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: Do you think the claim of the legal heirs is justified in the absence of any medical issues of the employee?

Answer & Explanation:

The investigations were carried out as required under section 45 of the Insurance Act, 1938. However if the investigation would not have shown any health problems found with the life assured then it would have satisfied all the requirements of the claim made under the policy. Thus if the investigation does not result in any problem with the health conditions of the life assured then there was no non- disclosure of any material fact related to subject matter of insurance. So there is no reason for the insurance company to treat the contract as void and the claim as filed under the Insurance policy would be payable to the legal heirs of the assured as per the conditions of the policy. Thus in such a situation, the claim of the legal heirs would be fully justified, in the absence of any medical issue of the life assured.

Topics: Life Insurance

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