract of insurance falling in the category of contract uberrimae fidei, meaning a contract of utmost good faith on the part of the assured. Thus, it needs little emphasis that when an information on a specific aspect is asked for in the proposal form, an assured is under a solemn obligation to make a true and full disclosure of the information on the subject which is within his knowledge. It is not for the proposer to determine whether the information sought for is material for the purpose of the policy or not. Of course, obligation to disclose extends only to facts which are known to the applicatnt and not to what he ought to have known. The obligation to disclose necessarily depends upon the knowledge one possesses. His opinion of the materiality of that knowledge is of no moment. (see: Joel Vs. Law Union & Crown Ins. Co. [1908] 2 K. B. 863).
17. The term "material fact" is not defined in the Act and, therefore, it has been understood and explained by the Courts in general terms to mean as any fact which would influence the judgment of a prudent insurer in fixing the premium or determining whether he would like to accept the risk. Any fact which goes the root of the Contract of insurance and has a bearing on the risk involved would be "material".
22. Answers given by the proposer to the two questions were "Sound Health" and "Nil" respectively. It would be beyond anybody's comprehension that the insured was not aware of the state of his health and the fact that he was suffering from Diabetes as also chronic Renal Failure, more so when he was stated to be on regular haemodialysis. There can hardly be any scope for doubt that the information required in the afore-extracted questions was on material facts and answers given to those questions were definetely factors which would have influenced and guided the respondent-Insurance Company to enter into the Contract of Mediclaim Insurance with the insured. It is also pertinent to note that in the claim form the appellant had stated that the deceased was suffering from Chronic Renal Failure and Diabetic Nephropathy from 1st June, 1990, i.e. within three weeks of taking the policy. Judged from any angle, we have no hesitation in coming to the conclusion that the statement made by the insured in the proposal form as to the state of his health was palpably untrue to his knowledge. There was clear suppression of material facts in regard to the health of the insured and, therefore, the respondent-insurer was fully justified in repudiating the insurance contract. We do not find any substance in the contention of learned counsel for the appellant that reliance could not be placed on the certificate obtained by the respondent from the hospital, where the insured was treated. Apart from the fact that at no stage the appellant had pleaded that the insured was not treated Vijaya Health Centre at Chennai, where he ultimately died. It is more than clear from the said certificate that information about the medical history of the deceased must have been supplied by his family mambers at the time of Dismissed Page 8 of 10 Appeal No. Harihar Yadav Order Pronounced FA/2023/38 Vs On-04.09.2023 Manager, DHFL Pramerica Life Ins. Co. Ltd. & Anr. admission in the hospital, a normal practice in any hospital. Significantly, even the declaration in the proposal form by the proposer authorises the insurer to seek information from any hospital he had attended or may attend concerning any decease or illness which may affect his health.
24. In view of the foregoing discussed, we do not find any merit in this appeal, which is dismissed accordingly but with no order as to costs." 13- New India Assurance Company Ltd. Vs. Shri Vishwanath Manglunia (RP No. 164/2006) esa ekuuh; jk"Vªh; vk;ksx us ;g izfrikfnr fd;k gS fd%& "7. We have heard Learned counsel for the parties and perused the relevant record, including the terms and conditions in the policy. In our view, the State Commission has erred in properly construing the scope and purport of the Exclusions contained in the policy. For the sake of ready reference the relevant portion of the policy conditions is extracted below:
1. Pre-existing diseases/condition: All Diseases/ injuries/conditions, which are pre-existing when the cover incepts for the first time (except as shown hereunder). Any complication arising from pre-existing disease/ailment/injury will be considered as a part of pre-existing condition. This exclusion will be deleted after four consecutive claim free policy year provided there was no hospitalization for the pre-existing disease/ailment/ condition/injury during the said four years of insurance with our Company.
Compulsory Coverage For Specific Pre-Existing Conditions On payment of additional premium, which is compulsory for persons suffering from pre-existing conditions of Diabetes Mellitus and Hypertension, these specific pre-existing conditions only are covered in the following manner:
1st year No Claim
2nd year No Claim
3rd year 50% of admissible claim or 50% of the sum
insured set for the individual whichever is less 4th year 75% of admissible claim or 75% of the sum insured set for the individual whichever is less 5th year 100% of admissible claim or sum insured set for the individual whichever is less
8. It is manifest from a plain reading of the afore-extracted Clauses, in particular Clause 4.1 that if a policy is obtained by a person suffering from pre-existing conditions of Diabetes Mellitus and Hypertension, which case has to be considered under the category of "Compulsory Coverage for Specific Pre-Existing Conditions", no claim preferred under two years of its inception, is payable by the Insurance Company. In the instant case, indubitably, the insured was a patient of Diabetic Mellitus as well as Hypertension, as also of Coronary Disease. In our view the observation by the State Commission that Since the cause of death of the insured was Chronic Renal Failure, the same did not fall within the ambit of the said Exclusion Clause, is not the correct interpretation of the otherwise unambiguous Exclusion Clause. Since admitedly the claim under the policy was preferred Dismissed Page 9 of 10 Appeal No. Harihar Yadav Order Pronounced FA/2023/38 Vs On-04.09.2023 Manager, DHFL Pramerica Life Ins. Co. Ltd. & Anr. within a period of two years and as a matter of fact within two months of obtaining the same, it was squarely covered under the Exclusion Clause.
9. For the afore-going reasons the Revision Petition is allowed and the impugned order is set aside with no order as to costs.
10. If any amount has been deposited by the Insurance Company in terms of order dated 13.07.2015, the same shall be refunded on its moving appropriate application in that behalf."
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Prononced On-04th September 2023 Dismissed Page 10 of 10