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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
A.P. Sahi, President
ICICI Prudential Life Insurance
Co. Ltd. and Anr. – Appellants
versus
Kumar Gaurav and Anr. – Respondents
First Appeal Nos.593 and 673 of 2019
Decided on 22.3.2024
Consumer Protection Act, 1986 – Section 19 [Consumer Protection Act, 2019 – Section 51] – Appeal – Services – Medical Negligence – Insurance – repudiation of claim – Concealment of material facts – There is no evidence to indicate that the Insurance Company officials were informed about it, when the policy was being processed. Assuming for the sake of arguments that the agent knew about it as urged by the complainant, then the agent was acting on behalf of the complainant and there is no evidence to that effect that the agent ever conveyed this information to the Insurance Company. There is no pleading or evidence to demonstrate that there was any evidence led by the complainant about any such disclosure being made by the agent to the Insurance Company officials. The bald allegation made in this regard has been categorically denied in the written version as indicated above – In the background above there was no occasion for the Insurance Company to have conducted any further diagnostic medical tests for ascertaining the health condition of the insured regarding his previous and existing ailment of cancer. The duty of disclosure by the insured cannot be a shortfall presumed against the Insurance Company without there being any evidence as indicated above – The assured was suffering from lung cancer, who had and was also undergoing treatment for the same as referred to hereinabove. Undisputedly, those material facts were suppressed and an incorrect disclosure was made in the proposal form and therefore there is no deficiency in service in so far as the Insurance Company is concerned. The conclusions drawn by the State Commission to that extent are therefore not sustainable – On facts, impugned order set aside, Appeal allowed. [Paras 10 to 21].
Result: Appeals allowed.
ORDER
A.P. Sahi, President—These two appeals arise out of a common order dated 29.01.2019, passed by the State Consumer Disputes Redressal Commission, Punjab, Chandigarh. One Late Mr. Kewal Krishan, who was the policy holder tendered a proposal to the Insurance Company on 09.05.2016 for a life insurance policy. It was initially for a period of 15 years, but the period was reduced thereafter to 5 years and the excess premium was returned. The complainant, Mr. Kumar Gaurav is the son of Late Mr. Kewal Krishan, and was the nominee of the said policy.
2. The assured, Mr. Kewal Krishan died on 01.12.2017, and the death claim intimation was made to the company on 13.12.2017. The claim was repudiated on 17.02.2018, on the ground that the insured/ assured had undergone a treatment of lung cancer for which a biopsy and PET ((positron-emission tomography) Scan had been carried out prior to the issuance of the policy. The proposal form filled by the insured had categorically replied in the negative against the question regarding pre-existing diseases including cancer.
3. Upon the repudiation of the claim, the claimant filed a complaint (CC/748/2018) before the State Commission, alleging that the assured was hail and hearty and in good health, and therefore the proposal form was neither deceptive nor suffering from any non-disclosure. It was also urged that the Insurance Company officials and the agent had themselves guided the insured in the filling up of the forms, and that the insured has simply put his signatures on the dotted lines on the suggestions made by the agent. It was also urged that the annual premium for the policy, which was for 15 years was paid on 09.05.2016 and at the time of the acceptance of the policy, the medical tests of the assured were carried out by a doctor affiliated with the Insurance Company. The assured received a letter on 18.08.2016 stating that excess premium had been paid and a refund was made keeping in view the fact that the term of the policy was reduced for 5 years only. The contention raised before the State Commission was that this reduction in the period of policy was with full information about the health condition of the insured and the Insurance Company accepted a fresh reduced premium of Rs.31,293/-. Consequently, the Insurance Company knew about the health condition of the assured and there was nothing which had been concealed.
4. The Insurance Company took a plea bringing on record the fact that the insured much prior to the proposal dated 09.05.2016 had already been diagnosed and was suffering from cancer for which he had undergone lung needle biopsy on 05.11.2015 that revealed malignancy. The PET (positron-emission tomography) Scan was done on 17.11.2015, which revealed and confirmed the said malignancy, indicating existence of lymph nodes. The assured was under the treatment of doctors at Guru Govind Singh Medical College & Hospital, Faridkot and then he underwent radio therapy treatment for the same followed by six cycles of chemotherapy that was done till 05.03.2016 and again on 31.03.2016, 06.05.2016 and 04.06.2016. He was also prescribed and was taking anti-cancer drug Gefitinib 250 mg.
5. It was therefore submitted on behalf of the Insurance Company that these facts were not disclosed and were replied in the negative in the proposal form filled up on 09.05.2016.
6. The written version of the Insurance Company filed before the State Commission, in reply to paragraph 3 of the complaint, clearly denied any knowledge or information to the officials of the Insurance Company about the said pre-existing disease. It was categorically stated that the tests which were carried out at the time of the policy by the doctor of the Insurance Company were routine tests and was not a diagnostic test. The Insurance Company relied on the judgment of the Apex Court in the case of P.C. Chacko & Anr. Vs. Chairman, Life Insurance Corporation of India & Ors., (2008) 1 SCC 321 and the order of this Commissio
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