ICICI PRUDENTIAL LIFE INSURANCE CO. LTD. & ANR. vs KALI KISKU

The husband of the complainant, namely Mihan Kisku, obtained two life insurance policies from the petitioner ICICI Prudential Life Insurance Co. Ltd. for a total sum of Rs.13,00,000/-. The insured died of Cardio Respiratory Failure on 12-10-2008. The claim lodged by the complainant for payment in terms of the policy, however, came to be repudiated by the insurance company vide its letter dated 07-09-2009 on the ground that the insured had suppressed material

information with respect to his ailment at the time of obtaining the insurance policy since he was suffering from high blood pressure and hyper acidity which was not disclosed to the insurance company.

Being aggrieved from the rejection of the claim the complainant approached the concerned District Forum seeking the following reliefs: (a) Rs.3,00,000/- as assured amount under the Crisis Cover Policy bearing No.09864348,

(b) Rs.10,00,000/- as assured amount under the Life Time Gold Policy bearing No.09622673 and

(c) Rs.3,00,000/- as compensation towards mental pain, agony and harassment.

The complaint was resisted by the insurance company on the same ground on which the claim was repudiated. It was further alleged that the insured had produced a fake proof of his age while submitting the proposal for obtaining the insurance policy.

Vide its order dated 31-01-2012 the concerned District Forum directed the insurance company to pay the policy amount of Rs.13,00,000/- to the complainant along with Rs.3,00,000/- towards compensation and Rs.2,000/- towards cost of litigation.

Being aggrieved from the order passed by the District Forum the insurance company approached the concerned State Commission by way of an appeal. Vide impugned order dated 03-02-2015 the State Commission dismissed the appeal filed by the petitioner company. Being still dissatisfied the insurance company is before us by way of this revision petition.

The first question which arises for our consideration in this petition is as to whether the insured had submitted a forged document as a proof of his age at the time of obtaining the insurance policy and if so what impact it would have on the claim of the complainant. We may notice at the very outset that the submission of an alleged fake document as a proof of the age of the insured was not a ground for repudiation of the claim. Hence, the complainant had no reason to address the aforesaid plea in the complaint filed by her. More importantly, it is an admitted case that the insured had also submitted a Pan Card along with the proposal, as a proof of his age. This is not the case of the petitioner company that the Pan Card submitted by the insured was a forged document. The insurance company has not made its own verification as regards the age of the insured. This is not the case of the petitioner company that the age of the insured as reflected in the Pan Card submitted by him was inaccurate. Therefore, it cannot be said that the petitioner company was misled on account of the alleged forged school certificate submitted by the insured.

Coming to the ground on which the claim has been rejected by the insurance company we find that while responding to question No.23(c), the insured replied in negative to the question as to whether he had consulted any doctor or was currently undergoing any test, investigations or awaiting result of any test or investigation or whether he had been advised to undergo any test, investigation or surgery or had been hospitalized for any general checkup, observation, treatment or surgery. The proposal form was submitted on 06-08-2008. There is no evidence that at that time the insured was undergoing any test, investigation, etc. or had been advised to undergo any test, investigations or surgery. There is no evidence of his having hospitalized for any checkup, surgery or other treatment. Therefore, the answer to question No.23(c) cannot be said to be a false answer.

In reply to question No.23(h), whereby he was required to inform whether he was suffering from high/low blood pressure, gastritis, stomach or duodenal ulcer, hernia, jaundice, hepatitis, fistula, piles or any other disease or disorders of the gastro-intestinal system, the insured replied in negative, meaning thereby that he was not suffering from any of the aforesaid ailments at the time the proposal was submitted by him.

In order to substantiate its case that the petitioner was actually suffering from high blood pressure and hyper-acidity, the insurance company has relied upon the prescription purporting to be issued by one Dr. J.B. Ghosh, DHMS (Hons.) to one Mihan Kisku on 25-08-2005, 10-10-2006 and 21-03-2007. The petitioner company also relied upon a certificate purporting to be issued by Dr. J.B. Ghosh stating therein that Mihan Kisku aged about 40 years was under his treatment from 25-06-2005 to 21-03-2007 as he was suffering from hyper tension and hyper acidity.

Admittedly, the insurance company has not examined either Dr. J.B. Ghosh or the investigator who collected the aforesaid document from Dr. Ghosh. In our opinion, in order to prove the case set up by it, it was incumbent upon the insurance company to file affidavit either of Dr. Ghosh or at least of the investigator who allegedly collected the aforesaid prescription from him. That having not been done, it would be difficult to say that the insurance company has been able to discharge the onus placed on it to prove that the insured had suppressed the material information with respect to the state of his health, while taking the insurance cover.

More importantly, we fail to appreciate how the copies of prescriptions which Dr. J.B. Ghosh allegedly issued to the insured could have been in possession of Dr. Ghosh after 3-4 years of having been issued to the patient. The prescription purporting to be issued by Dr. J. B. Ghosh which are hand written and not typed or computer typed prescriptions. They are supposed to be in possession of the patient and not in possession of the doctor who issued them. There is no explanation from the insurance company as to how the aforesaid documents came to be possessed by Dr. J.B. Ghosh till 16-08-2009 when a certificate was issued by him certifying that Mr. Mihan Kisku was under his treatment from 25-06-2005 to 21-03-2007. This is yet another reason, for which we would not like to rely upon the aforesaid documents in order to deny the claim preferred by the complainant.

Even if we go by the documents submitted by the insurance company, they prove only this much that the petitioner was taking some homeopathic treatment upto 21-03-2007, for hyper acidity and hyper tension. There is absolutely no evidence that the complainant had continued to suffer from the aforesaid ailment till the time proposal was submitted by him to the insurance company on 06-08-2008. It is quite possible, considering the nature of the aforesaid ailment that by maintaining diet control and regular exercise, etc., the insured was able to get rid of the aforesaid life style ailment by the time the insurance cover was taken by him. In order to succeed the insurance company was required to prove that the insured had continued to suffer from the aforesaid ailments at the time the proposal for taking insurance policy was submitted by him. That having not been proved, denial of the claim cannot be justified.

For the reasons stated hereinabove we find no merit in the revision petition and the same is accordingly dismissed.