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2025 Supreme(Online)(SCDRC) 6584
STATE CONSUMER DISPUTES REDRESSAL COMMISSION
Justice Inder Singh Mehta, President, Mr.Partap Singh Thakur, Member, Ms.Yogita Dutta, Member
SBI Life Insurance Co. Ltd., SBI India Insurance Co. Ltd. – Appellant
Versus
Smt.Meena Kumari – Respondent
First Appeal No. : 238/2024
For the Appellants: Mr.Himanshu Kapila
For the Respondent: Mr.K.D. Sharma
Insurers must prove claims of pre-existing illnesses and conduct thorough evaluations to avoid repudiating insurance benefits.
Headnote:(A) Consumer Protection Act, 2019 - Claim repudiation - Absence of proof of pre-existing conditions - Insurer failed to provide adequate evidence to substantiate claims of concealment of material facts. (Paras 17, 18, 19)
(B) Evidence - Insurer's duty to investigate before policy issuance - The court emphasized that it is the insurer's responsibility to conduct due diligence regarding the insured's medical history and obtain necessary evidence. (Paras 15, 16)
Facts of the case:
The complainant's husband purchased a life insurance policy and died thereafter, leading to a disputed claim settlement where the insurer offered only partial payment citing undisclosed prior medical conditions.
Findings of Court:
The insurer did not prove previous ailment or claim concealment; it was determined that they cannot refuse to indemnify the complainant based on insufficient evidence.
Issues: The primary issues were whether the deceased concealed medical history and if the insurer sufficiently proved their claims for repudiation.
Ratio Decidendi: The court ruled that the insurer failed to demonstrate prior ailments, stressing that policy issuance is contingent upon full disclosure.
Result: Appeal dismissed.
| Table of Content |
|---|
| 1. dispute arises from partial payment and claim repudiation based on alleged concealment. (Para 2 , 3 , 4) |
| 2. insurer must provide sufficient proof of pre-existing conditions to deny claims. (Para 15 , 16 , 18) |
| 3. court upholds prior decision due to lack of evidence from insurer. (Para 19 , 20) |
Coram Hon’ble Justice Inder Singh Mehta, President Hon’ble Mr.Partap Singh Thakur, Member Hon’ble Ms.Yogita Dutta, Member.
1 Whether approved for reporting? Yes.
For the Appellants: Mr.Himanshu Kapila, Advocate vice Mr.Manohar Lal Sharma, Advocate.
For the Respondent: Mr.K.D. Sharma, Advocate.
Justice Inder Singh Mehta, President O R D E R Instant appeal is arising out of the order dated
17.05.2024 passed by Learned District Consumer Commission, Hamirpur, in Consumer Complaint No.73/2022 titled Smt.Meena Kumari Versus SBI Life Insurance Co. Ltd. & Anr., whereby, complaint filed by the complainant was allowed and the opposite parties were jointly and severally directed to pay an amount of Rs.5,00,000/- to the complainant alongwith interest @ 9% per annum from the date of the complaint i.e. 04.03.2022 till its realization. The opposite parties were jointly and severally directed to pay compensation to the complainant to the tune of Rs.20,000/-, besides litigation costs quantified as Rs.10,000/-.
Brief facts of Case:
2. Brief facts of the case are that on 19.05.2018, husband of complainant Sh.Surinder Kumar (deceased life assured) purchased insurance policy No.IK670551906 from the opposite parties/insurance company. During the subsistence of policy, husband of complainant expired on 01.09.2019. The complainant being nominee and legal heir of her deceased husband, lodged the claim with the opposite parties/insurance company, but the opposite parties have given only amount of Rs.2,00,000/- and it was assured that balance amount will be sent to the complainant later on, but thereafter, no amount was given to the complainant and repudiated the claim of the complainant. The said act on the part of the opposite parties amounts to deficiency in service.
Hence, this complaint.
3. The opposite parties/insurance company filed reply to the complaint and stated that deceased life assured had committed breach of principle of utmost good faith by suppressing the material fact that he was suffering from Liver Disease and was taking treatment for the same prior to the date of proposal form. At the time of signing the proposal form, deceased life assured replied in negative to the relevant questions, but the record reveals that he was suffering from Liver Disease and was taking treatment for the same prior to the date of signing the proposal form. The deceased life assured has deliberately suppressed this material fact from the insurance company and obtained the policy fraudulently. A prayer for dismissal of complaint was made.
4. In rejoinder, the complainant has reiterated the contents of complaint and refuted the objections put forth by the opposite parties.
5. Thereafter, the parties led evidence in support of their pleadings.
6. After hearing the parties, learned District Commission allowed the complaint of the complainant against the insurance company.
7. Feeling aggrieved by the order of learned District Commission, the appellants/insurance company have preferred the instant appeal before this Commission.
8. Arguments heard on behalf of the parties and perused the record carefully.
9. Learned counsel of the appellants/insurance company has submitted that husband of the complainant has taken SBI life insurance policy from the appellant-company on 19.05.2018. He further submitted that the deceased life assured died on 01.09.2019. He further submitted that claim of the complainant was repudiated on the ground of concealment of pre-existing disease, as life assured was suffering from alcoholic liver disease for the last four years and was taking treatment for the same. He further su
