The burden of proof rests entirely on the insurer to affirmatively establish that the insured suppressed material facts regarding a pre-existing disease; mere production of medical records without corroborative evidence is insufficient to justify the repudiation of an insurance claim.

ORDER

KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION VAZHUTHACAUD, THIRUVANANTHAPURAM

APPEAL No.374/2017

ORDER DATED : 08.04.2026

(Against the order in C.C.No.136/2013 on the files of DCDRC, Kozhikode)

PRESENT:

HON’BLE JUSTICE SRI. B. SUDHEENDRA KUMAR : PRESIDENT

SRI. AJITH KUMAR D. : JUDICIAL MEMBER

SRI. K.R. RADHAKRISHNAN : MEMBER

This is an appeal filed under Section 15 of the Consumer Protection Act, 1986 by the complainant in C.C.No.136/2013 on the files of the District Consumer Disputes Redressal Commission, Kozhikode (for short, ‘the District Commission”). As per the order dated 04.04.2017, the District Commission dismissed the complaint. Aggrieved by the said order, the complainant has filed this appeal.

2. The brief details of the complaint are as follows:

The complainant had taken a Family Health Optima insurance policy, No.P1811311/01/2012/00/2032, from the opposite party for the period from 29.07.2011 to 28.07.2012 by paying a premium of Rs.1,628/-(Rupees One Thousand Six Hundred and Twenty Eight only). The complainant was admitted in Baby Memorial Hospital, Kozhikode on 09.11.2011 due to left chronic otitis media and was discharged on 10.11.2011. The complainant submitted a request for cashless facility to the opposite party/insurer, which was denied by them without valid reasons. Hence, she had to remit the hospital expenses of Rs.32,362/-(Rupees Thirty Two Thousand Three Hundred and Sixty Two only) to the hospital by pledging her gold ornaments. Thereafter, she submitted all the medical records and bills to the opposite party for reimbursement of the hospital expenses paid by her. But it was rejected by the opposite parties vide letter dated 27.03.2012 on the reason that there was suppression of material facts regarding pre-existing illness. Thereafter, she sent a lawyer notice to the opposite parties on 08.06.2012. The opposite parties replied to the said notice on 13.07.2012, justifying the repudiation. According to the complainant, she had no pre-existing illness and had not suppressed any material facts in the proposal form. Hence, she is entitled to get the claim in respect of the hospitalisation expenses of Rs.32,362/-(Rupees Thirty Two Thousand Three Hundred and Sixty Two only) from the opposite parties. The denial of her legitimate claim on flimsy and unreasonable grounds amounts to deficiency in service and unfair trade practice on the part of the opposite party, and hence, she filed the complaint claiming an amount of Rs.32,362/-(Rupees Thirty Two Thousand Three Hundred and Sixty Two only) spent for hospitalisation expenses with compensation and costs.

3. Notice was issued to the opposite parties who appeared and filed their joint version. They admitted having issued the Family Health Optima insurance policy covering the complainant and her two children for the period from 29.07.2011 to 28.07.2012. The complainant was admitted for treatment of left chronic otitis media on 09.03.2011 and as per the pre-authorisation request from the hospital, she had a history of bronchial asthma for 15 years. The records also revealed that she had undergone tracheostomy about 10 years ago. These pre-existing diseases were not revealed in the proposal form submitted by the complainant at the time of taking the insurance. Insurance is a contract and the proposal form is the basis and integral part of the contract. The policy is issued