HON’BLE MR. JUSTICE V.K.JAIN, PRESIDING MEMBER (ORAL)

          The complainant/respondent obtained an insurance protection plan from the petitioner company where-under he was entitled to the payment in terms of the policy, in case an accidental injury was to be suffered by him.  The policy was valid for the period from 16.12.2015 to 15.12.2016.  During the subsistence of the policy, the complainant allegedly met with an accident on 08.02.2016 and was taken to Dhanwantri Hospital, Mansarovar, Jaipur where his right leg had to be amputated.  The disability of the complainant was certified to be 65%.  The claim submitted by him for payment in terms of the policy however, was repudiated vide letter dated 18.12.2016 which, to the extent it is relevant, reads as under:

          On perusal of the claim documents submitted by you, the statements received and the independent service provider’s report, it is observed that

• Certificate given by the primary centre is not genuine.

• The date of accident is on 08-FEB-2016 and amputation of right leg was alleged to have been performed on 10-FEB-2016 without any justification.

• The insured has taken three insurance policies in three different companies, in order to avail undue benefit by claiming for already injured right leg.

• Further existence of three policies without any sound financial background is also not disclosed to us.

• The accident has not occurred in the manner as narrated in FIR and as concluded by IO of the case, which was confirmed by our verification.

          In view of the above mentioned facts, we regret our inability to entertain the claim as per the policy terms and conditions.

2.      Being aggrieved from the repudiation of the claim, the complainant approached the concerned District Forum by way of a Consumer Complaint.  The District Forum, vide its order dated 28.02.2019, directed the petitioner to pay a sum of Rs.10 lacs to the complainant alongwith interest @ 9% per annum from the date of the complaint and compensation quantified at Rs.50,000/-. 

3.      Being aggrieved from the order passed by the District Forum, the petitioner approached the concerned State Commission by way of an appeal.  The said appeal also having been dismissed, the petitioner is before this Commission. 

4.      The first ground given in the repudiation letter was that the certificate given by the Primary Centre was not genuine.  The learned counsel for the petitioner states that they are no more pressing this ground.  Therefore, the said ground need not be examined.

5.      The second ground in the repudiation letter was that though the accident happened on 08.02.2016, the amputation was done on 10.02.2016 without any justification.  I am really unable to appreciate this ground taken in the repudiation letter.  No one will allow his leg to be amputated unless the doctor treating him after the accident feels that such an amputation is absolutely essential.  It was for the concerned doctor and not for the investigator appointed by the insurer to decide whether the amputation of the complainant was justified or not.  The doctor who treated the complainant, would not have gained anything by advising unnecessary amputation of his leg.  I am also unable to accept that the complainant got his leg amputated only for the purpose of claiming the benefit under the policy taken by him.  The monetary benefit which the complainant would receive under the policy, could never have been the reason for his getting his leg amputated unless otherwise advised by the doctor. 

6.      As regards the other policies taken by the complainant, the repudiation letter does not even say that the complainant was required to disclose the existing policies or the applications which he had submitted for taking other policies, while applying for an accidental cover from the petitioner company.  The proposal form submitted by the complainant for taking the insurance policy has not been filed to show that he was required to disclose the existing policies or the policies for which he had already applied.  If there was no such obligation on the complainant, the non-disclosure of the other policies would not be material though it would have certainly been material had he been under an obligation to disclose the said policies/obligations in the proposal submitted by him. 

7.      The last ground taken in the repudiation letter was that the accident had not occurred in the manner stated in the FIR.  This, to my mind, would be immaterial so long as the injury was suffered by the complainant in an accident.  There is no evidence to show that the injury, which insisted the amputation of the leg of the complainant, was suffered by him otherwise than in an accident. 

8.      For the reasons stated hereinabove, the concurrent view taken by the fora below does not call for any interference by this Commission in exercise of its revisional jurisdiction.   The Revision Petition is therefore, dismissed.