The central legal point established in the judgment is the importance of disclosure of material facts in the insurance declaration form and the justification for repudiation of claims based on non-disclosure of pre-existing conditions.

Mr. Justice Sunil Kumar Garg, President—This appeal under Section 15 of the Consumer Protection Act, 1986 (hereinafter referred to as “the Act of 1986”) has been filed by the appellant against the order dated 25.5.2004 passed by the learned District Forum, Jaipur-II, Jaipur in Case No. 27/2004 by which the complaint filed by the complainant-respondent No. 1 under Section 12 of the Act of 1986 was allowed in the manner that the appellant-New India Assurance Company limited was directed to pay to the complainant-respondent No. 1 a sum of Rs. one lac as claim amount within two months failing which the complainant respondent No. 1 would be entitled to get interest @ 9% p.a. from the date of order till payment was made and the appellant was further directed to pay to the complainant respondent No. 1 a sum of Rs. 5,000 as amount towards mental agony and Rs. 1,000 as cost of litigation.

2. The necessary facts giving rise to this appeal are as follows :

On 3.1.2004, the complainant-respondent No. 1 had filed a complaint under Section 12 of the Act of 1986 against the appellant and present respondent No. 2 before the District Forum, Jaipur-II, Jaipur stating inter alia that he took medi-claim insurance policy from the appellant on 14.9.1999 for the period from 14.9.1999 to 13.9.2000 and that policy was not renewed again and it was valid for the period from 16.1.2002 to 15.1.2003. It was further stated in the complaint that thereafter, that policy was again got renewed by the complainant-respondent No. 1 and mediclaim policy bearing No. 330203/48/2/04126 for Rs. one lac was issued by the appellant for the period from 17.1.2003 to 16.1.2004. It was further stated in the complaint that premium of that policy was being paid by the complainant-respondent No. 1 regularly in the office of the appellant. It was further stated in the complaint that on 20.6.2002, the complainant respondent No. 1 became ill suddenly, as a result of which, he was got admitted in the Saket Hospital, Jaipur for treatment, from where he was discharged on 22.6.2002 and some trouble in the chest was found there. It was further stated in the complaint that thereafter, on 8.7.2002, the respondent No. 1-complainant got his checkup in the Tongia Heart and General Hospital, Jaipur where he was advised for CABG as some trouble in the arteries was found. Thereafter, the complainant-respondent No. 1 approached the Escorts Heart Institute and Research Centre, New Delhi where he had remained admitted from 16.2.2003 to 26.2.2003 and bypass surgery of his heart was done there and for that, a claim for Rs. one lac was preferred by the complainant respondent No. 1 before the appellant, but the same was repudiated by the appellant stating inter alia that complainant-respondent was patient of hypertension and IHD for last 3 years and his CAG was done in Tongia Heart Hospital, Jaipur revealing double vessel disease admitted in EHIRC for CAGB and, thus, claim was repudiated on the following reasons:

“Patient is covered under policy on 17.1.2002. According to Clause 4.2 which states that any such disease which have been in existence at the time of proposing this insurance is an exclusion. Hence claim stands non-payable.”

Thereafer, the present complaint was filed by the complainant-respondent.

A reply was filed by the appellant and its case was that there was no dispute on the point that for the first time, mediclaim insurance policy was issued by the appellant in favour of the respondent No. 1 complainant for the period from 14.9.1999 to 13.9.2000 for himself as well as his other family members and, thereafter, it was got renewed from 14.9.2000 to 13.9.2001, but after the expiry of the policy on 13.9.2001, the complainant respondent No. 1 had submitted a fresh proposal for obtaining new mediclaim policy from the appellant in the month of January, 2002 and in response of that, a proposal form was taken from the complainant respondent No. 1 on 17.1.2002 and in that proposal form, the comp