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2025 Supreme(Online)(SCDRC) 8295
STATE CONSUMER DISPUTES REDRESSAL COMMISSION
K. Ranga Rao, Presiding Officer Member, R. S. Rajeshree, Member
Jangam Raghunath Gowd – Appellant
Versus
Oriental Insurance Company – Respondent
CC.NO. 86 OF 2020
For the Appellants/Petitioners: KRR Associates
For the Respondents: S. Satyananada Rao
An insurance company bears the burden of proving a pre-existing condition to justify claim repudiation. Such evidence must be cogent and cannot rely on retrospective, non-specialist opinions to override official fitness certifications issued by regulatory authorities at the time of policy inception, especially when the insured performed professional duties.
Headnote:(A) Consumer Protection Act, 2019 - Section 47(1) - Insurance - Loss of License - Repudiation of claim on ground of pre-existing disease - Burden of proof - Held, when an Insurance Company repudiates a claim, the onus is on the insurer to justify the repudiation by cogent and convincing evidence. An insurance company cannot be permitted to travel beyond the grounds of repudiation mentioned in the repudiation letter by adding new bases. The reliance on a medical opinion from a panel expert, which contradicts the official assessment by government-certified aviation medical specialists who had previously certified the insured as fit, is insufficient to justify repudiation without concrete documentary evidence to the contrary. (Paras 6)
(B) Insurance Policy - Interpretation - Terms and conditions - Where premium is collected and policy is issued based on regular medical fitness assessments required for professional licensing, subsequent rejection of claims based on speculative assumptions regarding the commencement of an illness prior to policy inception, despite the insured having performed professional duties during the policy period, is unsustainable. (Paras 5, 6)
Facts of the case:
The complainant, a commercial airline pilot, held a valid license renewed periodically by the national civil aviation regulator based on rigorous medical assessments. While covered under a base group insurance policy and an additional top-up policy for 'loss of license', the complainant was eventually declared permanently unfit for flying. The insurer paid the claim under the base policy but repudiated the claim under the top-up policy, alleging that the complainant suffered from a pre-existing diabetic condition prior to the inception of the policy. The complainant challenged this, providing pathology reports showing normal blood sugar levels at the relevant times.
Findings of Court:
The Commission found that the insurer failed to provide any concrete evidence that the ailment existed prior to the policy inception. The insurer's reliance on a retrospective opinion from a non-specialist consultant was deemed insufficient against the findings of government-certified aviation medical experts who had consistently cleared the pilot for flying duties.
Issues: Whether the insurer was justified in repudiating the 'loss of license' insurance claim on the ground of a pre-existing medical condition, and whether the insurer's medical evidence was sufficient to overcome the official fitness certifications issued by the aviation authorities.
Ratio Decidendi: The insurer bears the burden of proving that a pre-existing condition existed such that it invalidates the claim. Retrospective medical opinions obtained by the insurer cannot override the official medical assessments performed by designated national authorities at the time of renewal of the professional license. Since the insurer continued to cover the pilot and relied on the regulator's fitness certifications, it is estopped from denying the claim on grounds of pre-existing illness without conclusive evidence.
Result: Complaint allowed; the opposite party is directed to pay the insurance amount with interest.
| Table of Content |
|---|
| 1. establishment of the complainant's employment and insurance coverage. (Para 1 , 2) |
| 2. insurance company's defense based on the policy exclusion of pre-existing diseases. (Para 3 , 4) |
| 3. admissibility of claim and the burden of proof for repudiation. (Para 5 , 6) |
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Order : (Per Hon’ble Sri K.Ranga Rao- Presiding Officer Member - (Judicial).
1). This complaint is filed on 29.12.2020 by the Complainant namely Mr.Captain Jangam Raghunath Gowd u/s. 47(1) of Consumer Protection Act,2019 praying this State Commission to direct opposite party No.1 Insurance company :
(a) To pay TOP-UP Policy amount of Rs.1,15,00,000.00(Rupees one crore fifteen lakhs only) with interest @ Rate of 24% p.a. from the date of payment till realization.
(b) To pay balance amount of Rs.57,50,000/-. Towards the base policy and to pay compensation of Rs.10,00,000/- with interest @ 24% p.a. from the date of payment till realization.
(c) To pay a sum of Rs.10,00,000/- towards mental agony and unfair trade practice with interest @ 24% p.a. from the date of payment till realization.
(d) To pay damages and costs of Rs.1,00,000/-with interest @ 24% p.a. from the date of payment till realization.
And to pass such other relief or reliefs as this State Commission deems fit and proper in the circumstances of the case.The brief averments of complaint are as follows:
2). The complainant was an Airline Pilot and having the Airline Transport Pilots Licence (ALTP) vide No.1485, issued on 08.09.1989 by the Director General of Civil Aviation, Government of India.
The complainant was employed by the opposite party No.2 M/s. Jet Airways ( India) Limited from 21.11.1993 and was Designated as Senior Commander and was flying Air Bus Airplanes A330/300 all over the World with an impeccable record of about 20,000/- Hours of Flying time experience till the last operated flight on 21.01.2016, which the complainant had flown the International Flight from Brussels to Mumbai. The complainant has worked with the opposite party No. 2 during his entire service period and was operating flights(Flying) till the last day of his ALTP Licence was cancelled.
The opposite party No.2 Jet Airways has obtained a Group Insurance Policy in the year 2009 from opposite party No.1 Oriental Insurance Co. Ltd and the said policy was in existence till 2018. The policy is named as wad tailor made and was called “Aviation Lose of License Insurance Policy (Group) vide Policy No.112400/43/2016/65 (LOL) by paying premium amount of Rs.1,06,01,973/-. The policy was issued to all the employees of about one thousand members of opposite party No.2, by opposite party No.1 upon agreed terms and conditions. The complainant was also member of the group (LOL) Policy since 2009 and was also a member of the National Aviators Guild (NAG) Pilots union since inception. As per the terms and conditions of policy, in case of any claim, the policy is covered for an amount of Rs.1,15,00,000/- (Rupees one crore fifteen lakhs only).
The complainant further submits that opposite party No. 1 insurance company along with Opposite party no.2 Jet Airways and the Pilot Association (NAG) after vide consultations since the year 2013, have come up with the Tailor made additional “TOP UP” Insurance Policy along with the existing primary policy for the staff of about 1000 Employees of Opposite party No. 2 Jet airways. The complainant has also opted for the Additional Top UP Policy vide No.1124000/43/2016/159, and apart from primary insurance LOL policy the “ADD ON TOP UP” policy was also taken and additional top up policy which is also loss of license (LOL). Premium amounts were deducted from the salary of the complainant. The Additional Top UP Policy which is also obtained for the first year from 07.12.2015 to 06.12.2016 for which premium was deducted from the salary of the complainant from November 2015 salary by Opposite party No.2 (Employer) and paid the same to the Opposite party No.1 insurance company. The pr
