IMPORTANT POINT
Pre-existing disease must be proved by documentary evidence.

J.M. Malik, Presiding Member—The present controversy revolves round the question “whether ‘history’, by the illiterate wife of the deceased insured, is a conclusive proof of suppression of an ailment?.

2. Sh. Deepak Kumar Pandya, since deceased, husband of the complainant/respondent, Smt. Hansaben Deepak Kumar Pandya, obtained insurance policy in the sum of Rs.3,60,000/- covering the period from 10.01.2008 to 10.01.2018 for which he has also paid premium amount of Rs. 36,306/-.

3. On 05.07.2008, due to heart attack, Sh. Deepak Kumar Pandya passed away. The complainant filed claim with Sahara India Life Insurance Co. Ltd, one of the petitioners in this case. The petitioner No.1 sent a cheque in the sum of Rs.17,563.96ps to the complainant and repudiated her claim. Complainant sent a Legal notice, but it did not ring the bell. Ultimately, the complainant filed a complaint with the District Forum with the prayer that a sum of Rs.3,60,000/-, along with interest @ 18%, be granted, in her favour. The defence set up by the petitioner was that the insured had suppressed the material fact that he was suffering from heart ailment. The District Forum allowed the complaint and directed the petitioner Nos.1 and 2 to pay Rs.3,42,436/-, to the complainant, with interest @ 8% from the date of filing of complaint till date of payment . It also awarded costs of Rs.5,000/- payable by the petitioners to the complainant.

4. Aggrieved by the order of the District Forum, the insurance company filed appeal before the State Commission. The State Commission affirmed the order passed by the District Forum.

5. Aggrieved by this order, the present revision petition has been filed by the petitioners.

6. We have heard the counsel for the petitioner. He laid emphasis on the ground that the insured had suppressed the material fact. Our attention was invited to the fact that the insured died within six months’ from the date of taking the policy in question. In the proposal form, the deceased had stated that he did not suffer from any ailment. The attention of this Commission is invited to Annexure P-4, where the following questions were asked from the insured:-

QUESTIONS REPLY

A. Proposal Form

3. Q.No. 7-4. ‘Do you use or have ever used tobacco or tobacco products, in any form? If “Yes”, please give the details of the substance and quantity consumed per day”. No

4. Q.No.7-8 ‘Are you presently in good health? If not, please give details’. Yes

6. However, thereafter, it transpired that the deceased was admitted in Adventist Wockhardt Heart Hospital, Surat, Gujarat, on 04.07.2008, wherein the history of the patient was given his wife, the complainant Smt. Hansaben Deepak Kumar Pandya. The relevant portion of the hospital record is reproduced as follows:

ADMISSION HISTORY AND PHYSICAL ASSESSMENT FORM

1. XXXX

2. XXXX

3. XXXX

4. Past History: If yes, since when

Hypertension Yes/No No

Diabetes Yes/No No

Tuberculosis Yes/No No

IDH Yes/No- —?4 years

Dyslipidemia Yes/No No

Jaundice Yes/No No

Others

7. Again, to the question of smoking, the answer was given in “positive”. The learned counsel for the petitioner vehemently argued that this is a clear case of suppression of fact. In another question, regarding description of job, it was mentioned :”To be asked”. The so called history dated 04.07.2008 was ‘thumb-marked’ by the complainant.

8. The entire case of the petitioner hinges upon the above said history. This kind of evidence is exiguous. It carries no value in the eyes of law. The petitioner should have produced some concrete evidence in support of its case. The examination of a Doctor who checked the patient, prior to the obtaining of the policy in question, some treatment papers, some prescriptions, etc., should have been produced. There isno evidence which may go to show that he had ever consulted the Doctor for taking treatment for the said disease. In the absence of solid and unflappable evidence, dallops of mystery surrounds