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Insurance company committed fraud

By Shivendra Pratap Singh

I am a school teacher in middle school. I took an insurance policy for my two children and my wife. Insurance policy is for medical treatment up to 2 lac in selective hospitals. According to the policy, it covers all the critical diseases mentioned in the policy.

Insurance agent explained the terms of policy and said that insured person can avail this policy after the expiration of one month from the date of commencement of the policy. My child is suffering from heart disease.

When claimed medical treatment of my child under the policy it was refused by the insurance company that I was not stated health condition of my child at the time of insurance. Please help.

Insurance policy is a contract. This contract of insurance is a contract of uberrima fides means contract of utmost good faith. You are bound to state all the facts, at the time of the making of the contract, about the health condition of your children and wife. You knew at the time of signing of policy that your one child is suffering from heart disorder. This is an important fact it is required by the law that such facts should be stated at the time of signing of policy. You committed a breach of a duty imposed upon him by uberrima fides.

United India Insurance Co. Ltd Vs. M. K. J. Corporation AIR 1996 SC; (1996) 6 SCC 428; held by the supreme court that It is a fundamental principle of insurance law that utmost good faith must be observed by the contracting parties. 

You have committed a breach of this fundamental principle. Now you have no right to execute terms of insurance police i.e. claim medical expenses of your child under the policy. The court cannot construe terms of policy in favour of the insured person if there is a breach of fiduciary relation. 

You should amend your policy on the new terms. Contact insurer and take novation of the policy. State medical condition of your child otherwise this policy will have no effect.

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