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GUJARAT STATE CONSUMER DISPUTES REDRESSAL COMMISSION
R.N. Mehta, Presiding Member and P.R. Shah, Member
Bajaj Alliance General Insurance
Company Limited – Applicant
versus
Kanan Pravinbhai Masrani – Respondent
Appeal No.1296 of 2015
Decided on 12.9.2023
Counsel for the Parties:
For the Applicant:Mr. M.J. Shelat, Advocate
For the Respondent:Mr. S.G. Shah, Advocate
IMPORTANT POINT
Stringent duty is imposed on assured to provide all material facts that might influence decision of Insurer—It is duty of assured to disclose all material facts within their knowledge.
Headnote:
Consumer Protection Act, 1986 – Section 15[Consumer Protection Act, 2019 – Section 47] – Insurance – Repudiation of claim on the ground of concealment of pre-existing ailment – Stringent duty is imposed on assured to provide all material facts that might influence decision of Insurer – It is duty of assured to disclose all material facts within their knowledge – There may be circumstances also affecting particular individuals which are not likely to be known to Insurer and which had they been known, have been made subject to specific enquiries – Question as to which information is material to the contract is a wide one – When insurer established prima facie that Company had reason to believe that injury caused to insured is not subsequent to policy but there are probabilities of previous injury – Burden then lies upon complainant to prove that injury was never existed on the date of proposal – Complainant could have established it – Complainant has not discharged its burden whereas insurer has discharged its initial burden – Under such circumstances, order of District Commission is required to be quashed and set aside as there was no case of deficiency in service on part of opponent Insurance Company – Order of District Commission set aside and complaint dismissed. (Paras 9 and 10)
Result: Appeal allowed.
ORDER
R.N. Mehta, Presiding Member—Being aggrieved and dissatisfied with the order dated 15/09/2015 of District Commission Surat (Additional) in complaint No. 735 of 2013 the Insurance Company preferred this appeal under the provisions of Section 15 of Consumer Protection Act, 1986 and submitted that the District Commission has wrongly concluded that the complainant is entitle to claim and it is subject matter of the complaint. It is further submitted that the District Commission has erroneously allowed the complaint contrary to documentary evidence available on record and also ignored settled principles of law. It is further submitted the District Commission has materially erred in saying that the appellant company has not produced a copy of proposal form that was filled in by the complainant for the insurance period from 24/01/2013 to 23/01/2014. It is submitted that the appellant company had already produced copy of proposal form. It is noteworthy that the complainant has not mentioned any previous injury or illness in the said proposal form. It is submitted that the investigator appointed by the company found that the complainant had consulted at Navin Orthopedic Hospital during the October, 2012 and the said fact is also confirmed from the hospital record. The Insurance Company has therefore rightly repudiated the claim. It is also further submitted that the District Forum failed to appreciate that the insured has taken treatment from 06/04/2013 to 08/04/2013 at Navin Orthopedic Hospital for left knee joint ACL repair. However, the insured has not disclosed the fact that the said hospital was previously consulted for treatment in October 2012, November 2012, December 2012 and January 2013 and therefore, the Insurance Company had rightly repudiated the claim.
2. For the purpose of convenience the parties are addressed at its original nomenclature.
3. The complainant had filed a complaint before the District Commission and stated that a policy was taken from the opponent Insurance Company for the period from 24/01/2013 to 23/01/2014, wherein the insurance coverage was available for medical and personal accident up to Rs. 10,00,000/-. It is the say of the complainant that the Insurance Company issued policy schedule but never provided terms and conditions of the policy. It is stated that on 18/02/2013, the insured fell down from the staircase and was taken to Navin Orthopedic and Trauma Centre for the treatment and treatment given at left knee. The complainant submitted claim before the Insurance Company and also provided necessary documents, bills, prescription, discharge card etc. The complainant had claimed Rs. 1,71,910/- from the Insurance Company. It is alleged in the complaint that the Insurance Company vide its letter dated 15/07/2013 repudiated the claim on false ground and, therefore, the complainant had filed complaint before the District Commission.
4. On receipt of notice from the District Commission, the Insurance Company filed reply on record wherein it was contended that the complainant had previously taken the treatment from Navin Orthopedic Hospital but the same fact was never disclosed to the Insurance Company. It is also stated in the reply that the opponent company is liable to make payment under the contract of insurance only when the insured makes full and truthful disclosure in the proposal form. However, in the instant case, the complainant has intentionally not disclosed the fact that treatment was taken from the Navin Orthopedic Hospital and therefore, the Insurance Company was misguided through misrepresentation. The Insurance Company denied that the insured was provided with policy schedule only and terms and conditions were not provided. During the policy period and till the repudiation of the claim, the complainant has never made any grievance for the same. The Insurance Company has denied the fact that the insured had suffered injury on account of falling from the staircase on 18/02/2013 as it c
