DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION
Sangita Dhingra Sehgal, (President) and Pinki, Member (Judicial)
Dinesh Kumar Jain —Appellant
versus
M/s Oriental Insurance Co. Ltd. —Respondent
First Appeal No.50 of 2016
Decided on 14.11.2022

IMPORTANT POINTS
(1) Proof of delivery - In the absence of proof of delivery, therefore, Commission cannot rely solely on the Respondent’s statement before the District Commission that it had duly supplied the terms and conditions of policy to the Appellant.
(2) Exclusionary clauses - Unless the insured is duly informed about the terms and conditions of the policy, the exclusionary clauses of the policy cannot be made applicable upon him.
(3) Suppression of information - Suppression of information regarding any pre-existing disease, if it has not resulted in death or has no connection to cause of death, would not disentitle the claimant for the claim.

Headnote:

A. Consumer Protection Act, 1986 – S.15[Consumer Protection Act, 2019 – S.41] – Appeal Against order of District Commission - Services – Medical Insurance – Floater Policy - Repudiation of Claim – Proof of supply of Policy Document - Non Supply of policy Documents - Whether the Respondent has supplied the copy of said policy to the Appellant in order to make him aware about the terms and conditions of the policy – On perusal of the record, the Commission found, that the Respondent has filed the copy of terms & conditions annexed with the subject policy before the District Commission – Thus, failed to find any document pertaining to the proof of service regarding the delivery of terms and conditions attached with the policy to the Respondent. Hence, in the absence of proof of delivery, therefore, Commission cannot rely solely on the Respondent’s statement before the District Commission that it had duly supplied the terms and conditions of policy to the Appellant. [Paras 6, 7].

B. Consumer Protection Act, 1986 – S.15[Consumer Protection Act, 2019 – S.41] – Appeal Against order of District Commission - Services – Medical Insurance – Floater Policy - Repudiation of Claim – exclusionary clauses of the policy – if can be made applicable – Without informing - Held, unless the insured is duly informed about the terms and conditions of the policy, the exclusionary clauses of the policy cannot be made applicable upon him - Returning to the facts of the present case, it is clear that the copy of the terms and conditions containing exclusion clauses was not supplied to the Respondent as no proof of service has been filed by the Respondent before the District Commission to prove that the said terms and conditions were duly supplied to the Appellant - Therefore, exclusionary clauses in the said policy are not applicable in the present case and the contention of the Appellant that no policy documents were provided to him is justified as per the facts of present case. [Paras 8, 9].

C. Consumer Protection Act, 1986 – S.15[Consumer Protection Act, 2019 – S.41] – Appeal Against order of District Commission - Services – Medical Insurance – Floater Policy - Repudiation of Claim – Suppression of material facts – Pre-existing disease - Death connected with the policy - Whether the insured i.e. Complainant’s deceased son has deliberately concealed the material fact of pre-existing disease i.e. Hypertension etc. at the time of obtaining the policy - As per the death summary, the death was due to a sudden cardiac arrest and in-spite of best resuscitative measures, the patient could not be revived - In the present case, the deceased assured was suffering from diabetes mellitus and chronic liver disease when bought to the hospital - But, the death was due to cardiac arrest, thus death is nowhere connected – Therefore, suppression of information regarding any pre-existing disease, if it has not resulted in death or has no connection to cause of death, would not disentitle the claimant for the claim – On facts, Respondent was deficient in providing its services by repudiating the claim of the Appellant on the basis of Pre-Existing Disease - Respondent are directed to pay a sum of Rs. 1,50,000/- (Medical Expenses) to the Appellant along with interest @ 6% p.a. calculated from 26.07.2012 (being the date on which the said claim of the Appellant was provisionally repudiated) till 14.11.2022 (being the date of the present judgment) – Appeal allowed. [Paras 8 to 18]

Result: Appeal allowed.