This Revision Petition has been filed by the Petitioner Sunil Kumar Sharma against the order dated 23.07.2013 of the State Consumer Disputes Redressal Commission, Rajasthan, (in short ‘State Commission’) passed in Appeal no.1758 of 2011.

2.      Brief facts of the case are that on 09.09.2008 Smt. Pushpa Devi put her thumb impression before Respondent No.2 on the proposal form duly filled by the agent.  The Insurance Company issued Life Insurance Policy No.U014764840 for Rs.7,50,000/-.  Her son Sunil Kumar Sharma was nominee in the Policy. On 16.11.2009, the insured Smt. Pushpa Devi suffered from pneumonia.  She was taken to Riyabadi Hospital and subsequently was shifted to Jawahar Lal Nehru Hospital, Ajmer where she died.  On 12.01.2010, the nominee filed Insurance Claim, along with all required information and original documents after giving intimation of death of Smt. Pushhpa Devi.  The Insurance Company repudiated the claim on the ground that the insured concealed the fact that she was suffering from diabetes mellitus and high blood pressure at the time of filing the proposal form.  On 05.05.2010, Sunil Kumar Sharma submitted an application to the Insurance Company to reconsider the Insurance Claim, which was not considered. On 01.11.2010, Sunil Kumar Sharma filed Complaint No.441/2010 before the District Consumer Forum, Ajmer (in short ‘the District Forum) and prayed to award Insurance Claim amount of Rs.7,50,000/-, Rs.50,000/- for physical, economical and mental loss, Rs.5,000/- each towards travelling and litigation costs. He also sought interest @ 18% p.a. on the above amount.

3.      The Complaint was resisted by the Opposite Party/Insurance Company by filing written statement.  It was stated that the insured had concealed material information in respect of her health while filing the proposal form. The Deceased Life Assured (DLA) was suffering from diabetes for the past 20 years and hyper tension, as is evident from the bed head ticket of Jawahar Lal Nehru Hospital, Ajmer, where she was admitted on 03.11.2009 and finally died on 16.11.2009. 

4.      The District Forum, vide its order dated 07.07.2011, allowed the Complaint and directed the Respondent/Insurance Company to pay Rs.7,50,000/- with interest @ 9% from the date of filing of the claim before the Insurance Company and Rs.2,000/- as cost of litigation. 

5.      Aggrieved by the order of the District Forum, the Insurance Company preferred Appeal No.1758 of 2011 before the State Commission and the State Commission, vide its order dated 23.07.2013, allowed the Appeal of the Insurance Company and set aside the order of the District Forum.

6.      Hence the present Revision Petition.

7.      Heard the Learned Counsel for both the Parties and carefully perused the record.  Learned Counsel for the Petitioner stated that the insured was not suffering from diabetes before filing the proposal form.  The bed head ticket had not been proved by any doctor or any authority of the hospital and therefore the District Forum ought not to have relied upon the bed head ticket.  Only a photocopy was filed by the Insurance Company and without any affidavit of the concerned doctor or any authority of the hospital or without any examination-in-chief, the same cannot be accepted.  The Insurance Company had not filed any documents prior to the date of the Proposal, showing any treatment record of the insured for diabetes.  The onus to prove that any material information had been concealed by the Proposer lies with the Insurance Company and the Insurance Company failed in providing any cogent evidence of the same.  The State Commission wrongly relied upon bed head ticket.  The Learned Counsel stated that it is not clear as to who had recorded this observation and on whose instruction. The State Commission had presumed that this information might have been given by the patient herself or her relative, but the fact is that the Proposer was not suffering from diabetes before filling the proposal form.  Simply on the basis of some entry on the bed head ticket, the genuine Insurance Claim of the nominee of the DLA cannot be rejected and particularly when the bed head ticket had not been proved before the District Forum or the State Commission.

8.      On the other hand Learned Counsel for the Respondent/Insurance Company stated that bed head ticket is an authentic document of the treatment record of the hospital where the insured was admitted from 03.11.2009 till 16.11.2009, when the patient died.  In the bed head ticket, it was clearly recorded under the column of past history that the “DM for 20 years, patient is on insulin”.  The doctor recording this observation in the bed head ticket had no enmity with the patient and would not have recorded such an observation on his own.  The information must have been provided by the patient herself or by some relative of the patient. The information, therefore, cannot be treated as unreliable.  In the Doctor’s certificate, the cause of death had been reported as “septicemia”.  In the column of other disease, diabetes mellitus is also recorded.  It is wrong to say that the patient died of pneumonia, as alleged by the Complainant.  Septicemia has a direct relationship with diabetes and diabetes increases the risk of septicemia.  From the cause of death also, the possibility of patient suffering from diabetes for a long time is confirmed. Learned Counsel further stated that the bed head ticket was from a Government Hospital and cannot be disputed.  There was no necessity of proving the bed head ticket.  Thus, it is clearly proved that the proposer had concealed material information in respect of her disease while filing the proposal form.  The Learned Counsel further argued that the patient was also suffering from hyper tension as recorded in the “Past history”.  Thus, the repudiation of the Insurance claim by the Company was totally justified. 

9.      The Learned Counsel for the Respondent stated that this Commission had relied on the bed head ticket in Revision Petition No.210 of 2018, Tata AIG Life Insurance Co. Ltd. Vs. Smt. Mampi Dhar (Ghosh) & anr., decided on 27.07.2020 (NC) and allowed the Revision Petition of the Insurance Company, setting aside the concurrent orders of the Fora below. The Learned Counsel emphasized that bed head ticket was sufficient to prove the concealment of information and discharge summary of the patient was not really required.  

10.    I have carefully considered the arguments advanced by the Learned Counsel for both the Parties and have examined the material on record. The Insurance Company had relied on bed head ticket of the Jawaharlal Nehru hospital for the period 03.11.2009 till 16.11.2009, when the insured died. This bed head ticket was even not a certified copy issued by the hospital, nor the same had been proved by the concerned doctor or any authority of the hospital, either in examination in chief or by way of an affidavit. The repudiation letter was on the ground that the insured was suffering from the diabetes for the last 20 years. The Complainant had mentioned in the Complaint itself that his mother was not suffering from diabetes prior to filing the proposal form. Under these circumstances, the onus lies on the Insurance Company to prove that the insured was suffering from diabetes prior to filing the proposal form. The bed head ticket mentioned under the column of past history “DM for 20 years, the patient is on insulin”. As this document is part of the record of the hospital and it's copy was not provided to the patient, the patient or the family members may not be aware about the exact contents of the bed head ticket. A discharge summary is generally provided to the patient or the family members when the patient is discharged from the hospital or if the patient dies, a discharge cum death summary is given to the family members of the patient. As the bed head ticket was not provided to the Complainant, there was no occasion for the Complainant to know the contents of this bed head ticket and to get it rectified, if something incorrect was recorded in it. The Insurance Company had not filed the discharge summary to prove that the patient was suffering from diabetes for last so many years. The Insurance Company had not filed any other document, either a treatment prescription or any other admission details, in any other hospital where the patient was treated for diabetes during the past 20 years. It would have been a clear proof that the patient was suffering from diabetes prior to filing of the proposal form. On the basis of one entry in the bed head ticket, which had not even been proved by either the doctor or any other staff of the hospital or even duly certified by the hospital authorities, particularly when the fact of diabetes was denied by the Complainant in the Complaint itself, the Insurance Claim of the Complainant cannot be repudiated.

11.    It is further seen that the doctor’s certificate mentioned the following:-

12.    From the above, it can be seen that the treating doctor had not mentioned the duration of the diabetes in this certificate and thus the patient’s suffering from diabetes for last 20 years is not corroborated from the Doctor's certificate. Here it is important to note that the bed head ticket is generally prepared by some junior doctor, whereas the doctor’s certificate is given by the treating doctor and is more authentic.

“Insurance- Mediclaim-Reimbursement- Present Petition filed for appropriate directions to respondent to reimburse expenses incurred by him for his medical treatment, in accordance with policy of insurance- Held, there is no dispute that diabetes was a condition at time of submission of proposal, so was hyper tension-Petitioner was advised to undergo ECG, which he did- Insurer accepted proposal and issued cover note- It is universally known that hypertension and diabetes can lead to a host of ailments, such as stroke, cardiac disease, renal failure, liver complications depending upon varied factors-  That implies that there is probability of such ailments, equally they can arise in non-diabetics or those without hypertension- It would be apparent that giving a textual effect to Clause 4.1 of policy would in most such cases render mediclaim cover meaningless- Policy would be reduced to a contract with no content, in event of happening of contingency- Therefore Clause 4.1 of policy cannot be allowed to override insurer’s primary liability- Main purpose rule would have to be pressed into service- Insurer renewed policy after petitioner underwent CABG procedure- Therefore refusal by insurer to process and reimburse petitioner’s claim is arbitrary and unreasonable- As a state agency, it has to set standards of model behaviour; its attitude here has displayed a contrary tendency- Therefore direction issued to respondent to process petitioner’s claim, and ensure that he is reimbursed for procedure undergone by him according to claim lodged with it, within six weeks and petition allowed.”

15.    In RP No.4461 of 2012, Neelam Chopra Vs. Life Insurance Corporation of India &Ors., decided on 08.10.2018, (NC), it was held that:

“11.   From the above, it is clear that the insurance claim cannot be denied on the ground of these life style diseases that are so common. However, it does not give any right to the person insured to suppress information in respect of such diseases.  The person insured may suffer consequences in terms of the reduced claims.

14.    Moreover, the non-disclosure of information in respect of this life style disease of diabetes, will not totally disentitle the complainant for indemnification of the claim in the light of the judgement of Hon’ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., (supra).”