1.       The present Revision Petition (RP) has been filed by the Petitioner against Respondent as detailed above, under section 21 of Consumer Protection Act 1986, against the order dated 09.02.2017 of the State Consumer Disputes Redressal Commission Chhatisgarh (hereinafter referred to as the ‘State Commission’), in First Appeal (FA) No. 675 of 2016 in which order dated 05.10.2016 of Raipur District Consumer Disputes Redressal Forum (hereinafter referred to as District Forum) in Consumer Complaint (CC) no. 76 of 2015 was challenged, inter alia praying for setting aside the order dated 09.02.2017 of the State Commission.

2.       While the Revision Petitioner(s) (hereinafter also referred to as Complainant) was Appellant before the State Commission and Complainant before the District Forum, the Respondent (hereinafter also referred to as OP) was Respondent before the State Commission and OP before the District Forum.

3.       Notice was issued to the Respondent on 18.12.2017. Parties filed Written Arguments/Synopsis on 21.08.2023 ( Petitioner ) and 17.11.2023 ( Respondent ) respectively. Reply to the RP has also been filed by the respondent.

4.       Brief facts of the case, as emerged from the RP, Order of the State Commission, Order of the District Forum and other case records are that Complainant had taken Happy Family Floater Policy for Rs. 1.00 lakh per person for the period from 16.11.2013 to 15.11.2014 from the OP for self, her husband and her daughter.  At the time of taking the said mediclaim policy, had provided all the health related information to the OP and health of the complainant at the time of taking the policy was good.  The complainant for the first time took policy from the OP for the period from 16.11.2011 to 15.11.2012 which was subsequenty renewed for 16.11.2012 to 15.11.2013 and then from 16.11.2013 to 15.11.2014.  The complainant suffered pain in the chest on 04.03.2024, for which she consulted Dr.Ashish Malhotra based at Raipur and after examining the complainant and on the possibility of heart attack,  she was advised to get admitted in Ramkrishna Hospital for treatment. The Complainant intimated the OP about the same on 04.03.2014.  The complainant was admitted in Ramkrishna Hospital, Raipur on 04.03.2014, where she was operated for heart attack related treatment and was discharged on 08.03.2014.   Total expenses incurred in the treatment was Rs.2,85,858/-. The Complainant submitted the claim form to the OP On 24.03.2014 alongwith all the related documents for payment of the amount.  The OP on 11.07.2014 sent a letter to the complainant repudiating the claim on the grounds of pre-existing disease. However, the complainant was not suffering of any disease and the complainant has been taking the insurance policy continuously for the past 03 years.  The complainant even sent the legal notice but OP did not settle the claim.  Being aggrieved, the Complainant filed CC before the District Forum and District Forum vide order dated 05.10.2016 dismissed the complaint of the Complainant.  Being aggrieved, the Complainant preferred FA before the State Commission, who also dismissed the Appeal of the Complainant.  Therefore, the Complainant is before this Commission now in the present RP.

5.       Petitioner(s) have challenged the said Order dated 09.02.2017 of the State Commission mainly on following grounds:

1. State Commission failed to note that  Complainant did not violate any terms and conditions of the medi-claim insurance policy.  At the time of operation, she was insured by the OP against all medical losses and had paid insurance premium from time to time.

2. State Commission failed to note that complainant took the medi-claim policy from the OP for the first time for the period 16.11.2011 to 15.11.2012, which was subsequently renewed from time to time i.e. from 16.11.2012 to 15.11.2013 and then 16.11.2013 to 15.11.202014 after payment of premium amount.

3. State Commission failed to note that at the time when the insurance policy was first taken and subsequently renewed, the Complainant had not concealed any material information from the OP and she was not suffering from any heart related disease and hence there was no scope or occasion for the Complainant to provide information to the OP with respect to any heart related disease.

4. State Commission failed to note that it is only on 04.03.2014 that Complainant suffered chest pain due to which she was taken to the doctor.

5. State Commission failed to note that Complainant was not having pre-existing of which she was aware.  Reliance has been placed on the order of National Commission in RP No. 1696 of 2005 titled Praveen Damani Vs. Oriental Insurance Company Ltd.

6. State Commission failed to note that  Complainant had not suppressed any fact and OP has failed to show that  Complainant at the time of making the statement, knew it be false.

6.       Heard counsels of both sides.  Contentions/pleas of the parties, on various issues raised in the RP, Written Arguments, and Oral Arguments advanced during the hearing, are summed up below.

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6.2     Learned counsel for the respondent argued that respondent has filed written statement denying the averments made in the complaint and pleaded that cover under the insurance policy was subject to the conditions, clauses, warranties and endorsements and since the claim was not payable as per condition no.4.1 of the insurance policy, hence the same was repudiated. The four year period started from the date of inception of insurance policy and diseases of diabetes and hypertension were kept under exclusion, whether such diseases were declared / not declared, treated / not treated, while taking the policy, which means that for the first four  years, no amount was payable for the treatment of these diseases because it was the subject matter of the policy exclusion clause.  The maximum value of insurance was fixed at Rs.1.00 lakh while taking the policy and for this reason Rs.2,58,858/-was not payable by the insurance company as per insurance. 

6.3.    Learned counsel relied on the following judgments of the Hon’ble Supreme Court:

1. Export Credit Guarantee Corpn. Of India Ltd. Vs. M/s Garg Sons International 2013 (1) Scale 410

2. General Assurance Society Ltd. Vs. Chandumull Jain and Anr. ( 1966) 3 SCR 500

3. Oriental Insurance Co. Ltd. Vs. Sony Cherian, II 1999 CPJ 13 SC

4. Oriental Insurance Co. Ltd. Vs. Mahender Construction 2019 ( 7) Scale 187

5. Reliance Life Insurance Co Ltd. and Anr. Vs. Rekhaben Nareshbhai Rathod SLP ( C) No. 14312 of 2015

6. Life Insurance Corporation of India Vs. Manish Gupta, SLP ( C) No. 5001  of 2019

7. LIC of India Vs. Sunita 2021 (13) Scale 125

8. Vikram Greentech ( I) Ltd. Vs. New India assurance Co. Ltd. (2009) 5 SCC 599

1. Oriental Insurance Co. Ltd. Vs. Sony Cheriyan AIR 1999 SC 3252

10. United India Insurance Co. Ltd. Vs. Harchand Rai Chandan lal  (2004) 8 SCC 644.

7.       We have carefully gone through the orders of the State Commission, District Forum, other relevant records and rival contentions of the parties.  In this case, the claim has been rejected by the Insurance Company on ground of suppression of material facts pertaining to pre existing ailments as mentioned in the discharge summary.  As Insurance Company had not placed on record the copy of the proposal form to show whether complainant gave false declaration with respect to pre existing ailments, while concluding the hearing and reserving the judgment on 22.03.2024, the respondent was instructed to place on record copy of the proposal form.  In compliance of this order, the respondent – Insurance Company has filed an affidavit dated 22.03.2024 ( filed on 05.04.2024) in which it is stated that Respondent – Insurance Company inquired about the proposal form concerning the present insurance policy from the respondent’s regional office at Raipur, Chhattisgarh. However, it was found that same is not retained by the Insurance Company considering the fact that policy availed by the petitioner is almost 10 years ago.  Accordingly, Respondent – Insurance Company does not have a physical copy / records of the proposal form of the concerned insurance police.   

8.       In this case, the main reliance of the insurance company is on the discharge summary.  It is contended by the Insurance Company that said discharge summary states that Petitioner / Complainant was already suffering from diabetes mellitus, hypertension and thyroidism for 3-4 years and that she has also been taking medicines for the same.  The Respondent – Insurance Company contends that discharge summary establishes that Petitioner / Complainant was suffering from pre existing ailments and therefore, was not eligible for the benefit under the exclusion clause of the insurance policy. 

9.       No doubt, the Insurance Company is entitled to repudiate the claim in case of suppression of material facts relating to pre existing ailments but onus to prove the suppression of such facts relating to pre existing ailment is on the insurance company. In the present case, the insurance company has not placed on record copy of the proposal form and has expressed its inability to do so even now, which could have shown whether complainant gave any false declaration with respect to any pre existing ailments.  No doubt, said discharge summary makes a mention of earlier ailments and medications, extract of which is reproduced below :

“Final Diagnosis

            HTN,CAD, TVD

HISTORY

ANNAMMA ABRAHAM, aged 57.00.00 yrs, female presented with

c/o Chest pain associated with both shoulder and  burning sensation of neck at 09.00 am on 01.03.2014

C/O     DM                  -           3-4 years on regular medication

            HTN                -           3-4 years on regular medication

            Thyroidism    -           3-4 years on regular medication”

10.     In the absence of the proposal form and the requisite medical records of the prior treatment, the insurance company has not been able to establish with reliable and cogent evidence that Petitioner / Complainant has suppressed material facts relating to pre existing ailments, hence repudiation of claim on this ground is not tenable.  In view of the foregoing, the order of the District Forum dismissing the Complaint and order of the State Commission dismissing the Appeal of the Petitioner / Complainant herein cannot be sustained and same are hereby set aside.  RP is allowed.  The respondent – Insurance Company is directed to pay eligible amount alongwith interest @ 6% p.a. w.e.f. expiry of one month from the date of filing the claim till the date of payment.  The entire amount payable as per this order shall be paid by the insurance company within 45 days from the date of this order, failing which the entire amount payable at the end of 45 days shall carry interest @ 9% p.a.

11.     The pending IAs in the case, if any, also stand disposed off.