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`2009(5) Supreme 523
SUPREME COURT OF INDIA
D.K. Jain and R.M. Lodha, JJ.
Satwant Kaur Sandhu — Appellant
versus
New India Assurance Company Ltd. — Respondents
Civil Appeal No. 2776 of 2002
Decided on : 10-07-2009
[1908] 2 K.B. 863; (1996) 6 SCC 428; (2000) 2 SCC 734; (1766) 3 Burr. 1905 – Relied upon.
(b) Words and Phrases – Material fact – Any fact which would influence the mind of a prudent insurer in deciding whether to accept or not to accept the risk is a “material fact”. (Para 20)
Facts of the case :
1. On 7th May, 1990 appellant’s husband, late Shri Pritpal Singh Sandhu, insured himself under a mediclaim policy provided by the respondent. The policy was for a period from 7th May, 1990 to 6th May, 1991.
2. On 11th September, 1990, Pritpal Singh suddenly fell ill and was admitted in Hospital. He died on 26th December, 1990.
3. On 29th April, 1991 she filed a claim for Rs.23,217.80 for reimbursement of the expenses incurred on hospitalization.
4. The respondent - Insurance Company repudiated the claim on the basis of medical history of the insured.
5. The District Forum directed the respondent to pay the claimed amount with interest at 12% per annum from 1st April, 1991 i.e., 3 months after the death of the insured till the date of actual payment. The respondent was also required to pay Rs.1000/- as cost of litigation.
6. The State Commission allowed the appeal thereagainst and set aside the order of the District Forum.
7. The appeal and revision thereagainst has been dismissed.
Finding of the Court :
The Insurance Company rightly repudiated the claim.
Result : Appeal dismissed.
JUDGMENT
D.K. Jain, J.—
1. This appeal, by special leave, is directed against the judgment and order dated 8th December, 2000 passed by the National Consumer Disputes Redressal Commission, (“the National Commission” for short) in Revision Petition No.322 of 1999 whereby the Commission has affirmed the order passed by the State Consumer Disputes Redressal Commission, New Delhi (for short “the State Commission”), rejecting appellant - complainant’s claim against the respondent - Insurance Company for compensation on account of deficiency in service for not processing her claim under a mediclaim policy.
2. Succinctly put, the material facts giving rise to the present appeal are as follows:
On 7th May, 1990 appellant’s husband, late Shri Pritpal Singh Sandhu, 48 years old and an advocate by profession, after completing necessary formalities insured himself under a mediclaim policy provided by the respondent. The policy was for a period from 7th May, 1990 to 6th May, 1991. The annual premium of Rs.1500/- was also paid by him. On 11th September, 1990, Pritpal Singh suddenly fell ill and was admitted in Dayanand Medical College and Hospital, Ludhiana. On 7th December, 1990 he was shifted to Madras Institute of Nephrology also known as, Vijaya Health Centre, Chennai where his condition deteriorated, ultimately leading to his death on 26th December, 1990. The appellant informed the respondent about the death of her husband on 17th January, 1991. On 29th April, 1991 she filed a claim for Rs.23,217.80 for reimbursement of the expenses incurred on hospitalization.
3. The respondent - Insurance Company made inquiries from Madras Institute of Nephrology (Vijaya Health Centre) and obtained a certificate dated 6th May, 1992, (Annex.P-6) stating that the deceased was a known case of “Chronic Renal Failure/Diabetic Nephropathy”; was on regular haemodialysis at his place and after admission on 7th December, 1990 with severe breathlessness developed sudden cardiac arrest on 26th December, 1990 leading to his death. The certificate also stated that the insured was a known diabetic for the last 16 years. Thereupon, the respondent vide letter dated 30th August, 1993 informed the appellant that her claim had been repudiated. Being aggrieved, the appellant filed Consumer Complaint Case No. 48 of 1996 before the Consumer Dispute Redressal Forum No.IV at Bunkar Vihar Nand Nagri, New Delhi (“District Forum” for short) with the prayer that the Insurance Company should be directed to pay the claim amount of Rs.23,217.80 along with interest @ 24% per annum and compensation for agony as also the litigation expenses.
4. Before the District Forum, the stand of the respondent was that the claim preferred by the appellant had been repudiated on the basis of the report supplied by Vijaya Health Centre, Chennai where appellant’s husband had died. In the written statement filed by the respondent before the District Forum, it was stated that while filling up the proposal form, against queries No.10 and 11, the insured had stated that he was in sound health and had not undergone any treatment or operation in the last 12 months, whereas the medical report revealed that he was a known case of “Chronic Renal Failure/Diabetic Nephropathy” being diabetic for the last 16 years. It was also added that the opinion of two independent doctors was obtained to affirm that the claim could not be honoured as material facts relating to the health of the insured were concealed at the time of taking out the policy.
5. The District Forum vide its order dated 20th May, 1997, refuted the opinion of the independent doctors on the ground that they had never personally treated the deceased. The Forum noted that report of Vijaya Hospital was not supported by any circumstantial evidence and was, therefore, unreliable. The policy was repudiated on 30th August, 1993 i.e. almost 2 years and 8 months after the death of the deceased. Preferring to rely on the letter written by the elder brother o
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