A was issued a Life Insurance 'Jeevan Anand' Policy No. 12345678 with sum assured of ₹ 5,00,000. B his spouse was a nominee under the said Policy. The date of commencement of the Policy was 4.12.2012. Unfortunately, on 2

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A was issued a Life Insurance 'Jeevan Anand' Policy No. 12345678 with sum assured of ₹ 5,00,000. B his spouse was a nominee under the said Policy. The date of commencement of the Policy was 4.12.2012. Unfortunately, on 26.9.2015, due to unknown reasons A committed suicide. B lodged a claim with the Divisional Manager of XYZ Insurance Co. Ltd., but the same was rejected, vide letter dated 24.6.2016, on the ground that the deceased concealed material facts at the time of buying the insurance policy. B filed an appeal before the Zonal Manager of XYZ Co. Ltd. against the order of the Divisional Manager of XYZ Co. Ltd. The Zonal Office upheld the repudiation decision of the Divisional Office and dismissed the Appeal, vide order dated 9.11.2016. B then filed an Appeal before the Claims Disputes Redressal Committee, XYZ Co. Ltd. of India, no decision was taken by the aforesaid Committee for quite a long time. B then filed a complaint before the National Consumer Redressal Commission, New Delhi. The Complaint was contested by XYZ Co. Ltd. stating that after the death of the deceased life assured (for brevity 'DLA'), a claim was lodged which was immediately examined and it was found that the DLA was suffering from Bipolar Disorder (a mental illness) and had taken treatment from different places and this material information had been deliberately suppressed by him while taking the Policy. In the proposal form made on 2.2.2012, while filling the questionnaire regarding his medical condition, he answered in the negative. However, the deceased remained hospitalised at Neuro Psychiatry and Drug Deaddiction Rehabilitation Centre during 2008 to 2009 and later in 2015. Hence, the claim of the Respondent (B) was repudiated, vide letter dated 24.6.2016, pleading that there was no deficiency in service or unfair trade practice on the part of the Insurer and prayed for dismissal of the Complaint. XYZ Co. Ltd. further stated that the Consumer Courts at District and State levels erred in interpreting section 45 of the Insurance Act, 1938. According to section 45 of the Act, which has been amended w.e.f. 26.12.2014, Policy is not to be questioned on ground of misstatement after three years. It was further stated that the State Commission and District Forum failed to appreciate the law laid down by this Commission in other cases. In one of the case, the Policy was questioned after two years and the Hon'ble Commission had observed that as the insured made untrue declaration, as such the orders of the Fora below were set aside and the Consumer Complaint was dismissed. The Insurance company submitted that the insured was under solemn obligation to make true and full disclosure of information which was within his knowledge, in the proposal form and withholding of such information or making misstatement was a fraudulent act and breach of principle of utmost good faith and the insurer was justified in repudiating the claim under the provisions of section 45 of the Insurance Act, 1938. It was further submitted that both the consumers forums at District as well as State Level erred in appreciating that life insurance agents do not act as an agent of XYZ Co. Ltd. The agents work on commission basis, and there was no relationship of employer-employee or master-agent between the XYZ Ltd. and the agents. It also submitted that in various cases Hon'ble Supreme Court has held, "It is settled law that terms of the policy shall govern the contract between the parties, they have to abide by the definition given therein and all those expressions appearing in the policy should be interpreted with reference to the terms of policy and not with reference to the definition given in other laws. It is a matter of contract and in terms of the contract the relation of the parties shall abide and it is presumed that when the parties have entered into a contract of insurance with their eyes wide open, they cannot rely on definition given in other enactment. XYZ Co. Ltd. also mentioned that in the said judgement, Hon'ble Supreme Court also observed that, "In interpreting documents relating to a contract of insurance, the duty of the court is to interpret the words in which the contract is expressed by the parties, because it is not for the court to make a new contract, however reasonable, if the parties have not made it themselves." The District Forum directed the Petitioner to pay ₹ 5,00,000 being death claim of the deceased to the Complainant and ₹ 25,000 as Compensation for deficiency in service, unfair trade practice and mental agony suffered by the Respondent along with ₹ 10,000 towards cost of litigation. The above order was to be complied within 30 days of its receipt by the Petitioner (Insurance Company). Thereafter, they shall be liable for an interest @ 12% p.a. from the date of institution of this Complaint, till it is paid, apart from cost of litigation. Being aggrieved by the order of the District Forum, the Petitioner filed an Appeal before the State Commission. The State Commission, vide order dated 28.11.2017, dismissed the Appeal and upheld the order passed by the District Forum. It stated that the A took the life insurance policy on 4.12.2012, whereas he died on 26.9.2015 i.e. after a period of more than two and a half years from the date of commencement of the policy. Being aggrieved by the order passed by the State Commission, the Petitioner Insurance company filed the Revision Petition before this Commission (National Commission). According to B, the deceased was asked to simply put his signature on the proposal form and rest of the columns and answers were filled by the insurance agent. The entire proposal form was filled in the handwriting of the insurance agent. The deceased cannot be made responsible for concealing information, filed by the insurance agents. The Respondent's contention was that the insured was simply asked to append his signature and all other answers were filled in by the agent, in his own handwriting. The deceased cannot be held responsible for concealing any facts. This aspect is well covered by judgment in LIC Vs. Bina Joshi where the entries filled by agents, the policy holders were not blamed for concealing information. It is very clear that as per Section 45 of the Act in force when the proposal was made and Policy taken, no Insurance Policy can be repudiated after two years on the grounds of concealment/suppression of facts. The amendment to Section 45 providing a period of three years came later in 2014. The present case is covered by this section before its amendment and the deceased died after more than two years nine months after taking the Policy. In view of the above, National Consumer Commission confirmed the orders of the State Commission and the District Forum and dismissed the Revision Petition filed by XYZ Co. Ltd. From the information given above, answer the following questions: Was the National Consumer Commission justified in its decision? Give reasons for your answers citing relevant case laws if any.

Answer & Explanation:

The decision of the District, State and National Consumer Commission was justified on the following grounds: Life Insurance Policy cycle starts with solicitation of insurance business by a Distributor. A Distributor can be an Individual Agent, Corporate Agent, Insurance Broker, Web Aggregator etc. Once they convince the Customer to buy an insurance product which suits the needs of the customer, an application form also known as the Proposal form is filled by the customer. The customer is required to give personal details like Name, Date of birth, address, Gender, Name of the nominee and other details about personal health, family history details. Since the insurance contracts are based on the principles of utmost good faith, the customer also termed as proposer is expected to disclose about the status of his/her health completely in the Proposal form. Under life insurance, up to a certain limit, Proposal forms are underwritten without any medical examination which are called Non-medical Proposals. In the present case the policy given to Mr. A under non-medical proposals. The Insurance Company had issued the Policy document based on the proposal form. The Policy document is the evidence of the insurance contract which mentions all the terms and conditions of the insurance. The insured buys not the policy contract, but the right to the sum of money and its future delivery. In the present case the assured, 'A' was issued policy after the proposal form was properly filled and signed by him with all the necessary documents as required for the issuance of policy. As per requirement the premium was paid in time and the policy was in force on the date of the death of the assured. The order of the National Commission is justified on the following grounds: The reasons for suicide of Mr. A are not known and the same was committed after more than 2 years of issuance of policy. The Section 45 of the Insurance Act, 1938 provides that a policy of life insurance can not be called in question by an insurer after the expiry of two years from the date on which it was effected on the ground that a statement made in the proposal for insurance or any other document leading to the issue of the policy was inaccurate or false. B's contention was that the insured was simply asked to append his signature and all other answers were filled in by the agent, in his own handwriting. The deceased cannot be held responsible for concealing any facts. This aspect is well covered by judgment in 'LIC vs. Bina Joshi' where the entries filled by agents, the policy holders were not blamed for concealing information. In 'L.I.C. of India vs. Promila Malhotra (N.CD.R.C.) 2003(2) ALT 11', it was observed that more than two years had elapsed between the date of issue of policy and the date of death, the policy could not be called in question by the insurer on the ground that the statement made in the proposal form or any report of the medical officers, or referee or friend of the insured or in any other document of the company leading to issue of policy, was inaccurate or false unless the insurer showed that such information was on a material matter and it was fraudulently made by the policy-holder. The onus of proving all these facts was with the Insurer. Thus, based on the above reasons District, State as well as National Consumer Commission was justified in its decision asking the insurer to pay the sum assured with interest and costs.

Topics: Consumer Protection

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