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SANGITA DHINGRA SEHGAL, PINKI
Kotak Mahindra Life Insuraance Co. Ltd. – Appellant
Versus
Anu Lamba – Respondent
Question 1? Question 2? Question 3?
Key Points: - The District Commission held that OP2 failed to prove pre-existing disease as a ground to repudiation and that there was deficiency in service by OP2; OP2 was ordered to pay Rs.19,06,191/- plus interest and other costs to the Complainant, and damages Rs.50,000/- and legal costs Rs.25,000/-. (!) (!) (!) - The appeal was dismissed; the District Commission’s findings that medical examination should have been conducted, especially given the age of the insured (57), and that mere good health declaration is insufficient, were upheld. (!) (!) (!) - The court noted that non-disclosure of lifestyle diseases like diabetes/hypertension cannot by itself justify repudiation; the death was due to sudden cardiac arrest, and there was no clear evidence linking pre-existing diseases to the cause of death. (!) (!) (!) - The appellent insurer’s obligation to conduct a pre-policy medical examination for an older insured was emphasized; and New India Assurance Co. Ltd. v. Hilli Multipurpose Cold Storage and Neelam Chopra line of authority were cited regarding assessment of lifestyle diseases and genuineness of claims. (!) (!) (!) (!) - The appellate court upheld that the insurer cannot rely solely on post-issuance medical history and must consider the terms of the policy and the obligation of good faith. (!) (!) - The policy in question was for a reducing cover plan; the appellate court found no basis to limit the claim to a lesser amount absent policy terms showing such reduction. (!) (!) - The written statement delay issue was resolved by not condoning the delay beyond 45 days; the District Commission had properly rejected the written statement on record. (!) (!) - Section 38(2)(a) and 49(1) of the Consumer Protection Act, 2019 guided procedural aspects of admitting copies and timing for written statements. (!) (!) (!) - The judgment reaffirms that concealment of pre-existing conditions does not automatically bar claims, and insurers should avoid overly technical repudiation. (!) (!) (!)
JUDGMENT
Sangita Dhingra Sehgal (President)—The facts of the case as per the District Commission record are under:—
“The Complainant has alleged deficiency in service on the part of OPs in not settling the insurance claim for the Insurance Policy taken by her husband late Sh. Jitender Lamba at the time of availing Housing Loan.
1. The facts as narrated in the complaint are that the husband of the Complainant Sh. Jitender Lamba availed a Housing Loan from OP1 (Account No.0KRM20-11000005031846). At the time of sanction of the said Housing Loan, OP1 also got issued one Life Insurance Policy of the husband of the Complainant through OP2 and the premium amount of Rs.87094/- was also deducted from the Loan Account and Policy No.GA000172 was issued by OP2. This Insurance Policy was for the period of 60 months i.e. from 30.11.2020 to 29.11.2025 and the sum assured was Rs.19,80,000/-. As per the Insurance Policy, in case of death of the insured, the Insurance Company shall be liable to pay the full sum assured either to the Nominee of the insured which is the Complainant or directly to the OP1.
2. Unfortunately, the husband of the Complainant, Sh. Jitender Lamba expired on 18.09.2021
Medical Examination – Insurance company is responsible for conducting a medical examination of the policyholder in advance.
(1) Proof of delivery - In the absence of proof of delivery, therefore, Commission cannot rely solely on the Respondent’s statement before the District Commission that it had duly supplied the terms ....
Insurance—Repudiation of death claim on the ground of concealment of disease must be supported with reliable and cogent evidence.
Life Insurance Policy – Repudiation of death claim on the ground of suppression of material facts – Mere existence of past medical records is insufficient unless knowledge on part of insured is prove....
(1) Contract of Insurance – A contract of insurance is one of utmost good faith. A proposer who seeks to obtain a policy of life insurance is duty bound to disclose all material facts bearing upon th....
Insurance – Repudiation of death claim – If insured had not been found to be medically deficient as on date of proposal form then question of any allegation about past disease has to be viewed accord....
(1) Insurance – A contract of insurance is one of utmost good faith. (2) Proposer – Proposer who seeks to obtain a policy of life insurance is duty bound to disclose all material facts bearing upon t....
(1) Contract of Insurance – The contract of insurance is liable to be avoided, as the DLA intentionally failed to bring on record his medical history.(2) Repudiation of insurance claim of the individ....
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