The central legal point established in the judgment is the burden of proof on the insurance company to establish the suppression of material facts in the insurance proposal form and the importance of providing credible medical evidence.

ORDER

Mrs. Vineeta Rai, Member - This revision petition has been filed by Sushil Kumar Jain (hereinafter referred to as the Petitioner ) being aggrieved by the order of the State Consumer Disputes Redressal Commission, Haryana (hereinafter referred to as the 'state Commission') in Appeal No. 255/2005 wherein the United India Insurance Co. Ltd. and Ors. were Respondents.

2. In his complaint before the District Forum, Petitioner had submitted that he along with his family members have got themselves insured with the Respondent/Insurance Company under the Group Mediclaim Insurance Cover from 28.9.2001 to 27.9.2002 for which a premium of Rs. 8,870 was paid. Under this policy, Respondent/Insurance Company undertook to reimburse any medical expenses incurred in respect of any medical treatment which insurers may have to undergo during the validity of the policy. Respondent was detected with a heart problem and was treated at Mukat Hospital, Chandigarh and Fortis Heart Institute at Mohali and he spent Rs. 1,32,335 for his treatment in the above two hospitals. He, therefore, lodged a claim with the Respondent/Insurance Company. However, the Respondent/Insurance Company cancelled the policy by citing that Petitioner had "breached utmost good faith" by suppressing material facts about his previous diseases. Petitioner denied this contention of the Respondent and, therefore, filed a complaint before the District Forum on grounds of deficiency in service and requested that the Respondent/Insurance Company be directed to pay the Petitioner, Rs. 1,32,335 towards medical expenses incurred by him with interest @ 15% per annum and Rs. 3 lakh as compensation for mental agony and harassment beside litigation cost.

3. Respondent/Insurance Company on the other hand stated that the policy was rightly cancelled because the Petitioner in the insurance proposal form had suppressed material facts regarding his health by not stating in the Proposal Form that he had been suffering from diabetes mellitus, hypertension and was a heavy smoker. These facts came to light in the discharge summary from the two hospitals where he undertook treatment for which he had filed the present claim.

4. The District Forum after hearing the parties and considering the evidence on record and relying on several judgments including of the Apex Court in New India Insurance Co. Ltd. v. H.J.S. Bhatia, 2004 (1) Con.LT 489, allowed the complaint by observing that the Respondent had not been able to prove beyond reasonable doubt that the Petitioner had suppressed any material fact pertaining to his previous medical condition and even the medical expert who examined the Petitioner prior to his taking the mediclaim policy, had not indicated that the Petitioner suffered from any diseases. Thus, the claim was repudiated by the Respondent/Insurance Company on false and fictitious grounds. District Forum, therefore, directed the Respondent to pay the Petitioner, Rs. 1,32,335 on account of medical expenses incurred by him on his treatment with interest @ 10% from the date of repudiation of claim till realization, Rs. 1,000 as compensation for mental agony and harassment and Rs. 500 as litigation costs.

5. Aggrieved by this order, Respondent filed an appeal before the State Commission which allowed the same by stating that as per the documents produced by the Respondent/Insurance Company from Mukat Hospital and Fortis Hospital, it was established that the history of his past ailments was furnished by the Petitioner himself and the fact of his pre-existing diseases was also established from the investigation report of Capt. A.N. Chopra, the Investigator appointed by the Respondent. Therefore, even though Respondent was not able to file any other evidence including documents with regard to the treatment which the Petitioner may have undergone for his pre-existing diseases, since Petitioner himself had given facts pertaining to these diseases, it was sufficient to conclude that the Petitioner was