NUTSHELL
Person taking medi-claim policy by suppressing fact of ailment - Insured or his heirs not entitled to claim compensation in case of death or injury.
A. Insurance Act, 1938, Section 45 - Consumer Protection Act, 1986, Section 2(1)(o)(g) and (c)(xiii) - Medi-claim Policy - Deficiency in service - Deceased took a medi-claim policy - At the time of taking policy he was suffering from Diabetic Nephropathy/Chronic Renal Failure - Deceased did not disclose the fact of ailment while taking the policy which was within his knowledge and he was required to disclose it under the terms of policy - Death of deceased after 7 months of taking the policy - Wife claiming compensation which was repudiated by the insurance company - Held, fact suppressed was a material fact - There is no deficiency in service - Insurance company justified in repudiating the claim - Material fact means any fact which would influence the judgment of a prudent insurer in fixing insurer the premium or determining whether to accept the risk or not. [Paras 16 to 23] B. Insurance Act, 1938, Section 45 - Mediclaim Policy - A mediclaim policy is a non-life insurance policy meant to assure the policy holder in respect of certain expenses pertaining to injury, accidents or hospitalizations - It is a contract of insurance policy falling in the category of contract uberrimae fidei. [Para 12] C. Insurance Act, 1938, Section 45 - Consumer Protection Act, 1986, Sections 2(1)(o)(g) and (c)(xiii) - Insurance Regulating and Development Authority (Protection of Policy holders interests) Regulations, 2002 Regulation 2(1)(d) - Repudiations of medical insurance claim - Material Fact - Suppression of - "Material fact" means any fact which would influence the judgement of a prudent insurer in fixing the premium or determining whether to accept the risk or not - If the proposer has knowledge of such fact, he is obliged to disclose the same - Failure to do so entitled the insurer to repudiate his liability under the policy. [Para 20] Cases Referred :- Joel v. Law Union & Crown Ins. Co., [1908]2 K.B. 863. United India Insurance Co. Ltd. v. M.K.J. Corporation, 1997(1) RCR (Civil) 32 : (1996)6 SCC 428. Modern Insulators Ltd. v. Oriental Insurance Co. Ltd., (2000)2 SCC 734. Carter v. Boehm, (1766)3 Burr. 1905"10. Details of illness/would which may require treatment in near future : | Sound Health |
11. Details of Treatment/surgical operation in the last two months : | Nil |
Details of Treatment | |
Duration of Treatment | |
From.....to...... | |
Doctor/Hospital | |
If fully recovered, attached certificate | |
For attending Doctor/Surgeon" |