Kathmandu. An insured person from Kavre got life insurance after suffering from an intestinal ailment. He died of a heart attack less than a month after he was insured.
Naturally, the patient’s family members filed a death claim with the insurance company, Reliable Nepal Life Insurance. The company put the claim application in the list of doubtful applications after the death of the insured died within a month of the insured. A thorough study was conducted and it was finally found that the insured was suffering from a serious illness even before he was insured. The company did not pay the claim after it was proved that the sick person had insured.
After failing to receive the claim, Ambika Guragain filed an application against the company at the Nepal Insurance Authority on Chaitra 7, 2078. According to NEA, the insured Raghunath Guragain of Kavre had already taken the life insurance of Realable Nepal Life Insurance on January 7, 2018 and died of cardiac arrest on February 7. His family members had filed a death claim on this basis as he died of a heart attack.
However, the company refused to pay the claim, concluding that the death from a heart attack was a chronic disease, and that the insurance had violated the principle of utmost goodfait by concealing the disease.
In response to the reply sought by the authority, the company had submitted a reply to the authority on April 4, 2078 that the claim was rejected as the insured died due to illness before the insurance was taken as the insured person was admitted to the ICU at Sheer Memorial Adventist Hospital, Banepa on July 15, 2018.
Judgment and Judgment of the Authority
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The hospital had informed the authority in writing on June 27, 2080 when it sought information from the hospital on April 27, 2080. In the letter of the hospital, it was mentioned in the discharge summary that the insured Raghunath Guragain was admitted on May 15, 2018 i.e. before the start date of the insurance on January 23, 2018 and was suffering from severe disease due to the consumption of alcohol in the Acute Pancreas-Alcoholic Intestine.
On the basis of the details given by the hospital and the argument of the insurer, the authority has dismissed the complaint filed by the petitioner as per Section 128 of the Insurance Act, 2079 as the claim of the petitioner is not sufficient as the insured has already suffered from a serious disease and the insurance was insured without disclosing the facts about such disease.
