Dalbir Singh aged 40 took a policy on 5th August, 2014 for a sum insured of ₹10 lakh from a private Indian Insurer on the basis of the solicitation made by an agent of the insurer. The agent had indicated to Dalbir Singh
CS Professional · Insurance - Law & Practice · PYQS · June 2022
Dalbir Singh aged 40 took a policy on 5th August, 2014 for a sum insured of ₹10 lakh from a private Indian Insurer on the basis of the solicitation made by an agent of the insurer. The agent had indicated to Dalbir Singh that in the event of death, twice the amount of the sum insured will be paid under the policy by the insurer on the payment of a small additional premium at the inception of the policy. Dalbir signed the proposal form on the strength of the advice of the insurance agent who guided the proposer in answering the questions in the proposal form and getting it completed. One of the specific questions in the proposal form was on the subject of recent health condition of the proposer, viz, "whether the proposer had within six months of the date of the proposal had any disease or disorder of the respiratory system like asthma, tuberculosis, fever etc. To this question the proposer had indicated "No" as the answer. The proposal was put through the normal process in the insurer's office and after a medical examination of the proposal and on the payment of the first annual premium and the additional payment of the sum assured, the policy was issued. Dalbir Singh nominated his wife Smt Pushpa to secure the benefits under the policy. On 28th December, 2014 the insurer received an intimation from the beneficiary through the insurance agent that Dalbir Singh had died on 20th December, 2014- apparently by natural causes. A medical report from a doctor was filed along with the claim. The beneficiary asked for the double payment under the conditions of the policy. Since the claim by death arose within six months of the inception of the policy the insurer was surprised by the shortness of the time lapse between the dates of issue of the policy and the death claim. It instituted an investigation into the claim. The investigator went through the proposal form etc. and made enquiries in the neighbourhood where Dalbir had lived. He found out that hardly a fortnight before the proposal, Dalbir had been hospitalised for about a week in the end of July, 2014. He then proceeded to check with the hospital where Dalbir had received the treatment and found that around 20th July, 2014 Dalbir had vomited blood and had suffered from a stomach ailment probably caused by an infected liver. Dalbir had stayed in the hospital for a week and had been discharged on 31st July, 2014. On the strength of the investigation report the insurance company repudiated the claim for non-disclosure of material facts and purposely giving a wrong and misleading information in the proposal form viz that he had not suffered from any disease during the period of six months prior to issue of the policy. The beneficiary appealed to the Dispute Resolution Board of the insurance company but was not successful. She then proceeded against the insurer in the District Consumer's Forum which decided in her favour considering the fact that Dalbir had suffered from a minor stomach upset and the answer contained in the proposal form was not incorrect. The insurer then took up the matter to the State's Consumers' Council which confirmed the view of the District Forum. On this, the insurance company filed an appeal in the Supreme Court of India contending that there was a material non-disclosure of the facts and the proposal form did not indicate the real state of health of the proposer. There was breach of contract terms and the insurer wanted the Supreme Court to set aside the decision of the Council. In the given case the Proposal form was signed by the proposer under the guidance and help from the insurance company's own agent. Can this be questioned by the insurance Company? What are the agent's liabilities to an insured in such a case?
Answer & Explanation:
The question of material facts not being disclosed to an insurer is the basic test to be passed by an insurer under section 45 of the Insurance Act. This feature may be present in cases of direct selling of policies through intermediaries that act under various schemes of the insurer without examining the issues. But in the case of an agent, the situation is totally different. An insurance agent is an employee or the agent of the insurer and his conducts binds the insurer. This can be gathered from the regulation made by IRDAI. If the agent had been posted with the information of Mr. Dalbir's illness just before making the proposal to the insurer and his having been admitted into the hospital, then a reasonable defence can be put up by the insured or the beneficiary under the policy that there was no fraud or mis-statement of material fact in the proposal leading to the cancellation of the policy under section 45 of the Insurance Act and non-payment of claim. Oftentimes, in many cases of less educated person, policies taken in the rural areas. The insurance agents themselves fill in the columns after a discussion with the proposer and clear certain admissions or statements of the proposal or the entries in the proposal form as non-material. The lure of the business and the achievement of targets leads to a mis-selling of the policies. In these circumstances, it will be difficult for an insurer to ask for application of section 45 of the Insurance Act. The difficulty in this area could well be cured by an insurer by proper training to its agents especially in cases of large policies. The answer to the question posed is that the applicability of section 45 cannot be made as far as the agent's liability to the proposer or the insured, there can be none. Agents need to be trained and qualified in this area. The agent cannot be held as personally liable to pay the insured, the sum assured when the insurer refuses the claim. If the cooperation of the agent in answering the question in the proposal form is accepted, then the proposer or the insured will not suffer. In these cases, it is for the insurer to pull up its agent and train properly its agency force.
Topics: Insurance Agents & Contract Law
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