An insurance claim cannot be repudiated on the ground of suppression of material facts if the undisclosed health condition is minor, non-life-threatening, and lacks a clear nexus to the risk covered or the actual cause of death.

JUSTICE ANOOP KUMAR MENDIRATTA, MEMBER

ORDER

1. Present Revision Petition has been preferred by the Petitioner/Complainant aggrieved against the order dated 20.03.2018 passed by the learned State Commission, Delhi in First Appeal No.334 of 2013 whereby the Appeal preferred on behalf of Life Insurance Corporation of India was allowed. Consequently, the order passed by the learned District Forum allowing the Complaint and directing the Opposite Party/Respondent for settling the claim with the nominee and payment of ₹2 Lakhs within a period of 30 days, failing which to pay interest @ 9% p.a. for any period of delay was set aside. Petitioner and the Respondent are hereinafter referred to as the “Complainant” and “Opposite Party” respectively, for convenience.

2. The undisputed facts of the case are that late Head Constable Charan Singh had obtained a life insurance policy from the Opposite Party during his lifetime with cover of ₹2 Lakhs and nominated his wife (Complainant) as nominee. On account of death of Charan Singh/Deceased Life Assured (DLA) on 28.11.2007 due to heart attack, Complainant lodged a claim with the Opposite Party. The claim was repudiated by the Opposite Party on the ground that the deceased life assured (DLA) was diagnosed suffering from Diabetes Mellitus since 19.11.2003 with M. Boil with cellulites, before he applied for the above policy. Further, the DLA had consulted a Doctor and undertaken treatment from the Hospital with medical leave on different dates. The DLA is alleged to have suppressed and wrongly given answers in the proposal form though he had personal knowledge of the medical ailments. Aggrieved against the repudiation of claim, Complainant preferred an application before the Ombudsman, which was rejected.

3. In the aforesaid background, complaint was preferred by the Complainant before the District Forum alleging deficiency in service on the part of the Opposite Party. Learned District Forum vide order dated 11.02.2013 allowed the complaint and directed the Opposite Party No.1 to settle the insurance claim in question and pay ₹2 Lakhs to the nominee, within a period of 30 days of the receipt of the order, failing which to pay interest @ 9% p.a. for the period of delay.

4. Learned District Forum relied upon the decision of the State Commission in Appeal No.482 of 2005 Sh. Pushpender Kumar Garg vs. National Insurance Company Limited decided on 01.08.2008, wherein it was observed that the claim of the insured should not be or cannot be repudiated by taking a clue or remote reference to any so-called disease from the discharge summary of the insured by invoking the exclusion clause or non-disclosure of pre-existing disease, unless the insured had concealed his hospitalization or operation undertaken in the reasonable near proximity. It was further observed that day-to-day history of several years of some or the other physical problem one may face occasionally, without having landed for hospitalization or operation for the disease cannot be used for repudiating the claim. Reliance was also placed upon the decision of this Commission in LIC vs. Chandra Kanta Lohande, II (2009) CPJ 300 (NC) wherein it was held that in today’s world, many people face problems of diabetes, blood pressure, acidity, indigestion, back pain and headache and non-disclosure of such minor diseases is not fatal for claims submitted by the insured.

5. The order passed by the learned District Forum was assailed on behalf of Insurance Company/Opposite Party by way of First Appeal No.334 of