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Judgment
This Civil First Miscellaneous Appeal is preferred against the order of the Consumer Dispute Redressal Commission, Jammu, dated 9-12-2013
awarding total compensation of Rs.5.50 lacs to the respondent No.1 as he had taken a mediclaim policy and during the period of insurance policy
he underwent surgery of coronary artery disease (Open Heart Surgery).
The main grievance of the appellant is that respondent No.1 took the policy when he was already having hypertension and he suppressed that
fact while taking the policy, therefore he is not entitled to claim medical claim for open heart surgery.
When the appeal was taken up on 20-11-2014, this Court wanted to know as to whether respondent No.1 has given any declaration while
filling up the pro forma of Insurance that he was hale and healthy and did not suffer from any disease including hypertension to satisfy as to whether
there was any material suppression of facts to repudiate the claim in terms of the judgment of Hon'ble the Supreme Court reported in 2009 (IV)
CPJ 8 : (2009 AIR SCW 7213) (Satwant Kaur Sandhu v. New India Assurance Co. Ltd). The Division Bench noticed that neither before
the State Commission nor before this Court the original record has been produced along with original proforma filled up by the respondent No.1.
The learned counsel for the appellant was directed to get the declaration form and produce the same as early as on 20-11-2014. The declaration
form was not produced in spite of granting time which was sought again on 11-7-2016. Even thereafter the same was not produced today also
during the hearing of the case the original record and in particular the declaration form filled up by the insured has not been produced. In such
circumstances the ground raised by the appellant is without any basis i.e. the respondent No.1 suppressed the fact about his disease of
hypertension in his declaration form.
Even otherwise the insurance claim of the insured can be repudiated only if he has suppressed the material fact. The material fact depends upon
each case. Here in this case the respondent No.1 was not having any heart ailment till his open heart surgery conducted at Asian Heart Institute,
Kurla Bandra, Mumbai on 11-9-2009.
The contention of the learned counsel appearing for respondent No.1 is that even if respondent was having hypotension, as alleged, the same is
not a material fact as heart ailment will come due to various factors and not due to hypertension alone. Thus at the most the non-mentioning of
hypertension may come under the category of suppression and not material suppression. The decision of Hon'ble the Supreme Court reported in
(2009) 4 CPJ 8 (SC) : (2009 AIR SCW 7213) is distinguishable on facts. The insured in that case was already on dialysis which factor was not
mentioned while seeking coverage.
Considering the said submissions and the fact that the original declaration form filled up by the respondent No.1 has not been produced either
before the State Consumer Commission or before this Court despite specific directions given, we are unable to find any reason to interfere with the
order of the State Consumer Commission. The appeal is dismissed. No costs.