Ashwini, aged 30 years, was employed as a supervisor in a bank. On 4th June, 2012, he took two life endowment insurance policies on his life for ₹50,000 each from Prudent Life Insurance Co. Ltd. Each policy had a differe

CS Professional · Insurance - Law and Practice · PYQS · June 2016
Ashwini, aged 30 years, was employed as a supervisor in a bank. On 4th June, 2012, he took two life endowment insurance policies on his life for ₹50,000 each from Prudent Life Insurance Co. Ltd. Each policy had a different maturity term and period. Both the policies had accident claim benefit of an equivalent amount, viz. in the case of death of the insured due to an accident, the amount payable by the insurer would be twice the amount of the sum assured. Ashwini made his wife Smt. Asha as his nominee under the policies and also the legal assignee, since the couple had no issues then. On 31st May, 2014, Ashwini while going to his office on his two-wheeler was involved in a head-on collision with a motor car coming from the opposite direction and was severely injured. He was admitted to a hospital, but succumbed to the injuries and died in the hospital on the morning of 2nd June, 2014. Smt. Asha filed a claim under the policies with the insurer for payment of the sum assured together with the accident benefits. The company, after processing the claim, informed her on 15th July, 2014 that they were rejecting the claim on the ground that Ashwini, while taking the policies, had suppressed material facts. The insurer indicated that Ashwini did not mention in the proposal form, the fact of an earlier ailment of having suffered from para-typhoid in June - July, 2010 and having been away from his employer on medical leave between 6th June, 2010 and 5th July, 2010. The nominee filed a complaint on 18th August, 2014 with the District Consumer Forum stating that the repudiation of the claim was not justified. The insurer reiterated its argument that the non-mention of the previous ailment to it was a suppression of material facts and affected the fundamental nature of the contract. The District Consumer Forum on consideration of the arguments before it held in favour of the insurer agreeing with it that the deceased had suppressed material facts at the time of the proposal. Smt. Asha, not accepting the decision of the District Consumer Forum, filed an appeal with the State Forum. Her counsel contended before the Forum that even if the deceased had suffered from para-typhoid less than two years prior to obtaining the policies and did not give the necessary information in the proposal form, it did not amount to a material suppression of facts. His main argument was that the cause of death was the accident with the motor vehicle and the cause had no nexus whatsoever with the alleged ailment. Thus, there was no suppression of facts. The State Forum after hearing the arguments of both the parties, allowed Smt. Asha's appeal and held that the cause of death was accident and not illness. The non-mention of the fact of illness and hospitalisation did not amount to any non-disclosure of material facts. The Forum granted the relief asked for and directed the insurance company to pay Smt. Asha ₹2,00,000 under the policies. The decision taken on 6th January, 2015 also entitled the nominee with interest at 9% per annum from the date of filing the claim, viz. 18th August, 2014. From the information given above, answer the following questions: Was the State Forum justified in its conclusion in terms of the conditions of life policies issued by Indian insurance companies? Give reasons for your answer. Cite relevant case law, if any.

Answer & Explanation:

The decision of the State Forum is justified on the following grounds: That the Death of Late Shri Ashwini Kumar was as a result of an accident and not any illness. That Section 45 of the Insurance Act, 1938 provides that a policy of life insurance cannot 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. That the Death of Shri Ashwini Kumar was within two years of taking a life Insurance Policy from "Prudent Life Insurance Company". The policy was taken on the 4th of June 2012 and the death of the assured occurred on 2nd of June 2014. That the accident of Motor Cycle with car resulting in death of the assured had nothing to do with any illness and hence cannot come under the purview of section 45 of the Insurance Act. In the light of the foregoing, the decision taken by the state forum was correct and in favour of the claimant. Relevant Case: Life Insurance Corporation of India v. Shakuntala Bai on 17 July, 1973 (AIR 1975 AP 68)

Topics: Life Insurance Claims

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