Andrew Johnson v Seabilt Insurance Co. Ltd.

(Based on a true story)

Characters:
 Andrew Johnson - Eric
 Chloe - Wife - Ronisha
 Insurance Agent - Aniket
 Ombudsman - Soundarya
 High Court Judge - Bryna
 Doctor - Justin
 Narrator - Soundarya & Bryna
 Extras

SCENE 1: Andrew’s Insurance Office Visit

Narrator (Soundarya 2011183): Andrew Johnson, a healthy male in his mid-thirties, is an
employee at a famous MNC in Bengaluru. Andrew works the night shift and is constantly
bombarded with arduous work, demanding longer working hours, sometimes starting even
before his actual shift timings. Andrew’s work habits worry his family, especially his wife,
who requested he take an insurance policy for the family. Andrew pays heed to his wife
and visits Seabilt Life Insurance Co., a reputed Life Insurance provider, and requests a
relevant Insurance Plan to provide good cover for his family. The insurance agent selects
Seabilt Health Insurance Family Policy and proposes to enter a contract with Andrew.
Andrew chooses the plan and begins to pay the calculated premium from thereon.

SCENE 2: Andrew’s Morning Walk

Narrator (Bryna 2011346): Andrew is now a manager at the firm and continues to work
during the night shifts, keeping his commitments to his employer on the outside while
internally cursing his luck since the job has depraved every bit of his life from ever
enjoying or having an enjoyable time. He condemned the firm for its strict work hours and
his desperate need to work here to repay his family’s past debts.

The time is 06:30 AM, and it is the end of his shift. Andrew steps out of the building,
dishevelled and sleeps deprived since the arrogant New Zealander he was consulting for
kept increasing his workload with constant complaints about the Indian branches, their
shift timings and functioning while not paying attention to his own blunders, something
which Andrew’s bosses had pointed out their superiors. The Board in Chicago refused to
upset the Kiwi since he was a significant client. Andrew goes to the nearby park to walk a
bit before dropping on his plush bed at home, wakes up hours later, and prepares for work
while his family prepares to sleep.

Andrew (Eric 2011212): Goddarn Kiwis exist at some corner of the globe, adding to my
headache. Like I do not have any life left in me! These clowns think work is accessible, eh? If
only my dad did not have so many debts, I would be glad to quit this rotten company and take
a lovely long holiday to the Bahamas. Just the sun, sand, sea, and a boat to keep company.
God, why do my troubles not end?

Narrator (Soundarya R 2011183): Andrew starts walking amongst the tracksuit-clad

population of the early morning when tragedy strikes him.
Andrew (Eric 2011212): Whoa, what is happening to me? Ohh, my God, am I having a
stroke right now? I cannot……I cannot bear it. Ohh no!!

Narrator (Bryna 2011346): Andrew collapses due to fatigue and chest pain and is spotted
by a passer-by who takes him to the hospital. After conducting tests and doing an
angiography, the doctors deduce that he must undergo a bypass Surgery.

SCENE 3: Hospital Scene

Doctor (Justin 2011275): Mr. Johnson, I am sorry to say this, but we need to put you on a
bypass surgery immediately; the results are not good.

Andrew (Eric 2011212): What are you talking about? I am a perfectly healthy man; I have
had no diseases for a while. Are you saying that I had a heart attack?

Doctor (Justin 2011275): Look, Sir, as per the tests conducted, your coronary arteries have
drastically narrowed and have begun to obstruct proper blood flow. We do not have so many
options to ignore this situation. We must conduct a bypass surgery for you immediately
before all hell breaks loose. You must inform the nearest of kith and kin, even your employer,
and try to get this procedure done directly.

Narrator (Soundarya R 2011183): While the two discuss this, Andrew’s wife arrives
petrified after getting the call at 7 AM on a school morning. Andrew’s wife's panic adds to
the comedy that follows.

Chloe (Ronisha 2011158): Oh My God!! I am so glad to see you in one piece; I thought we
had lost you forever.

Andrew (Eric 2011212): Good Lord, woman, keep that thought to yourself; I am not dying
anytime soon.

Chloe (Ronisha 2011158): Even if you do, we are covered, I believe. Doctor, what is my
husband diagnosed with?

Doctor (Justin 2011275): A block in the coronary arteries has slightly obstructed blood flow.
He needs a bypass surgery immediately; I request you to inform the Insurance company and
prepare the necessary documents.

Chloe (Ronisha 2011158): OH MY GOD, IS HE GOING TO DIE AND MAKE ME A

WIDOW?

Andrew (Eric 2011212): Woman, I got chest pains and now need surgery. Is that so hard to
understand?

Chloe (Ronisha 2011158): Ohh, you will die on me, will you? I cannot believe this, doctor,
get him treated. As it is, he does not show his face in the house, and now he intends never to
show it forever.

Andrew (Eric 2011212): Okay, I am not dying……

Chloe (Ronisha 2011158): Shut up before your weak heart gives up! I will not be able to do
anything without his help, Doc! Please do not kill him in that room.
Narrator (Bryna 2011346): Saying this, the wife goes to get the necessary procedures done
while the doctors prep Andrew for surgery. However, the scenario is different.

SCENE 4: Insurance Agent

Chloe (Ronisha 2011158): Hello, Sir! I am here on behalf of my husband, who had chest
pain this morning and is now undergoing bypass surgery at Curtiss Hospital. I kindly request
you process our claim amount as per this invoice provided by the hospital.

Agent (Aniket 2011003): I am sorry to hear that, Ma’am. Kindly wait for us to process the
application. I hope you have brought all the necessary information and documents for us.
This application will proceed only after document verification.

Chloe (Ronisha 2011158): I have everything here per the policy document requirements.
These are all the forms, receipts, identity proofs, and everything else asked here.

Narrator (Soundarya R 2011183): Taking the items, the agent leaves and comes back a
few minutes later. In an apologetic yet assertive tone, the agent does not look pleased and
rejects the claim request.

Agent (Aniket 2011003): Thank You for patiently waiting; I know this must be a tough time
for you, but I am sorry to inform you that we have no reason to entertain this claim since your
husband violated one of the main principles of Insurance.

Chloe (Ronisha 2011158): I am confused; what has he done now? And why are you rejecting
my request? He needs it right now.

Agent (Aniket 2011003): Ma’am! Your husband had Sarcoidosis a few years back if you
remember? We came to know about it right now after checking his medical history. That tells
you everything about my response.

Chloe (Ronisha 2011158): You are not making this easy; I do not understand what
something he had a few years ago has to do with him now. Are you not able to do your job of
providing the claim, or should I go to your superiors now?

Agent (Aniket 2011003): The managers have themselves rejected the claim. The liability
cannot be ascertained at this juncture, as the patient has a history of Sarcoidosis since 2010,
which is pre-existing to the policy inception with Seabilt, which is the non-disclosure of
material facts; hence cashless denied.

Chloe (Ronisha 2011158): This is outrageous; I will take you to court, you filthy evil devil
of an agent. You crook, you cheat, you have not heard the last of me, you do not know what I
can do. How dare you cheat my dying husband and me? Giving some lame excuses to deny
the claim, eh?

Wait till he comes back to life and then watch!

Narrator (Bryna 2011346): Saying this, she storms off from the office. After the surgery,
the wife brings the issue to the notice of Andrew, who confronts the agent for his rejection
of the claim.
Andrew (Eric 2011212): Sir, I am wrongfully accused of violating a particular principle of
Insurance as the base for rejecting my requested claim amount.

Agent (Aniket 2011003): Mr. Andrew Johnson, keeping your incident with Sarcoidosis away
from the company violates the basic principle of Utmost Good Faith since you have hidden a
previously known or occurred disease from the knowledge of the firm.

Andrew (Eric 2011212): I do not think there is a reason for considering that; it was not such
a significant incident. I was down in 2010, and within three months of steroid usage, I was
feeling normal and was advised to discontinue taking those steroids and lead a careful but
everyday life. Besides, I had a bypass last week, not for Sarcoidosis, so what is there to reject
the claim? Will you still deny the claim even if somebody had a slight fever, an injury, or
even a cut that healed on time, and they still did not reveal that to anybody? This is
ridiculous!!

Agent (Aniket 2011003): My superiors have gone through your request and have denied the
claim once more and will terminate the Policy on the grounds of "non-disclosure of a relevant
fact." You will be informed of the status of your rejected claim and cancelled policy later
through e-mail or any suitable medium.

SCENE 5: Ombudsman:
Narrator (Bryna 2011346): The distressed couple decides to accept the issue with an
Ombudsman, as the role of such a person of authority is to settle disputes from a neutral,
independent point of view. However, their luck does not favour them, as the ombudsman
feels that Andrew violated the Utmost Good Faith principle. 

Ombudsman (Soundarya 2011183): I heard both sides; the complainant and the Insurance
Company. During the hearing, the complainant reiterated that he had been hospitalized in
Curtiss Hospital from 23.09.2022 to 01.10.2022 for treatment of coronary angiography, and
bypass surgery was done. He only submitted claim documents for Rs.600309/-, and his claim
was rejected. The company terminated the policy due to nondisclosure of Sarcoidosis disease
at the insurance policy's inception. The Insurance Company reiterated that the insured
complainant did not disclose the previous history of Sarcoidosis of the patient at the
beginning of the Insurance Policy. Hence, they terminated the said policy and rejected the
claim.

The Discharge Summary dated 01.10.2022 confirms that the insured patient has had
Sarcoidosis since 2010. During the Pre-Medical Examination, the insured did not reveal his
previous medical history of Sarcoidosis at the inception of the said insurance policy. Hence,
the said claim is not payable per the policy's terms and conditions. It is a clear case of non-
disclosure. As per the Supreme Court judgment in the case of Satwant Kaur Sandhu vs. New
India Assurance (2009) 8 SCC 316, the Hon'ble Supreme Court emphasized that insurance is
a contract of utmost good faith on the part of the insured when a piece of information on a
specific aspect is asked for in the proposal form. An insured is under a solemn obligation to
make a valid and full disclosure of the information on the subject, which is within his
knowledge. The Insurance Company is not liable to pay any expenses in case of non-
disclosure of material facts at the time of taking the policy. The claim was denied due to the
non-disclosure of material information per policy conditions. I see no reason to interfere with
the decision of the Insurance Company.
Andrew and Chloe (Eric 2011212 and Ronisha 2011158):
“We are disappointed in this judgment.”: (both) This does not seem fair to us. We will
proceed with a court case as these allegations and treatment violate our consumer rights.

We must contact Aniket; he will know what to do now. He is an expert in Insurance claims
and fraud cases.

SCENE 6: Court and Final Verdict

Narrator (Soundarya R 2011183): The sad couple then files a patient with an advocate
friend of theirs who proceeds with the wrongful suit against Seabilt Insurance. After weeks
of arguments between the plaintiff and the defendant, the court sides with the plaintiffs
and settles the case.

Judge (Bryna 2011346): Coming back to the facts of the present case, the petitioner suffered
from Sarcoidosis in 2010, and it is stated that he was cured of it within three months.

The petitioner acquired the insurance policy in 2017, 7 years after suffering from the said
disease. It cannot be held that disclosure of such infection would be “material information,”
and the non-disclosure thereof would make the Policy null and void under Clause VIII.1 of
the terms and conditions of the Policy or the general principles applicable to the insurance
contracts.

In the present case, the Ombudsman has failed to apply the correct test to the dispute. The
debated order records that "the Discharge Summary dated 01.10.2022 confirms that the
insured patient had Sarcoidosis since 2010". The Discharge Summary records "Past Medical
History" under "Sarcoidosis 2010 took steroids for 3 months."

The above remark in the Discharge Summary cannot be read to mean that the petitioner
continued to suffer from Sarcoidosis as has been interpreted by the Ombudsman. Therefore,
the impugned order has proceeded incorrectly and cannot be sustained.

Accordingly, the insurance company is directed to pay to the petitioner, within four weeks
from the date of the judgment, a sum of Rs. 6,00,309/- (Rupees five lakhs only) along with
simple interest at the rate of 9% per annum with effect from 01.10.2022 till the date of
payment. The insurance company shall also pay costs quantified as Rs. 25,000/- (Rupees
twenty-five thousand only) to the petitioner.

This court stands with the aggrieved petitioner, who in his rightful request for the claim of an
event against which he was insured, was denied the claim based on violating the Principle of
Utmost Good Faith, which the petitioner clearly has not according to the advice and the
findings by the expert council appointed by the court. The Judgement serves as a stern
reminder for insurance companies and agents appointed by the firms to avoid practicing the
principle of caveat emptor and to follow caveat venditor since the industry of insurance runs
on mutual trust, which is absent from the case. The case is hereby settled with the figures
presented earlier as compensation for the victim. The court is adjourned!

*******