National Consumer Disputes Redressal
New India Assurance Co. Ltd. vs Shri Vishwanath Manglunia on 12 April, 2010
OP 10/1998 NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 164 OF 2006 [Against the order dated 10.11.2005 in Appeal No. 1243/2004 of the Rajasthan State Consumer Disputes Redressal Commission, Jaipur] New India Assurance Co. Ltd. 5th Floor, Tower-II, Jeewan Bharti Building, Connaught Place, New Delhi (through its Principal Officer) Vs. Shri Vishwanath Manglunia, S/o Late Mahaveer Prasad Manglunia, R/o 26, Sarti Nagar, Yamuna Path, New Sanganer Road, Jaipur (Rajasthan). Petitioner/Opposite Party Respondent/Complainant Appearance : For the petitioner/opposite party Mr. R. Sushil Kr. Gupta, Adv. For the respondent/complainant Mr. A.K. Kohli, Advocate BEFORE: HON'BLE MR. JUSTICE B.N.P. SINGH, PRESIDING MEMBER HON'BLE MR. S.K. NAIK, MEMBER Pronounced on :_12.04.2010 ORDER
PER S.K. NAIK, MEMBER The plea advanced by the present petitioner/New India Assurance Company Limited before the Consumer Disputes Redressal Forum-II, Jaipur (District Forum for short) in their written submissions to the complaint and also in appeal before the Rajasthan State Consumer Disputes Redressal Commission, Jaipur (State Commission for short) that the claim of the respondent has been rightly repudiated as the diseases were pre-existing, has been rejected by both the fora below, resulting in the passing of a concurrent order vide which the petitioner/opposite party/New India Assurance Company Limited has been directed to pay a sum of Rs.1,00,000/- to the respondent/complainant within two months from the date of the order and in default the said amount shall carry interest @ 9% per annum from the date of the order till realization, besides a sum of Rs.5000/- as compensation for mental agony and Rs.1000/- for cost of litigation.
The facts of the case in nutshell are that the respondent/complainant has been purchasing mediclaim policy from the petitioner/New India Assurance Company Limited from time to time. His first mediclaim policy covered his entire family, which included his wife, two sons, one daughter-in-law and a grandson for varying amounts, initially for the period from 14.09.1999 to 13.09.2000.
This was renewed only for a year upto 13.09.2001. Yet, the respondent/complainant is alleged to have obtained another mediclaim policy covering the period from 17.01.2001 to 16.01.2002 after submitting a fresh proposal. After expiry of this policy, he again obtained another medicalim policy on 15.01.2003 for the period from 17.01.2003 to 16.01.2004. While in all the earlier policies the sum insured for himself was only for Rs.25,000/-, in the policy obtained for the period from 17.01.2003 to 16.01.2004 the sum insured was increased abruptly to Rs.1,00,000/- for the respondent/complainant without any change in respect of the other family members, which continued to remain at the earlier level of Rs.25,000/Rs.15,000. Since the respondent/complainant had undergone Coronary Artery Bypass Graft (CABG) within 40 days of obtaining the last mediclaim policy, enhancing the amount of insurance, the petitioner/New India Assurance Company Limited got the claim investigated and found that the respondent/complainant had deliberately failed to disclose that he had a medical history of suffering from Hypertension and Ischaemic Heart Disease (IHD) for a number of years. In particular, he had suppressed the fact that he was admitted into Saket Hospital at Jaipur for the period from 20.06.2002 to 22.06.2002. The hospital records revealed that he was suffering from Coronary Artery Disease (CAD), particularly, Antero-Septal Myocardial Infarction (Ant.-Septal MI) with Hypertension Stage-Iic and Left Bundle Branch Block (LBBB). Again he had been admitted in Tongia Heart & General Hospital, Jaipur on 08.07.2002 and was found to be suffering from IHD with unstable angina. These facts, however, were suppressed from the petitioner/New India Assurance Company Limited at the time of obtaining the last mediclaim policy covering the period from 17.01.2003 to 16.01.2004.
The District Forum, however, rejected the plea of the petitioner/New India Assurance Company Limited that there was any suppression of material fact as the ailments suffered by the respondent/complainant were totally new and were not related to pre-existing diseases.
The District Forum also held that the respondent/complainant was not aware of any such disease at the time of obtaining the policy. This view was upheld by the State Commission. It was in this background that the petitioner/New India Assurance Company Limited is before is in revision petition.
We have heard the learned counsel for the parties. The short question for adjudication is whether in the facts of the case, there was any suppression of material fact attracting the provisions of Exclusionary Clause. From the history of the case, it is established that the mediclaim policy initially obtained by the respondent/complainant for his entire family and covering himself for a sum of Rs.25,000/- was not renewed from year to year basis continuously. There have been intermittent breaks resulting in the lapse of the policy and every time after the first renewal the respondent/complainant has been obtaining fresh mediclaim policies. Since the petitioner/New India Assurance Company Limited have produced the medical records obtained from various hospitals, which have not been denied or rebutted by the respondent/complainant, it is to be seen as to whether the respondent/complainant while filling up of the proposal form had truthfully disclosed the correct status of his health.
When the mediclaim policy for the period 17.01.2003 to 16.01.2004 was obtained clearly the respondent/complainant had concealed the fact that he was suffering from Hypertension and Ischaemic Heart Disease (IHD) as he had been admitted in Saket Hospital, Jaipur and Tongia Heart & General Hospital at Jaipur prior thereto for Coronary Artery disease. Since contract of insurance is based on the principle of Uberrima Fides, it was the duty of the respondent/complainant to disclose the true facts with regard to state of his health, which obviously he has failed to do. The reliance of the learned counsel for the respondent/complainant that the principle laid down by the Honble Apex Court in the case of Mithoolal Nayak Vs. Life Insurance Corporation of India [AIR 1962 SC 814] that the policy holder must have known at the time of making the statement that it was false or that it suppressed fact which was material to disclose and that in the case in hand, the respondent/complainant was not aware that he is suffering from any heart problem and therefore it would be wrong to contend that he had suppressed any material fact will not help him as the facts of the case clearly bring out that he had failed to mention about the fact of his treatment with Saket Hospital and Tongia Heart & General Hospital, which cannot but be said that it was a deliberate act on his part to suppress these facts, which were material to the issue of the policy. Once we hold that there indeed has been suppression of material fact, there is no escape from holding that the petitioner/New India Assurance Company Limited would not be liable. Both the fora below, in our view, have drawn erroneous inference from the history of the case and have wrongly held that the ailments suffered by the respondent/complainant were totally new and were not related to the pre-existing diseases.
That the claim was made for reimbursement of the expenditure incurred for the byepass surgery speaks for itself that the respondent/complainant had a history of heart ailments, as corroborated by the medical records, which could not be discarded on the plea that the affidavit of the doctors who had treated the respondent/complainant had not been produced. Since the respondent/complainant at no stage had challenged or denied that he had ever approached the hospitals, it was a lopsided logic on the part of the fora below to ignore the treatment papers on technical ground. The law by now is well settled by a catena of decisions that the insurer would be fully justified in repudiating the insurance contract for suppression of material fact. In this regard, learned counsel for the petitioner/New India Assurance Company Limited has referred to a number of judgments of the Honble Apex Court, in particular that of (i) Smt. Krishnawanti Puri Vs. LIC of India [AIR 1975 Delhi. 19]; (ii) V. Sriniwasa Pillai Vs. LIC of India [AIR 1977 Mad. 381]; (iii) Smt. Dipashri Vs. LIC of India [AIR 1985 Bom. 192]; and the latest judgment in the case of (iv) Satwant Kaur Sandhu Vs. New India Assurance Company Limited [2009 INDLAW SC 856]. The gist of all the citations point towards the legal proposition that insurance is a contract based on complete good faith and any suppression of material fact would be a breach of such contract and the insurer would be justified in repudiating the claim once such suppression is established.
In view of the above discussion, the impugned order passed by the State Commission is set aside and the revision petition is allowed but under the facts and circumstances of the case there will be no order as to costs.
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(B.N.P. SINGH) (PRESIDING MEMBER) Sd/-
(S.K. NAIK) MEMBER Mukesh/