The court affirmed fraud in an insurance claim, emphasizing the necessity of full disclosure and honesty in policy applications.

[1] This is a writ action for various declaratory reliefs which essentially sought to nullify the insurance claims which were said to have been fraudulently made to the plaintiff by the defendant, and for the recovery of the insurance pay-out effected by the plaintiff to the defendant.

[2] Following the completion of trial, I ruled for the plaintiff and highlighted the key reasons for my decision. This judgment contains the full reasons for my decision.

Key Background Facts

The Policies, The Claim And The Pay-out

[3] The plaintiff is an approved insurance company. The defendant, a male individual, bought two insurance policies from the plaintiff. The total premiums payable for the first policy was RM9,895.10 and for the second policy, RM8,447.70. Both were for the basic assured sums of RM200,000 each, as well as a rider on, crucially for present purposes, total and permanent disability benefits amounting to RM300,000.

[4] On or about 19 May 2016, the defendant submitted a claim for critical illness benefits under both policies, by reason of his claim that he had suffered from a stroke with left-sided hemiparesis caused by hypertension.

[5] In making the claim to the plaintiff, the defendant also furnished the following key documents. First, and most critically, is the CT scan results performed on 2 May 2016 at Hospital Ampang ("the first scan"). Secondly, a confidential medical certificate issued by Dr Ami Fairuza Abdul Aziz of Hospital Ampang dated 11 May 2016. Subsequently, the defendant handed over to the plaintiff another confidential medical certificate signed off by Dr Izzad Emir Ismail of the same Hospital Ampang.

[6] Significantly, this certificate, dated 14 November 2016 confirmed that as a result of a neurological assessment performed on 10 November 2016, the defendant had been detected to have slurred speech, left-sided muscle wasting with 0-1/5 muscle power on the left upper and lower limbs. The specific diagnosis was identified as Cerebrovascular Accident (CVA) with left hemiparesis. No less importantly, the prognosis was that it was likely to be permanent.

[7] After having evaluated the claims made by the defendant, the plaintiff approved the claim and make payment of a total sum of RM1,013,667.69 direct into the defendant's Public Islamic Bank account on 1 December 2016.

The Suspicion Of Fraudulent Claim

[8] The plaintiff first got wind of a possible issue on the claim made by the defendant when the former was alerted by the Social Security Organisation (SOCSO) early October 2017 of SOCSO's suspicion that the defendant may have submitted a fraudulent claim to the plaintiff.

[9] Pursuant to inquiries performed by the plaintiff, the following came to light. First, the defendant had been issued with a "type 2" traffic summons on 12 September 2016 for driving a vehicle with a dirty/faded/fancy number plate. This suggested that the defendant was physically able to drive a car on 12 September 2016.

[10] Secondly, the plaintiff was informed by one Dr Streetharan of Klinik Sri Singgam at Sungai Pelek Selangor that the defendant had consulted him in December 2016 but never indicated he was a stroke patient. And neither did Dr Streetharan observe any stroke-related disability affecting the defendant.

[11] Similarly, thirdly, when the defendant registered as a patient at Hospital Columbia Asia Seremban between 23 January 2017 and 27 July 2017, he neither notified the attending doctor that he was a stroke patient nor exhibited any appearance or gait of one. Further, the medical examinations conducted by the doctor too did not produc