Page 27 - Suri’s - NCDRC ON LIFE INSURANCE 2017 V1.3

Suri’s - NCDRC ON LIFE INSURANCE 2017 27

concealment of material facts by the complainant regarding his previous ailments. It
is submitted that thereafter no claim was submitted and as such there is no cause of
action for filing the complaint.
5. The District Forum on consideration of the pleadings and the evidence came
to the conclusion that there was no concealment of fact on the part of the complainant
and the opposite party was deficient in service. Complaint was therefore allowed and
opposite party insurance company was directed to pay to the complainant sum of
Rs.2,11,996/- with 9% interest thereon from the date of filing of the complaint till the
realization, besides cost of Rs.2,000/-.
6. Being aggrieved of the order of the District Forum, the petitioner insurance
company approached the State Commission in appeal. The State Commission on re-
evaluation of evidence did not find any fault with the order of the District Forum. The
appeal was accordingly dismissed. This has led to filing of the revision petition.
7. Learned counsel for the petitioner has contended that the impugned orders
of the Fora below are not sustainable because the Fora below have failed to appreciate
that the complainant had obtained the insurance policy by giving false information
regarding his health status. In this regard, learned counsel for the petitioner has drawn
our attention to the copy of the proposal form filled by the complainant on
th
28 March, 2012 wherein the complainant in response to the questionnaire pertaining
to his health, particularly regarding heath ailment and diabetes mellitus has answered
in the negative. Learned counsel has drawn our attention to the prescription issued by
Poonia hospital on 11.4.2013 wherein the concerned doctor has recorded that the
complainant visited his clinic with history of pain in chest and uneasiness and that the
patient was advised ECG which showed some changes. There is also a mention about
diabetes mellitus-2. This document, in our view, is of no avail to the petitioner insur-
ance company because the document is of the date after the submission of the pro-
posal form. Counsel for the petitioner has failed to show us any evidence which could
lead us to the conclusion that prior to 28.3.2012 the complainant was found suffering
from any heart ailment or diabetes mellitus. In absence of any such evidence, it can-
not be said that the complainant has concealed material fact while purchasing the in-
surance policy. Thus, we do not find merit in the plea of the petitioner that the com-
plainant/respondent No.1 entered into a contract by concealing information.
8. Learned counsel for the petitioner has further contended that in the instant
case the opposite party insurance company had refused cashless treatment because of
suspicion of concealment of fact on the part of the complainant. No insurance claim
after the treatment was filed, therefore, the complaint itself is pre-mature. We do not
find merit in this contention. It is not in dispute that the medi-claim policy issued to
the complainant was a cashless policy. Therefore, there was an implied assurance on
the part of the petitioner that in the event of the respondent/complainant suffering
from any ailment, he would be given cashless treatment at the concerned clinic or
hospital subject to the terms and conditions of the insurance policy. Counsel for the
petitioner has failed to show us any document which could induce a reasonable person
to suspect that the complainant has given wrong information in the proposal form
about his previous medical condition. Therefore, in our view, the refusal of the peti-
tioner to authorize cashless access to the respondent/complainant amounts to unfair
trade practice. Thus, under the circumstances, we do not find any fault with the con-

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