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DELHI STATE CONSUMER DISPUTES
REDRESSAL COMMISSION, NEW DELHI
Hon’ble Mr. Justice A.P. Chowdhri, President;
Ms. S. Brar & Mr. Desh Bandhu, Members
THE ORIENTAL INSURANCE CO. LTD.—Appellant
versus
MISS AMISHA JAIN—Respondent
Case No. A-264 of 1995—Decided on 26.3.1996

Counsel for the Parties :
For the Appellant :Mr. G.N. Rathi, Advocate.
For the Respondent:Mr. Sanjay Kumar & Mr. S.C. Aggarwal, Advocates.

Headnote:Consumer Protection Act, 1986 - Section 15 - Insurance - Complainant obtained medi-claim policy jointly with her minor daughter - Daughter found to have hole in heart - Operation carried out - Claim lodged - Repudiated - Complaint filed - Opposite Party resisted claim on ground that claim not bona fide - Father concealed material fact with regard to heart problem of minor - District Forum allowed complaint - Appeal - Onus of proving suppression of material information on Insurance Company - Instances brought on record show that symptoms appear late - Not easy to detect Cannot be said that child must have shown significant symptoms and father concealed those facts - No merit in appeal.

       Held: The instances brought on record show that symptoms appear late and they are not easy to detect. Moreover the symptoms would depend on the size of the hole and the physical activity in which the person concerned is engaged. In other words inspite of the fact that VSD is a congenital defect it cannot be said that the child must have shown significant symptoms and the father concealed those facts while submitting the proposal form.

       We find no merit in the appeal and dismiss the same. There will be no order as to costs in appeal. A copy of this order be communicated to both the parties as well as District Forum-II. (Paras 8 & 11)

       Result: Appeal dismissed.

ORDER

Mr. Justice A.P. Chowdhri, President— Facts material for the purpose of this appeal may be stated as follows :

2. Mr. Pankaj Jain obtained a medicalim policy jointly with her minor daughter Amisha (9) from the Oriental Insurance Company, opposite party-2, the 3.8.91. It was renewed on 24.8.92. Amisha fell ill during her visit to her maternal grand parents in Delhi in April, 1993. She was taken to Dr. A.K. Mittal, who suspected some heart problem and advised the grand father of the girl to take her to hospital. She was taken to All India Institute of Medical Sciences, New Delhi on 4.6.93 where she was advised to undergo ECHO test and angiography. As the waiting list at AIIMS was rather long, the said tests were carried out at G.B. Pant Hospital. She was found to be a case of hole in the heart. She was admitted to AIIMS on 21.6.93 where an operation was carried out on 23.6.93. A claim for Rs. 36,000/- odd was lodged with the Insurance Company on 6.9.93. It was repudiated on 3.5.94. The present complaint was filed on 13.5.94 claiming payment of Rs. 36,074/- alongwith interest and compensation to the tune of Rs. 50,000/-.

3. The complaint was resisted mainly on the ground that the claim was not bonafide and the father of the minor had concealed the material fact with regard to the heart problem which had been found to be congenital. The categorical case of the father of the minor, on the other hand, was that he had no knowledge about the hole in the heart of the child and it was only discovered during the course of investigations carried out in May/June, 1993 following her illness.

4. On a consideration of the matter, the District Forum-II held that there was no concealment of the facts in the proposal and that the opposite party had failed to establish that the existence of hole in the heart was known to the proposer at the time of taking the mediclaim policy. The opposite party was therefore, directed to pay the aforesaid sum of Rs. 36,074/- alongwith interest @ 18% p.a. w.e.f. 1.11.93 till the date of payment besides Rs. 5,000/- as compensation and costs. It was further directed that if the opposite party failed to pay the said amount within one month, the amount would carry interest @ 24% p.a. Aggrieved by the order, the opposite party had preferred this appeal.

5. We have heard Mr. G.N. Rathi, Advocate for the appellant and Mr. Sanjay Kumar and Mr. S.C. Aggarwal, Advocates for the respondent.

6. The contention of Mr. G.N. Rathi learned Counsel for the appellant is that admittedly Amisha Jain was a case of VSD i.e. with hole in the heart since birth. That being so the disorder must have produced certain symptoms. The symptoms could not escape the notice of the parents and therefore the irresistible conclusion was that the condition of the heart, which was a very material fact, was kept back at the time of submitting the proposal. Mr. Rathi pointed out that admittedly Amisha is one of the twins and no similar insurance policy had been obtained for the other child. The next contention of Mr. Rathi is that before the District Forum an application was made for production of certain documents and for cross-examination of Dr. A.K. Mittal. The same was disallowed by the District Forum by order dated 27.1.95. This had greatly prejudiced the decision of the case and his aforesaid prayer be allowed even at this stage.

7. We have carefully considered the contentions of Mr. Rathi. It cannot be disputed that the onus of proving supression of material information is on the Insurance Company. It is settled law that suspicion cannot take the place of proof. From the material placed on record, it is clear that symptoms appeared later, say around the age of 10-12. At the relevant time Amisha was 9. From the newspaper cuttings placed on record it was reported that Evander Holyfield, who was a heavyweight champion was discovered to have a tiny hold in his heart which was discovered at the age of 31, after he had retired as heavyweight champion. An











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