The burden of proof lies on the insurance company to substantiate claim repudiation due to non-disclosure of pre-existing diseases.

Per; Hon’ble Mr. Justice Sanjay Kumar, President

1.

Present appeal has been filed on behalf of appellant/opposite party for setting aside the judgment and order dated 23.01.2025 passed by the learned District Consumer Commission, Patna in consumer complaint case no.520/2022 whereby and whereunder complaint case has been allowed and appellant has been directed to pay Rs.50,00,000/- (Rs. Fifty lacs) with interest@9% p.a. from the date of repudiation along with Rs.1,00,000/- (Rs. One lac) as compensation for mental agony and Rs.25,000/- (Rs. Twenty Five thousand) as cost of litigation.

2.

DLA had filed a digital application form on 27.05.2021 and submitted a proposal form on the same date. Based on the information provided, the appellant issued the policy on 17.06.2021. The risk commencement date (RCD) was 28.05.2021.

3.

Life assured Binod Sharma purchased a life insurance policy from appellant PNB Metlife Insurance Company Ltd. policy details are as follows:-

4. DLA, Late Binod Sharma, passed away on 18.04.2022, i.e. within 1 year and 18 days from the risk commencement date. Respondent Smt. Gita Devi (Wife and nominee of the insured), submitted a claim intimation on 26.05.2022, and the claim was formally received by the insurer on 05.07.2022.

5. It was an early death claim, the appellant conducted an investigation before processing the claim. During the investigation, it was found that the DLA had a history of kidney disease and liver-related illness for at least 2 years prior to applying for the policy.

6. Several statements from the local Anganwadi worker, ward councillor, and Panchayat officials confirmed that the DLA was suffering from kidney illness and had been under treatment for the same.

7. The proposal form submitted by the DLA at the time of policy issuance incorrectly state ‘No’ to the question regarding pre-existing illnesses. Furthermore, the insured had previously applied for a policy with TATA AIA, which was declined due to underwriting concerns.

8. Appellant repudiated the claim on 29.09.2022, citing material non- disclosure of pre-

existing illnesses, which rendered the policy null and void as per the terms and conditions.

9.

Aggrieved by repudiation complainant filed consumer complaint case before the District Consumer Commission, Patna which was allowed by the impugned order.

10.

Aggrieved by judgment and order dated 23.01.2025 passed by the learned District Consumer Commission, Patna in consumer complaint case no.520/2022 appellant/opposite party has preferred this appeal before the State Commission.

11.

Heard Mr. Atul Anand learned counsel for the appellant.

12.

Neither copy of complaint petition nor written statement nor repudiation letter dated

29.09.2022 has been enclosed along with Memo of Appeal.

13.

Burden to proof that insurance policy was obtained by the policy holder by concealment of pre-existing disease lies upon the insurance company. Allegation is that policy holder had suppressed his illness at the time of submission of proposal form that he was suffering from chronic kidney disease (CKD) and in support of which certificate of Ward Member, Gram Panchayat, Nausha Phulwarisarif, Patna (Annexure-5) statement of Anganwadi Sewika of Gram Panchayat Nausha (Annexure- 6) has been enclosed which does not in any manner establishes that disease policy holder was suffering from any chronic kidney disease (CKD). No medical prescription of any medical practitioner or any document