An insurance company cannot repudiate a claim based on suppression of material facts without providing authenticated evidence that the medical records specifically pertain to the insured. Failure to prove such suppression constitutes a deficiency in service.

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Order : (Per Hon'ble Sri K.RangaRao, Member -Judicial)

1. This appeal is filed by the Appellants/opposite parties U/s.15 of the Consumer Protection Act, 1986, praying this State Commission to set aside the impugned order dt.26.04.2019 of the District Forum, Karimnagar, passed in CC. No. 24/2015 as prayed for.

2. For the sake of convenience, the parties are referred to as arrayed in the complaint. The appellants herein were opposite parties and the Respondents was the complainant in the complaint bearing No.CC 24/2015 filed by the complainant on the file of District Commission Karimnagar, hence the complainant filed this complaint against the deficiency in service by the opposite parties.

3. The brief averments of complaint are as follows:-

The Husband of the complainant of the who was the account holder of opposite parties bearing policy no.006085748 commencing from 19.04.2013 for an assured sum of Rs. 10,00,000/-. As per the policy conditions, in case of death of policy holder, the nominee is entitled to get the Death Benefit. While the policy was in existence the husband of the complainant died on 30.06.2013. After death of her husband, the complainant being the nominee of life assured submitted claim with relevant documents to the opposite parties. On receipt of claim from the complainant, the opposite parties sent a letter Dt: 25.02.2014 repudiated claim of the complainant on the ground of suppression of facts. Thereafter the complainant approached the opposite parties and requested to pay the Death Benefits covered under the policy as the deceased was hale and healthy till his death. But there is no response from opposite parties even after repeated requests made by the complainant. Non-settlement of claim by the opposite parties clearly amounts to deficiency in service besides causing unwanted mental agony to the complainant without fault on her part, hence the complainant filed this complaint against the deficiency in service by the opposite parties.

The opposite parties filed Counter denying the averments made in the complaint and submitted that this Forum has no jurisdiction to entertain the complaint. The complainant has failed to demonstrate any deficiency in service on the part of the opposite parties under section 2 (g) of C.P.Act. In the present case, the complainant has concealed the fact of correct age, income, occupation as well as with regard to past medical history that he was diagnosed with Cancer and was under treatment for the same prior to availing the policy in question. The complainant has not approached the Forum with clean hands. It is well settled legal proposition that "one who seeks justice must come to the court with clean hand".

In the case of Ravneet Singh Bagga Vs KLM Royal Dutch Airlines (2000) 1 SC 66, where the Hon'ble Supreme Court laid down that the test of deficiency in service by stating that

"the deficiency in service cannot be alleged without attributing fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be performed by a person in pursuance of a contract or otherwise in relation to any service. The burden of proving the deficiency in service is upon the person who alleges it. The complainant has, on facts, been found not established any willful fault, imperfection, shortcoming or inadequacy in the service of the respondent. The deficiency in service has to be distinguished from the tortious acts of the respondent. In the absence of deficiency in service the aggrieved person may have a remedy under the common law to file a suit for damages but cannot insist for grant of relief under the Act for the alleged acts of Forum and omission attributable to the respondent which otherwise do not amount to deficiency in service. In case of bonafide disputes no willful fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance in the service can be informed (sic). If on facts it is found