A, an employee of a government organization purchased a life insurance policy on 28-4-2011. It was a non-medical scheme policy as he was an employee of government organization and no medical examination was conducted. Th

CS Professional · Insurance - Law and Practice · PYQS · December 2018
A, an employee of a government organization purchased a life insurance policy on 28-4-2011. It was a non-medical scheme policy as he was an employee of government organization and no medical examination was conducted. The above policy lapsed due to non-payment of premium which was due from April, 2012 to October, 2012. The life assured got the policy revived on 3-1-2013 by depositing the premium which was due. Unfortunately the life assured died on 13-1-2013. The legal heirs of the assured submitted a claim with the insurance company with respect to the above said policy. As the life assured died within 2 years from the date of obtaining the policy and within ten days of the revival of the policy, the insurance company carried out an investigation for the policy and the life assured. The investigation revealed that the life assured was not keeping good health at the time of obtaining the policy and as well as at the time of revival of the policy, because his employer organization had supplied the details of earned leave and medical leave availed by the life assured during his service period w.e.f. 4-6-2007 to 18-9-2012. The details given for the leave were as under: Medical leave: 12-5-2008 30-5-2008 to 27-6-2008 27-7-2008 to 10-9-2008 06-8-2010 to 13-8-2010 13-6-2011 to 06-8-2011 05-9-2012 to 18-9-2012 The fact of the medical leave was made known to the insurance company only on investigation and the fact that the life assured was suffering also came to their knowledge. The fact was not disclosed by the life assured in the original proposal form at the time of taking the policy as well as at the time of revival. The life assured was suffering from epigastria C bleeding per rectum due to which he died in the hospital on 13-1-2013 where he was admitted on 4-1-2013. Thus, it was a clear case of concealment on the part of the life assured which was against the terms of the Insurance policy. Accordingly the insurance company repudiated the claim. The legal heirs of the life assured challenged the repudiation of the claim in District Consumer Forum where the claim was awarded in their favour and against the insurance company. The insurance company aggrieved by the decision of the District Consumer Forum filed an appeal with the State Commission where the appeal was accepted and the decision of the District Consumer Forum was set aside. Based on the above case, answer the following questions: Having issued a Life Insurance Policy on 'non-medical scheme', do you think the Insurance Company is justified in repudiating the claim? Was there lapse in 'Underwriting'? Discuss.

Answer & Explanation:

The facts stated in the case indicate that the life assured was suffering from epigastria C bleeding per rectum. He had been taking medical leave very frequently which is evident from the records provided by the employer of the life assured. In a short period of less than two years he had taken medical leave more than six times. Had the life assured mentioned the fact about the health condition in the proposal form, the insurance company based on condition of the existing critical illness would have rejected the proposal or might have carried out further medical examination as required for acceptance of the proposal for the applicants other than employees of government organisation. Looking at the health records the proposal would have been rejected by the insurance company. However, the policy is issued on non medical basis, the company would have not got any information about the health condition of Life assured then the company would have taken precaution and increased the premium as it was a non medical policy. Though, the policy is issued on non medical basis but the life assured is duty bound to disclose all material facts that would have influenced the judgment of a prudent insurer in deciding whether he would accept the risk in whole or in part and, if so, at what amount of premium. Hence, the insurance company is justified in repudiating the claim. There is no lapse in the underwriting process of the company due to being non medical scheme. The policy issued on the basis of non-medical is just a feature provided by the insurance company. The policy issued under non-medical is based on the risk appetite of the insurer, sum assured, age of the insured and employment details.

Topics: Life Insurance

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