Case Note & Summary
The petitioner, Gunvantbhai Bhogilal Shah, along with his wife, availed a Group Medical Insurance Scheme from United India Insurance Co. Ltd. (respondent No.1) through a trust (respondent No.3) in the year 2015, with a sum insured of Rs.5,00,000/-. On 28.05.2017, the petitioner's wife was admitted and underwent total knee replacement surgery of her left knee. The petitioner incurred medical expenses and submitted a claim to the insurance company. The insurance company repudiated the claim on the ground that the wife had a pre-existing knee ailment which was not disclosed at the time of taking the policy, and the surgery was within two years of the policy inception, attracting the exclusion clause. Aggrieved, the petitioner filed a complaint before the District Consumer Disputes Redressal Forum, which dismissed the complaint. The petitioner appealed to the State Consumer Disputes Redressal Commission, which also dismissed the appeal. The petitioner then filed revision petitions before the National Consumer Disputes Redressal Commission, which were dismissed by order dated 18.10.2023. The petitioner challenged the National Commission's order by way of a writ petition before the Gujarat High Court. The High Court examined the policy terms, the medical records, and the concurrent findings of the lower fora. The court noted that the petitioner had not produced any evidence to show that the knee ailment was not pre-existing. The court held that the burden of proof was on the insured to establish that the disease was not pre-existing, and the petitioner failed to discharge that burden. The court further held that the National Commission had not committed any jurisdictional error or perversity in dismissing the revision petitions. Accordingly, the High Court dismissed the writ petition, upholding the repudiation of the claim and the orders of the consumer fora.
Headnote
A) Insurance Law - Pre-existing Disease Exclusion - Disclosure Obligation - The petitioner's wife underwent total knee replacement surgery within two years of taking the policy; the insurance company repudiated the claim on ground of non-disclosure of pre-existing knee ailment. The National Commission dismissed the complaint holding that the petitioner failed to prove that the ailment was not pre-existing. The High Court upheld the order, observing that the policy exclusion clause for pre-existing diseases was binding and the petitioner had not disclosed the medical history. (Paras 1-10) B) Consumer Protection - Revision Petition - Scope of Interference - The National Commission, in revision, examined the concurrent findings of the District Forum and State Commission that the claim was rightly repudiated. The High Court held that the National Commission did not err in dismissing the revision petition as there was no jurisdictional error or perversity in the findings. (Paras 5-8) C) Insurance Law - Burden of Proof - Pre-existing Disease - The burden lies on the insured to prove that the disease was not pre-existing. In the absence of any evidence to show that the knee ailment was not pre-existing, the repudiation of claim was justified. (Paras 6-9)
Issue of Consideration
Whether the National Commission was justified in dismissing the complaint on the ground that the petitioner's wife had a pre-existing disease which was not disclosed at the time of taking the insurance policy, and whether the exclusion clause in the policy was applicable.
Final Decision
The High Court dismissed the writ petition, upholding the order of the National Commission and the concurrent findings of the consumer fora.
Law Points
- Insurance Law
- Consumer Protection
- Pre-existing Disease Exclusion
- Disclosure Obligation
- Policy Terms Binding
