1.      This revision petition assails the order dated 03.02.2017 in Appeal No. 871 of 2014 of the Punjab State Consumer Disputes Redressal Commission, Chandigarh (in short, the ‘State Commission’), arising from order dated 23.05.2014 of the District Consumer Disputes Redressal Forum Amritsar (in short, ‘the District Forum’) in Complaint no.371 of 2013.

2.     The facts of the case, in brief, according to the petitioner are that the respondent’s husband late Vijender Pal Mahajan had obtained an insurance policy, Aegon Religare Health Plan for himself and the respondent on 13.03.2012 with a tenure of 5 years for a sum assured of Rs.4,90,000/- with annual premium of Rs.34,705/-. A medical claim for reimbursement in respect of the respondent was submitted since the respondent was hospitalised in Medanta Medicity Hospital, Gurgaon on 20.04.2012 and was found to be suffering from severe Aortic Stenosis (AS) for which she was operated for aortic value replacement on 23.04.2012. As per the discharge summary dated 29.04.2012 she was diagnosed with Aortic Stenosis, Type II Diabetes Mellitus and hypothyroidism during hospital stay. The claim was repudiated by the petitioner as per clause 5.2 on the ground that the hospitalisation fell within the waiting period of 90 days of the policy and was also excluded under clause 6 of the policy relating to pre-existing medical conditions or their resultant complications unless specifically accepted by the Company. The petitioner claims that hospitalisation occurred within 34 days of the commencement of the policy and, therefore, it was correctly rejected.

3.     The respondent approached the District Forum by way of complaint which was dismissed on the ground that as per clause 5.2 of the policy, insured was not entitled to file claim for the treatment of any disease within 90 days from the date of commencement of the policy except in the case of an accident. The State Commission, on appeal, however, held that no cogent evidence had been placed on record by the petitioner for having dispatched the policy documents and the terms and conditions of the standard policy, wherein exclusion clause was included, were not disclosed to the appellant. The appeal filed by the respondent was accepted and the order of the District Forum was set aside.

4.     This revision petition impugns this order of setting aside the order of the State Commission on the grounds that the State Commission has erred in setting aside the order in holding that there was no evidence to prove the delivery of the terms and conditions of the policy by Blue Dart Courier on 17.03.2023 as claimed by the petitioner; the stipulation of waiting period of 90 days was ignored by the State Commission; the fact that the respondent paid the renewal premium was proof that the terms and conditions were delivered to the respondent that there was no date of printing on the policy. It is contended that this Commission in Gurmail Singh vs Aviva Life Insurance Company India Ltd., and Ors. RP no.1051 of 2016 had held that IRDA guidelines do not mandate printing the date on the documents containing the terms and conditions of the policy, and that the impugned order admitted the claim for the entire amount of Rs.4,04,039/- whereas the policy was  a fixed benefit plan and not an indemnity plan under which the admissible amount that can at best be admitted is Rs.1,02,000/- only. It is also averred that there was suppression of material facts while obtaining the policy, since Diabetes Mellitus and Hypothyroidism with severe Aortic Stenosis would have been pre-existing medical conditions as these illnesses do not occur overnight and are progressive disease. Reliance was placed on this Commission’s judgment in the case of Life Insurance Corporation of India vs Smt Minu Kalita,  III (2002) CPJ 10 (NC) which held that the contract of insurance is based on good faith and concealment of information is violative of those principles. The petitioner has also relied upon the judgment of the Hon’ble Supreme Court in the case of Satwant Kaur Sandhu vs New India Assurance Co. Ltd., in Civil Appeal no. 2776 of 2002 decided on 10.07.2009 which upheld ‘ubberimae fide’ as the basis of an insurance contract.

5.     I have heard the learned counsel for the parties and have perused the records carefully.

6.     The petitioner’s case is that the claim of the respondent that the policy document was not received by him and the arguments of the respondent does not merit consideration in view of the proof of delivery by Blue Dart Courier having been produced by him. According to him, the State Commission has erred in holding that delivery had not been effected. He also submits that the claim was within 90 days of the policy and was clearly excluded under clause 5.2 of the policy. Non disclosure of pre-existing illness under clause 6 of the policy amounted to suppression of material facts by respondents which was violative of the principles of uberrimae fide which is central to the contract of insurance.

7.     Learned counsel for the respondent has argued that the policy with the terms and conditions had not been delivered to the respondent. It is argued that the petitioner has not been able to prove that delivery by Blue Dart Courier was actually made since there are different dates on the documents produced and no evidence of the person who either delivered or the person who received the policy has been produced as evidence. Therefore, in the absence of the terms and conditions having been dispatched and disclosed to the respondent, the petitioner cannot deny the benefit of hospitalisation and medical reimbursement claimed since the policy documents had not been delivered to him.

8.     The respondent argued that the date of the delivery of the policy by Blue Dart not been incorrectly shown and the two documents produced by the petitioner indicated two different dates, i.e., 28.06.2017 and 13.03.2012. No original proof of delivery has been produced and no affidavit of the person who booked the courier or the person who delivered the policy had been brought on record. Therefore, the respondent’s averments that the terms and conditions were not in his knowledge were correctly upheld by the State Commission. It is argued that once the policy has been admitted according to the respondent, full claim needs to be allowed.

9.     From the foregoing it is apparent that the petitioner issued the said policy to the respondent and her late husband. The claim of the respondent was turned down on the ground that it was excluded under the waiting period of 90 days. It is also argued by the petitioner that in view of the respondent having been diagnosed with Diabetes Mellitus with Hypothroidism and having been operated for Aortic Stenosis, which are progressive diseases, there was a violation of the principles of ubberimae fide in not disclosing the pre-existing diseases and therefore, constituted suppression of material facts before obtaining the policy. On the contrary, the respondent’s argument is that the terms and conditions of the policy were not made known to him and that the policy document was never delivered to him. The documents relied upon by the petitioner are contested by the respondent on the ground that no evidence had been led at the trial stage to prove the delivery of the policy containing the terms and conditions to the respondent. It is also argued that there was no suppression of material facts as the disease were discovered during hospitalisation as per discharge summary.

10.   The insurance policy of Aegon Religare Health Plan issued by the petitioner is not in dispute. What is in dispute is whether the policy was delivered to the respondent or not and whether there was concealment of material facts. The State Commission in its order on the basis of documents produced before it has concluded that the policy document had not been delivered to the respondent and, therefore, in the absence of disclosure of the policy conditions, allowed the claim of the respondent holding that he was not aware of the waiting period. From the record it is evident that the petitioner has produced two documents with regard to delivery of the policy by Blue Dart Courier and has not brought on record the evidence of the person who dispatched or the person who delivered the same to the respondent. As regards the issue of concealment of material facts, as per the hospitals Discharge Summary, Diabetes Mellitus with Hypothyroidism were detected while the life assured was admitted in the hospital. The argument that it was a known pre-existing disease known to the respondents therefore, cannot be accepted. The policy was also not approved after a proper medical examination by the petitioner. For both these reasons, the petition is liable to be disallowed. The State Commission has allowed the claim for a sum of Rs.4,04,039/-. The petitioner has also submitted that the policy was not an indemnity scheme but a fixed benefit plan under which the claim could have been at best admitted for Rs.1,02,000/-.

11.   The policy has been concluded by the State Commission to have not been delivered to the respondent since it is not based on cogent evidence. In the absence of non-disclosure of the terms and conditions of the policy, the respondent has claimed that the policy be treated as not having been disclosed to him. The respondent’s contention that the policy is violative of the principle of ubberima fidei  since the respondent concealed material facts does not sustain as the medical discharge summary has recorded that the LA was suffering from Diabetes Mellitus, Hypothyroidism and Aortic Stenosis was detected only in the hospital. The conclusion that the illnesses was pre-existing in conjectural and based on surmise since no evidence has been brought on record to prove this contention. For the aforesaid reasons, the denial of the claim of medical reimbursement is a deficiency in service on part of the petitioner. The revision petition is, therefore, liable to fail.

12.   In the result, the revision petition is found to be without merit and is accordingly dismissed. The order of the District Forum is affirmed.