Research › Search › Judgment

Madras High Court · body

2021 DIGILAW 486 (MAD)

T. Nagammal v. Insurance Ombudsman Fathima Akthar Court, Chennai

2021-02-12

ABDUL QUDDHOSE

body2021
JUDGMENT : (Prayer: Writ Petition filed under Article 226 of the Constitution of India to issue a Writ of Certiorarified Mandamus to call for the records relating to the proceedings dated 27.08.2013 passed in Award No.10 (CHN) L-053/2013-14 in complaint No.10 (CHN)/21.07.2026/2013-14 on the file of the first respondent herein and quash the same and direct the fourth respondent to pay the petitioner the Insurance amount covered under Policy No.321871731 dated 26.06.2006, with interest at the rate of 18% per annum from 16.12.2008 till the date of the settlement of the entire policy claim.) 1. This writ petition has been filed challenging the order dated 27.08.2013 passed by the 1st respondent confirming the orders passed by the 4th, 3rd and 2nd respondents. 2. The petitioner made a claim under the medi-claim policy issued by the Life Insurance Corporation of India on 26.06.2006 which was rejected by the 4th respondent on 01.02.2012. Aggrieved by the same, she preferred an appeal before the 3rd respondent and the 3rd respondent also confirmed the order of the 4th respondent by rejecting the appeal on 21.08.2012. Aggrieved by the same, she preferred a Second Appeal before the 2nd respondent and the 2nd respondent also rejected the Second Appeal on 29.01.2013, confirming the orders passed by the 4th and 3rd respondents. Aggrieved by the order dated 29.01.2013, the petitioner approached the 1st respondent and the 1st respondent also rejected the petitioner’s appeal on 27.08.2013 by justifying the repudiation of the policy by the 4th respondent. Aggrieved by the orders passed by the respective respondents, this writ petition has been filed. 3. The petitioner’s husband S.Thommai Raj was issued with the medi-claim policy by the Life Insurance Corporation of India and the assured sum under the policy dated 26.06.2006 was Rs.1,00,000/-. S.Thommai Raj died on 15.12.2008. Thereafter, his wife, the petitioner herein made a claim before the 4th respondent under the medi-claim policy on 28.01.2010. All the respondents have rejected the petitioner’s claim and they have repudiated the petitioner’s claim on the ground that there was suppression of material facts with regard to the health condition of S.Thommai Raj under the application submitted by her to the Life Insurance Corporation of India for medi-claim policy. 4. All the respondents have rejected the petitioner’s claim and they have repudiated the petitioner’s claim on the ground that there was suppression of material facts with regard to the health condition of S.Thommai Raj under the application submitted by her to the Life Insurance Corporation of India for medi-claim policy. 4. A counter affidavit has been filed by the respondents denying the petitioner’s claim on the ground of suppression of material facts in the application submitted by the petitioner seeking for medi-claim insurance amount for the petitioner’s husband S.Thommai Raj. According to the respondents, after investigation, it was found that the petitioner’s husband S.Thommai Raj underwent a by-pass surgery in the year 1999 and was a chronic heart patient. According to them, this fact was suppressed by S.Thommai Raj, while he approached the Life Insurance Corporation of India for medi-claim insurance amount. According to them, on account of suppression of material facts, the claim of the petitioner has been rightly rejected by all the respondents. 5. Heard Ms.Elizabeth Rani, learned counsel for the petitioner and Ms.Rajashree, learned counsel for the respondents 2 to 4. Despite service of notice on the 1st respondent and their name having been printed in the cause list, there is no representation on their side. 6. Ms.Elizabeth Ravi, learned counsel for the petitioner would submit that it is the responsibility of the Insurance Company to medically examine the insured (petitioner’s husband) before issuing the medi-claim policy to the insured. According to her, there was no suppression of material facts by the insured (petitioner’s husband), as alleged by the respondents. It is further submitted by her that there would have been scars in the body due to the by-pass surgery that the insured (petitioner’s husband) had underwent and therefore, the respondents could have very well noticed the same and could have rejected the petitioner’s application seeking for medi-claim policy. Since, it was not done and the respondents having issued the medi-claim policy, they are liable to pay the proceeds under the medi-claim policy subsequent to the death of the insured (petitioner’s husband). 7. Per contra, learned counsel for the respondents drew the attention of this Court to the proposal form submitted by the insured (petitioner’s husband) and in particular, she drew the attention of this Court to Sl. 7. Per contra, learned counsel for the respondents drew the attention of this Court to the proposal form submitted by the insured (petitioner’s husband) and in particular, she drew the attention of this Court to Sl. No.11 of the proposal form, wherein, certain details were sought for by the Life Insurance Corporation of India from the insured (petitioner’s husband) with regard to his previous health condition. She would submit that despite the fact that the petitioner’s husband had underwent a by-pass surgery in the year 1999 and was a chronic heart patient, the insured (petitioner’s husband) had suppressed the said fact in the proposal form and has stated that his state of health was in good condition. The learned counsel for the respondents also drew the attention of this Court to the judgment of the Hon’ble Supreme Court in the case of Satwant Kaur Sandhu versus New India Assurance Company Ltd. reported in CDJ 2009 SCC 1391 and would submit that in identical set of facts, the Hon’ble Supreme Court has held that when there is suppression of material facts as regards the health condition of the insured, the repudiation of the policy by the insurer is correct. 8. Admittedly, the insured (petitioner’s husband) viz., Thommai Raj underwent a by-pass surgery in the year 1999, which is a major surgery and it is not a minor ailment, which can be suppressed while seeking for a medi-claim policy from any Insurance Company. In the case on hand, the insured(petitioner’s husband) as seen from the proposal form has not disclosed the fact that he underwent a major by-pass surgery in the year 1999. Even though specific columns in the proposal form requested the insured, to give information as regards the insured’s previous health condition. The insured (petitioner’s husband) has disclosed in the proposal form that he was in a sound state of health and has not revealed any particulars as regards his previous health condition. According to the respondents, even on the date of seeking for the medi-claim policy, the petitioner’s husband was under treatment for his heart ailment. The contention of the learned counsel for the petitioner is that the respondents having medically examined the insured (petitioner’s husband) before issuing the medi-claim policy in the year 2006 ought to have noticed the medical condition of the petitioner’s husband as they could have noticed scars in his body. The contention of the learned counsel for the petitioner is that the respondents having medically examined the insured (petitioner’s husband) before issuing the medi-claim policy in the year 2006 ought to have noticed the medical condition of the petitioner’s husband as they could have noticed scars in his body. Hence, according to her, the maturity amount under the medi-claim policy will have to be paid to the petitioner, who is the wife of the insured. With regard to the same issue, the Hon’ble Supreme Court in the decision relied upon by the learned counsel for the respondents in the case of Satwant Kaur Sandhu versus New India Assurance Company Ltd. reported in CDJ 2009 SC 1391 referred to supra has categorically held that the suppression of material facts by the insured in the proposal form with regard to the health of the insured will dis-entitle the claimant to get the maturity amount under the medi-claim policy. In that case also, the insured has given a declaration stating that he was having sound health despite the fact that the insured was suffering from Chronic Renal Failure and Diabetic Nephropathy. 9. The Hon’ble Supreme Court held that when there was a clear suppression of material facts with regard to the health of the insured, the Insurance Company was right in repudiating the claim made under the medi-claim policy. 10. The case on hand is similar to the facts of the case before the Hon’ble Supreme Court in the decision referred to supra. Therefore, this Court is of the considered view that on account of suppression of material facts with regard to the health condition of the insured (petitioner’s husband) at the time of the availing medi-claim policy with the respondents, the respondents were right in repudiating the claim of the petitioner under the medi-claim policy taken by her husband. Therefore, there is no merit in this writ petition. Accordingly, the writ petition stands dismissed. No costs.