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2022 DIGILAW 3167 (MAD)

S. Divya v. Life Insurance Corporation of India, rep. by its Chariman, Mumbai

2022-09-06

N.SATHISH KUMAR

body2022
JUDGMENT (Prayer: This Writ Petition is filed, under the Article 226 of Constitution of India, to issue a Writ of Certiorarified Mandamus calling for the records of the respondents. No.3, 4 and 5 issued in Proceedings No.Nil dated 30.03.2013; and in proceedings No.Nil dated 07.02.2014; and in Award No.IO[CHN]/A/LI-016/2014-15 dated 08.07.2014 respectively and quash the same and issue a consequential direction to the respondents to disburse the amount assured under the policy No.718506209 and 718506210 for a sum of Rs.1,00,000/- and Rs.1,25,000/- respectively with interest at 18% per annum.) Challenging the Order of the first respondent confirming the Order passed by the original authority, viz., the fifth respondent, rejecting the payment of money payable under the policy, the present Writ Petition has been filed. 2. Originally the petitioner's father has taken two policies bearing No.718506209 and 718506210 for a sum of Rs.one lakh and Rs.1,25,000/- respectively on 29.09.2009. Thereafter, the petitioner's father died on 04.01.2012 due to hyper tension. When the amount was claimed by the petitioner, the same was rejected by the third respondent by its Order dated 30.03.2013 on the ground that at the time of proposal, the insurer has suppressed certain facts of taking treatment in the hospital due to an accident. Accordingly, the claim has been rejected. The appellate authority without taking any independent decision, by a cryptic Order, just confirmed the Order of the original authority. As against which, an appeal has been filed before the fifth respondent. The fifth respondent partly allowed the claim and paid exgratia payment of Rs.50,000/-. While denying, it is specifically recorded by the fifth respondent that though there is suppression of the treatment of the insurer for certain fractures due to the accident, he has clearly recorded as follows : a] The Agent under Policy knows him since for the past 5 years. But has not noted any past ailments. b] No action has been taken against Agent or explanation called for. c] Impression under CT scan report of Govt. Stanley Hospital, Chennai dated 19.12.2008 which says contusion in posterior segment of the right lobe of liver. This appears to be arising out of the accident only and there is no other disease of the liver. Even the physical parameters recorded at the time of admission on 03.12.2008 referred to, No history of LOC, vomiting, ENT Bleed, Seizure and the BP is recorded as 11/70. This appears to be arising out of the accident only and there is no other disease of the liver. Even the physical parameters recorded at the time of admission on 03.12.2008 referred to, No history of LOC, vomiting, ENT Bleed, Seizure and the BP is recorded as 11/70. d] High Blood pressure is nowhere proved by documents as on 29.09.2009 i.e., the date of proposal. The history of accelerated HT was recorded only one week prior to death. e] Maturity sum assured has not been printed in the Policy document for both the policies. e] There is no nexus between the accident and the cause of death. and he had clearly recorded that there is no nexus between the accident and cause of death. By holding so, since the insurer has suppressed the fact of treatment for the accident, the claim has been rejected. As against which the present writ petition has been filed. 3. The learned counsel for the petitioner would submit that in the form, earlier treatment for fractures has not been stated and it would not amount to suppression of material facts. There is no nexus between the accident and cause of death, which has been admitted by the fifth respondent. In view of misstatement or suppression of facts which has no bearing on the risk of the insured, the claim cannot be rejected under the pretext of suppression of material facts. It is for the insurer to establish that such suppression is material one which had a bearing to the cause of death. However, the Insurance Company has not established the above fact. That apart, the Ombudsman has also clearly found that there is no nexus between the accident and cause of death. Hence, the rejection of the claim by the Insurance Company is not according to law and is liable to set aside. In support of his contentions, he relied on the judgment in M.Manimekalai Vs. Insurance Ombusman, Forum for Insurance Ombudsman, Fathima Akthar Court, represented by its Deputy Secretary reported in [2015] 7 MLJ 147. 4. Whereas, the learned counsel appearing for the respondents would submit that any facts which was suppressed, has to be construed as material facts. According to him, the contract of the insurance is based on good faith and if there is any misstatement or suppression of facts, the same result in rejection of the claim. 4. Whereas, the learned counsel appearing for the respondents would submit that any facts which was suppressed, has to be construed as material facts. According to him, the contract of the insurance is based on good faith and if there is any misstatement or suppression of facts, the same result in rejection of the claim. According to him, the treatment in the hospital, prior to the proposal form has been suppressed. Therefore, the Insurance Company has rightly rejected the claim. Though a part of the claim has been rejected by the Insurance Company, exgratia amount has been paid. Hence, opposed the writ petition. 5. I have perused the entire materials. Two policies have been taken on 28.09.2009 one for Rs.one lakh and another for Rs.1,25,000/- which is not disputed. It is the case of the Insurance Company that while taking policy for certain questions, the insured has not given correct details and suppressed the factum of his treatment for the accident prior to the policy. Therefore, they have rejected the claim. It is the specific contention of the Insurance company that the insured has met with an accident on 02.12.2018 and had a fracture in left tibia and those facts have not been disclosed, which amount to suppression of materials facts. Hence, opposed to writ petition. 6. As already pointed out, while taking the policies, in the questionnaire form, the insured has ticked 'no' as to whether he has taken any treatment. Now, it has to be seen whether such a statement amounts to suppression of material facts and the same will have any bearing on the risk of the insured. The original authority has simply rejected the claim mainly on the ground of accident and subsequent treatment has not been indicated at the time of taking the policy. Appellate Authority in one line Order just concurred with the Order of the Original Authority. Whereas, the Ombudsman has found that there is no nexus between the accident and cause of the death. It has been further held that the nature of the injures sustained at the time of the accident, prior to the policy has no nexus with the cause of his death. Whereas, the Ombudsman has found that there is no nexus between the accident and cause of the death. It has been further held that the nature of the injures sustained at the time of the accident, prior to the policy has no nexus with the cause of his death. It is relevant to note that S.45 of the Insurance Act makes it very clear that a policy of the life insurance may be called in question at any time within three years from the date of issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider to the policy, whichever is later, on the ground of fraud. Sub Clause 4 of Section 45 of the Insurance Act reads as follows : “[4] A policy of life insurance may be called in question at any time within three years from the date of issuance of the policy or the date of commencement of risk or the date of revival of the policy or the date of the rider of the policy, whichever is later, on the ground that any statement of or suppression of a fact material to the expectancy of the life of the insured was incorrectly made in the proposal or other document on the basis of which the policy was issued or revived or rider issued;” 7. The above clause makes it very clear that policy can be called in question, in respect of any misstatement or suppression of fact, which is mentioned to expectancy of the life of the insured. The explanation appended to Sub Clause 4 of Section 45 reads as follows : “For the purpose of this Sub-section, the mis-statement of or suppression of fact shall not be considered material unless it has a direct bearing on the risk undertaken by the insurer, the onus is on the insurer to show that had the insurer been aware of the said fact no life insurance policy would have been issued to the insured.” 8. A perusal of the above section and the explanation makes it clear that mere misstatement or suppression of fact shall not be construed as material, unless it has a direct bearing on the risk undertaken by the insured. A perusal of the above section and the explanation makes it clear that mere misstatement or suppression of fact shall not be construed as material, unless it has a direct bearing on the risk undertaken by the insured. Onus is on the insured to show that insurer is aware of the fact that no life insurance policy would have been issued to the insured. The explanation makes it clear that mere suppression of facts, unless it has direct bearing on the risk on the insured, would not be construed as suppression of material facts. It is not the case of the Insurance Company that the injuries sustained by the insurer prior to the policy had a direct bearing or any nexus with the cause of death. The Ombudsman has infact compared the nature of injuries sustained at the time of the accident and categorically held that there is no nexus between the accident and cause of death. Such being the matter, though there was suppression of fact of accident, the same cannot be construed as suppression of material facts which has a direct bearing on the risk of the insured. Hence, this Court is of the view that the rejection of the claim of the Insurance Company on that ground is not sustainable in the eye of law. 9. In the judgment in M.Manimekalai Vs. Insurance Ombusman, Forum for Insurance Ombudsman, Fathima Akthar Court, represented by its Deputy Secretary reported in [2015] 7 MLJ 147, this Court has held that in the absence of suppression of material facts, the claim of the petitioner cannot be with held at any point of time. In P.C.Chacko and Another  Vs. Chairman LIC of India reported in AIR 2008 SC 424 the Honourable Supreme Court while considering an identical issue with regard to the claim of insurance policy on the ground of misstatement has held that misstatement by itself was not a reason for repudiation of the policy unless the same is material in nature. However, a deliberate wrong answer given by insured having a great bearing on contract of insurance, if discovered may lead to policy being vitiated in law and also held that the policy can be repudiated if obtained with a fraudulent act. However, a deliberate wrong answer given by insured having a great bearing on contract of insurance, if discovered may lead to policy being vitiated in law and also held that the policy can be repudiated if obtained with a fraudulent act. Here, in this case, on the basis of mere suppression of some fact, which had no bearing on the risk of the insurer or no nexus with the cause of the death, rejection of the claim is unsustainable. 10. Accordingly, this Writ Petition is allowed and the Order of the third, fourth and fifth respondents dated 30.03.2013, 07.02.2014 and 08.07.2014 are set aside and the insurance company is directed to pay the sum assured as per the terms of the contract within a period of two months from the date of receipt of a copy of this Order. Consequently, connected miscellaneous petition is closed. No costs.