Life Insurance Corporation of India v. Insurance Ombudsman
2017-03-22
DEBANGSU BASAK
body2017
DigiLaw.ai
JUDGMENT : 1. An insurance company assails an award of the Insurance Ombudsman passed on October 23, 2015. 2. Learned Senior Advocate for the petitioners contends that, the insured is guilty of suppressing material facts while applying for life insurance policies. He refers to the nine policies of the insured. He submits that, material portions of the five policies were not filled up with appropriate facts. The insured not having acted in utmost good faith at the time of applying for the policies, the insurance company is within its rights to repudiate the contract of insurance. In support of such contention he relies upon Section 45 of the Insurance Act, 1938 and 2008 Volume 1 Supreme Court Cases page 321 (P.C. Chacko & Anr. v. Chairman, Life Insurance Corporation of India & Ors.) as well as 2009 Volume 8 Supreme Court Cases page 316 (Satwant Kaur Sandhu v. New India Assurance Company Limited). 3. Referring to the point of maintainability of a writ petition by an insurance company against an order passed by the Insurance Ombudsman, learned Senior Advocate for the petitioners relies upon an unreported decision of the Andhra Pradesh High Court rendered in W.P. No. 21044 of 2005 (Birla Sun Life Insurance Company Limited v. The Insurance Ombudsman & Anr.) and All India Reporter 2013 Punjab & Haryana page 30 (Oriental Insurance Company Ltd. v. Rajnish Gupta). Learned Senior Advocate for the petitioners relies upon a Circular dated March 31, 2016 issued by the Insurance Regulatory and Development Authority of India and submits that, IRDA permits filing of legal proceedings to challenge orders passed by the Insurance Ombudsman. 4. Learned Senior Advocate appearing for the respondent nos. 2 and 3 questions the maintainability of the writ petition on the ground that, an insurance company cannot be a person aggrieved to file a writ petition challenging an award of the Insurance Ombudsman. He submits that, the Insurance Ombudsman is appointed under the provisions of the Redressal of Public Grievances Rules, 1998. Such Rules have been framed by the Central Government in exercise of powers under Section 114(1) of the Insurance Act, 1938. He refers to the various provisions of the Rules of 1998 and submits that, at all stages the Rules contemplate an opportunity to be given to the insured to challenge a decision or an award of the Insurance Ombudsman.
Such Rules have been framed by the Central Government in exercise of powers under Section 114(1) of the Insurance Act, 1938. He refers to the various provisions of the Rules of 1998 and submits that, at all stages the Rules contemplate an opportunity to be given to the insured to challenge a decision or an award of the Insurance Ombudsman. The Rules are silent with regard to the right of the insurance company to challenge a decision or an award of the Ombudsman. Therefore, the intention of the Central Government is that the insurance company should not prefer any appeal against an award passed by the Insurance Ombudsman. He relies upon a Circular dated November 23, 2010 issued by the Executive Director in this regard. He submits that, an insurance company cannot claim violation of its rights by a decision rendered by an Insurance Ombudsman. An Insurance Ombudsman is appointed at the instance of an insurance company. An insurance company, therefore, cannot complain that, its rights stands infringed by the decision or award by the Insurance Ombudsman. He relies upon Section 45 of the Act of 1938 and submits that, a period in excess of three years had elapsed from the date of insurance till the date of the complaint. Assuming that there are mis-statements, the insurance company is no longer entitled to question such fact due to the provisions of Section 45 of the Insurance Act, 1938. Moreover, he submits that, neither the respondent nos. 2 and 3 nor the insured were guilty of making any mis-statement in the facts of the present case. The details sought for in the application form by the insurance company were available to the insurance company as noted in the impugned award. The applications were written by the agent of the insurance company as noted in the impugned award. 5. Therefore, the impugned award is correct. 6. The following issues arise for consideration in this writ petition:- (1) Can an insurance company be a person aggrieved by an award passed by the Insurance Ombudsman discharging powers under the Redressal of Public Grievances Rules, 1998? (2) Is a writ petition maintainable by an insurance company against an award passed the Insurance Ombudsman under the provisions of the Redressal of Public Grievance Rules, 1998? (3) Are the subject five insurance policies vitiated due to breach of principles of uberrima fides?
(2) Is a writ petition maintainable by an insurance company against an award passed the Insurance Ombudsman under the provisions of the Redressal of Public Grievance Rules, 1998? (3) Are the subject five insurance policies vitiated due to breach of principles of uberrima fides? (4) To what reliefs, if any, are the parties entitled to? 7. The complainants before the Insurance Ombudsman are natural persons. They claim to be the legal heirs and representatives of one Nirja Jaiswal, since deceased and nominee named in the relevant policies. The deceased had taken 9 policies on her life for a total sum assured of Rs.80.32 Lakhs from the first petitioner. Nirja Jaiswal had died on July 11, 2012. On her death, respondent no. 2 submitted claim in respect of 8 policies. The respondent no. 3 as the nominee had claimed in respect of the ninth policy. Out of the 9 policies, 4 policies were admitted by the first petitioner as non-early death claim. 5 policies were repudiated by the first petitioner on February 6, 2013 for suppression of the previous four policies in each of the proposal papers. The proposer had claimed in each of such proposal that it was a fresh proposal. The non-disclosure of the four earlier policies in the fresh proposals was considered to be a material fact entitling the first petitioner to repudiate the subject 5 policies. According to the first petitioner, the insured was not entitled to a policy of life insurance in view of the value of the first four insurance policies, without requisite medical examinations. The insured having suppressed such material fact and not undertaken the requisite medical test, the contract of insurance for the subject five policies stands vitiated. 8. On the first petitioner repudiating the five insurance contracts, the respondent nos. 2 and 3 had approached Zonal Claims Dispute Redressal Committee (ZOCDRC) for review. The claim for repudiation was upheld by the ZOCDRC. The respondent nos. 2 and 3 had, thereafter, approached the Central Office Claims Dispute Redressal Committee (COCDRC). The decision of ZOCDRC was upheld by COCDRC. The respondent nos. 2 and 3 had, thereafter, lodged a complaint before the Insurance Ombudsman on May 28, 2014. The complaint was contested by the first petitioner. By the impugned award, the claims of the respondent nos. 2 and 3 were allowed.
The decision of ZOCDRC was upheld by COCDRC. The respondent nos. 2 and 3 had, thereafter, lodged a complaint before the Insurance Ombudsman on May 28, 2014. The complaint was contested by the first petitioner. By the impugned award, the claims of the respondent nos. 2 and 3 were allowed. The petitioners claim to be aggrieved by such award passed by the Insurance Ombudsman. The respondents contend that, in order to approach a writ court, an insurance company has to have a cause of action. A cause of action will arise if any right of the insurance company stands violated. An award passed by an insurance ombudsman cannot be construed to violate any right of the insurance company. Therefore, it cannot approach a writ court as a party aggrieved by the award of the insurance ombudsman. 9. A writ petition being W.P. No. 17734 (W) of 2015 (Jayshree Polytex Ltd. v. The Union of India & Ors.) was appearing in the list along with the present writ petition. It appears from the record that Jayshree Polytex Ltd. (supra) was disposed of by a judgment and order dated February 2, 2016. The issue in such writ petition was whether repudiation of an insurance claim by an insurer could be made the subject-matter of a complaint before the Insurance Ombudsman under the Rules of 1998 at the instance of a company incorporated under the Companies Act, 1956. Such issue was answered in the affirmative. Jayshree Polytex Ltd. (supra) is not applicable in the present factual matrix. 10. Rajnish Gupta (supra) and The Insurance Ombudsman (supra) are writ petitions filed at the instance of two insurance companies against an award passed by the Insurance Ombudsman. However, in those two authorities, the first issue as raised in the writ petition was not raised and, therefore, not decided. An Insurance Ombudsman is appointed under the provisions of the Redressal of Public Grievances Rules, 1998. The Rules of 1998 were promulgated by the Central Government exercising powers conferred under Section 114(1) of the Insurance Act, 1938. Rule 3 specifies that objects of the Rules of 1998 that the Rules seek to achieve. Rule 6 deals with the appointment of an Ombudsman. Rule 12 specifies the power of Ombudsman. Rule 12(3) provides that, the Ombudsman’s decision as to whether the complaint is fit and proper to be considered by it or not, shall be final.
Rule 3 specifies that objects of the Rules of 1998 that the Rules seek to achieve. Rule 6 deals with the appointment of an Ombudsman. Rule 12 specifies the power of Ombudsman. Rule 12(3) provides that, the Ombudsman’s decision as to whether the complaint is fit and proper to be considered by it or not, shall be final. Rule 14 requires the Ombudsman to act fairly and equitably. Rule 15 allows the Ombudsman to make recommendations. In the event, the recommendations made by the Ombudsman are acceptable by the complainant, he has to signify the acceptance thereto. Rule 16 permits the Ombudsman to pass an award where a complaint is not settled by agreement under Rule 15. Rule 17 permits the insurance company not to implement an award which was not accepted by a complainant. 11. In view of the contentions of the parties Rule 3 and Rule 16 (6) assume significance. They are as follows:- “Rule 3 :- The objects of these rules are to resolve all complaints relating to settlement of claim on the part of insurance companies in cost-effective, efficient and impartial manner.” “Rule 16 (6) :- The insurer shall comply with the award within 15 days of the receipt of the acceptance letter under sub-rule (5) and it shall intimate the compliance to the Ombudsman.” 12. The Rules of 1998 has the object of resolving all complaints relating to settlement of claim on the part of the insurance companies in a cost effective, efficient and impartial manner. This is the stated object as would appear from Rule 3 of the Rules of 1998. Rules 16 Sub-Rule (6) mandates the insurer to comply with the award within 15 days of the receipt of the acceptance letter under Sub-Rule 5 from the complainant. This mandate read with the objects of the Rules of 1998, allows one to infer that, an insurer is obliged to honour and comply with an award of the Insurance Ombudsman within 15 days of the receipt of the acceptance letter under Rule 16(5) from the complainant. 13. A Writ Court is concerned with the decision making process rather than the decision itself. In the present case, an alternative redressal mechanism to deal with disputes relating to insurance is put in place under the Act of 1938. The Insurance Ombudsman is appointed by the Insurance Companies.
13. A Writ Court is concerned with the decision making process rather than the decision itself. In the present case, an alternative redressal mechanism to deal with disputes relating to insurance is put in place under the Act of 1938. The Insurance Ombudsman is appointed by the Insurance Companies. The Rules of 1998 lay down that the Insurance Ombudsman is required to decide on the complaint relating to an insurance lodged at the behest of a complainant. 14. Three circulars of the Insurance Regulatory and Development Authority of India (IRDA) are relevant to the first issue. The first is a Circular dated November 23, 2010. It refers to an order passed by the Delhi High Court on September 9, 2010 in W.P. (C) No. 10638 of 2006 (Vinod Kumar Aneja & Ors. v. New India Assurance Company Limited & Ors.). The circular specifies that, it is not open for the insurer to challenge the award of the Ombudsman and that the mechanism of adjudication by the Insurance Ombudsman is an alternative dispute redressal mechanism which the insurers themselves have devised and are, therefore, bound unconditionally to honour such award. The circular requests the insurers to review the cases filed in light of such decision. The next circular is dated November 3, 2015. IRDA notes in such circular that, it has been receiving complaints from policy holders against the insurers regarding noncompliance of Orders/Awards passed by Consumer forai, Motor Accident Claims Tribunals awards of Insurance Ombudsman. It notes that, the complainant is already aggrieved and that further delay in implementation of the Awards/Orders would cause undue hardship. It issues advise to the insurers under Section 14(2)(b) of the Insurance Regulatory Development Act, 1999 as follows:- “1. Orders of Judicial/Quasi Judicial bodies should be complied by the insurer within the time frame stipulated in the order or award and in cases where time frame is not specified in the order/award, the order/award should be complied within 60 days of the receipt of the order/award by the insurer and 2. In cases where the insurer prefers an appeal against the order of the judicial/quasi judicial body, such appeal against the order should be preferred within the stipulated time limit as per the rules applicable. 3. The Complainant should be informed in the matter accordingly.” 15. The third Circular of IRDA is dated March 31, 2016.
In cases where the insurer prefers an appeal against the order of the judicial/quasi judicial body, such appeal against the order should be preferred within the stipulated time limit as per the rules applicable. 3. The Complainant should be informed in the matter accordingly.” 15. The third Circular of IRDA is dated March 31, 2016. It relates to noncompliance of award of Insurance Ombudsman. It refers to the Circular dated November 23, 2010 and another Circular dated November 3, 2015. It calls for data from the insurers with regard to, inter alia, awards of Insurance Ombudsman pending compliance. 16. The three circulars read together emphasize the anxiety of the IRDA to have an efficient resolution of insurance disputes as expeditiously as possible. It urges the insurers to honour, inter alia, an award of the Insurance Ombudsman. It does not provide an opportunity or a licence to the insurer to challenge the award of the Insurance Ombudsman in any proceedings. Quite to the contrary, it advises the insurer to honour it. The Rules of 1998 does not contemplate a challenge to the award of an Insurance Ombudsman at the behest of the insurer. It allows the insurer not to comply with the award when the same is challenged at the behest of the complainant. The Rules of 1998 and the three circulars of IRDA does not envisage or recognize that, the insurer would be a party aggrieved by an award passed by the Insurance Ombudsmen acting under the Rules of 1998. 17. In view of the aforesaid discussions the first two issues are answered in the negative and against the petitioners. 18. P.C. Chacko & Anr. (supra) is of the view that, a deliberate wrong answer given by the insured having a great bearing on contract of insurance may lead to a policy being vitiated in law. Satwant Kaur Sandhu (supra) notes that, the term “material fact” is not defined in the Insurance Act and, therefore, it is to be 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 to the root of the contract of insurance and has a bearing on the risk involved would be “material”.
Any fact which goes to the root of the contract of insurance and has a bearing on the risk involved would be “material”. It notes the definition given in the Insurance Regulatory and Development Authority (Protection of Policyholders’ Interests) Regulations, 2002. Regulation 2(1)(d) of the Regulations of 2002 is as follows:- “2(1)(d). ‘proposal form’ means a form to be filled in by the proposer for insurance, for 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.” 19. In the present case, the insured did not fill up, the proposal forms for the 5 insurance policies concerned, so as to reflect that the insured had subsisting life insurance policies. One of the questions required to be answered by the insured in the proposal form is the existence of previous policies of life insurance. The insured did not answer it. Is it fatal? 20. The details required to be submitted in the proposal forms, therefore, has to be construed as material. It is important, essential and relevant information. The insured did not provide the same in the proposal form for the 5 subject insurance contracts. The Insurance Ombudsman in the impugned award considers such conduct of the insured and is of the view that, since the insured had taken the 4 earlier policies from the same insurance company, the information sought in the proposal for insurance in the next 5 insurance contracts were available to the insurance company and, therefore, the contracts of insurance are not vitiated. Essentially, it says that, the insured is not guilty of suppression as the information alleged to be suppressed was with the insurer. 21. Satwant Kaur Sandhu (supra) considers MacGillivray on Insurance Law (10th Edition). In paragraph 20 of the report it says as follows:- "MacGillivray on Insurance Law has summarised the assured’s duty to disclose as under:- ...the assured must disclose to the insurer all facts material to an insurer's appraisal of the risk which are known or deemed to be known by the assured but neither known nor deemed to be known by the insurer.
Breach of this duty by the assured entitles the insurer to avoid the contract of insurance so long as he can show that the non-disclosure induced the making of the contract on the relevant terms." 22. In the present case, the insured did not give such information to the insurer which information was otherwise available with the insurer. The information is whether the insured had preexisting policies or not. The insured had preexisting policies of insurance with the same insurance company. The insurer, therefore, knows such material fact, that is, the existence of four earlier policies of insurance, or is deemed to know of the same. The insurer has repudiated the subject five policies on the ground of breach of the duty to disclose material facts by the insured. However, in the facts of this case, the insured is not guilty of non-disclosure as the information alleged to have been non-disclosed by the insured was available with the insurer. In the facts of this case, the insured cannot be held guilty of non-disclosure. The Insurance Ombudsman has explained in the impugned award that, the agent and the development officer of the insurer were in a position to avail of such information. It is not open to an insurance company to repudiate a contract of insurance on the basis of non-disclosure of material facts when such material fact is available to the insurer and the insurer is deemed to know of the same. An insured cannot be charged with suppression of material fact when such information is available with the insurer or the insurer is deemed to have it. The repudiation of the contracts is, therefore, bad. 23. The third issue is answered in the negative and against the petitioners. 24. So far as the fourth issue is concerned, W.P. No.2299 (W) of 2016 is disposed of. The first petitioner is directed to settle the death claim in favour of the nominee of the deceased within 15 days from the date of the consent of the complainants. The first petitioner will also inform compliance of the order to the Insurance Ombudsman. 25. No order as to costs.