The Insurance Company's repudiation of claims based on unsubstantiated evidence is invalid; the burden of proof lies with the insurer to establish any pre-existing condition.

ORDER

1. This Appeal has been filed by the Complainants who lost the battle before the Chhattisgarh State Consumer Disputes Redressal Commission in Consumer Complaint No. 02 of 2011. The Complaint was dismissed on 30.04.2014 holding that the insured had suppressed the material fact of a pre-existing ailment while acquiring a life insurance policy from the Respondent Birla Sun Life Insurance Company.

2. The Appellants / Complainants are the legal heirs of Late Mr. Saurabh Selarka who had been insured under a Dream Plan Life Insurance Policy. He unfortunately died on 02.12.2009 after 81/z months of acquiring the policy.

3. The claim was set forth in respect of the risks and benefits under the policy where the coverage was Rs.48,92,000/- and had been issued on 28.03.2009. The Insurance Company appointed a claim investigator, Mr. Sanjay Aggarwal who made enquiries and on the basis of such investigation the claim was repudiated on 04.03.2010. The letter of repudiation is extracted herein under:JIHGFEDCBA

However, our investigations have established that the Life Assured was suffering from hypertension, vertigo and was taking treatment for the same prior to the application for insurance and Medical Examiner's Report. Hence, we are satisfied that the aforesaid replies in the application for insurance and Medical Examiner's report are false. We also note that the Life Assured has died due to complications of the above mentioned ailments.

Further our investigations have also established that the Life Assured had grossly overstated his income in the application for insurance. Hence the reply to question No.1 (F) in the application for Insurance is false.

If the true and correct facts pertaining to Life Assured's past medical history and annual income were disclosed at the proposal stage, the company would have not issued the Policy on the existing terms.

Since the CIHoGmFpEaDnyC hBaAs been misled to issue the Policy, we are, hereby repudiating our liability under the aforesaid Policy. However, we have received the premium amounting to Rs.2.921.70 (Rupees Two Thousand Nine Hundred Twenty One and Raise Seventy only), subsequent to the date of death, which is being refunded herewith, vide our Cheque No.404687 dated 4 March 2010.

If you feel that your case deserves further consideration, you may register your dissatisfaction regarding the same, justifying the grounds for reconsideration, with the Claims Redressal Machinery at the following address:-

4. The repudiation letter records that on investigations it was found that the insured was suffering from Hypertension and Vertigo and was being treated, and that he died due to complications of the above ailments. The second ground taken is that the assured had over stated his income in the application for insurance and therefore his reply was incorrect while filling up of the proposal form.JIHGFEDCBA - S'--

5. The State Commission examined the issues and the material collected by the investigator was also assessed. The said material included a certificate issued by one Dr. Ashish Dubey dated 17.02.2010. The same is extracted herein under:

6. Relying on the said certificate, and holding that the testimony of Dr. Ashish Dubey in support of the said document it was evident that the insured had suppressed his pre-existing diseases of hypertension and vertigo and the same being a material fact, the claim was rejected by the State Commission. Accordingly the repudiation letter was upheld.

7. The State Commission also commented upon the sharp increase in the insured amount which was initially for Rs. 1,08,200/- that was enhanced to Rs.48,92,000/-. The State Commission doubted the same and treated it to be suspicious.

8. Assailing the ord