Insurers must substantiate claims of non-disclosure with clear evidence; lacking this, repudiation of claims is unjustifiable.

PER DR. S. M. KANTIKAR, PRESIDING MEMBER

1. The present Revision Petition is against the impugned Order dated 11.01.2019 of the State Consumer Disputes Redressal Commission, Punjab (hereinafter “State Commission”) in First Appeal No. 392/2018, whereby the Appeal was dismissed.

2. Brief facts relevant for disposal of the case are that the Complainant took a policy from the OP - Ins. Co. for her son Kulwant Singh. She was the nominee in the said policy. The date of commencement of the policy was 12.08.2014. On maturity, the sum assured was Rs. 8,50,000/-, and in case of death of the insured, double the sum assured (Rs. 17 lakh) was to be paid. On 12.09.2014, Kulwant Singh, the insured, died a natural death at his residence. The insurance claim was submitted, but the OP - Ins. Co. repudiated the claim vide its letter dated 12.05.2015 on the ground of “misrepresentation of material facts” made by the insured in the proposal form, that the deceased insured actively made concealment of a pre-proposal hospitalization / treatment for vomiting of blood. Being aggrieved by the repudiation of the claim, the Complainant filed a Complaint in the District Forum, Taran Taran.

3. The Complaint was resisted by the OP – Ins. Co. by filing Written Version. It was contended that the assured had intentionally concealed true and correct facts at the time of answering the questions in the proposal form filled on 05.08.2014. As per a medical certificate issued by one Baba Budha Ji Charitable Hospital (where the insured was earlier admitted from 13.07.2014 to 14.07.2014), the deceased insured was suffering from vomiting of blood. Therefore, there was no ‘deficiency in service’ on their part.

4. The District Forum partly allowed the Complaint and ordered the OP - Ins. Co. to pay the death claim for the full assured amount and to also pay Rs. 10,000/- towards cost and compensation.

5. Being aggrieved, the OP- Ins. Co. appealed before the State Commission. On hearing both the parties and after the appraisal of the evidence, the State Commission dismissed the Appeal with inter alia the following observations:

8. … Nothing could be made out form this certificate Ex. OP 1 to 4/9 that the fact of vomiting of blood was due to any specific disease which was within the knowledge of the life assured. Vomiting of blood could be on account of many factors which could not be supposed to be in the knowledge of life assured. This certificate has been issued on the basis of document Ex. OPs 1 to 4/7 the certificate of hospital treatment. It has only recorded blood in vomiting in this certificate. It is not recorded as to what was the specific disease which caused it. Vomiting of blood could be due to many reasons and it cannot be said that he suffered from preexisting disease, which was in his knowledge and he fraudulently and deliberately concealed it from insurer. He was not an old person and vomiting of blood cannot be presumed to be within the knowledge of life assured on account of any specific disease or reason. There is no medical record on the file either by any tertiary hospital or by that hospital to establish this fact it was on account of any specific ailment only. Consequently, repudiation of claim on this ground by OPs is unsustainable and merits to be set aside.

6. Being aggrieved by the Order of the State Commission, the OP - Ins. Co. filed the present