The death summary said he had been treated in 2008. The proposal form, filed in 2011, said no

AVM J. Rajendra and Justice Saroj Yadav set aside concurrent findings for the claimants, holding that neither forum below had engaged with a hospital record of cardiac treatment three years before the policy.

Rajinder Kumar took out a life policy on 30 September 2011 and died on 5 April 2012. His widow and two children claimed ₹9,40,000; the insurer paid ₹92,297. The District Forum at Sri Ganganagar and the Rajasthan State Commission both held the family was entitled to the rest. The National Consumer Disputes Redressal Commission has now set both orders aside, because neither of them dealt with a line in the hospital's death summary recording that the insured had undergone cardiac resynchronisation therapy in 2008 — three years before he answered no to the health questions on the proposal form.

What happened

The proposal form was filled in on 30 September 2011 through an agent. A premium of ₹10,569 including tax was paid on 30 October 2011, with the next instalment due on 7 January 2012. Two further payments of ₹10,000 each followed, on 21 January and 5 April 2012. The family moved to Sri Ganganagar after the policy was taken.

On 2 April 2012 the insured fell ill. He was admitted to Fortis Escorts Hospital, Jaipur, the next day, and died there on 5 April. The claim went in on 3 January 2013 with the supporting documents. The insurer sanctioned ₹92,297 and sent it to the family's earlier address on 1 July 2013.

The complaint before the District Forum sought the full benefit of ₹9,40,000 with interest, compensation and costs. The Forum allowed it on 12 February 2014. The State Commission dismissed the insurer's appeal on 25 October 2017. The insurer came to the National Commission in revision under Section 21(b) of the Consumer Protection Act, 1986.

The insurer's defence was that the policy would never have been issued had the true health condition been disclosed, and that a cheque for the unit value of ₹92,297 dated 1 July 2013 had been sent in full and final settlement in terms of the policy.

The District Forum did not accept it. It ordered the insurer to pay ₹4,40,000 with simple interest at 9 per cent from three months after the death — that is, from 5 July 2012 — until actual payment, to pay the death benefit and other benefits under the policy terms within a month, and to pay ₹5,000 towards costs. The State Commission upheld that order, reasoning that the record of the court below did not show the deceased had been ill from the outset.

What the hospital record said

The document that decided the case is the death summary of 5 April 2012, and its authenticity was never disputed.

It records that the insured was a known case of dilated cardiomyopathy with severe left ventricular dysfunction, and that he was post cardiac resynchronisation therapy in 2008. It sets out his condition on admission — difficulty in breathing, heart failure and renal failure — and records ventricular tachycardia and ventricular fibrillation, cardiomyopathy, heart failure and renal failure in relation to his terminal illness.

The reference to therapy in 2008 is what mattered. The proposal form was submitted on 30 September 2011, nearly three years after it. On the form the insured answered Questions 5, 6 and 9C in the negative, and the complainants produced no evidence to rebut the entry about the 2008 therapy or to show that it was mistaken.

The District Forum had reasoned that, in the absence of evidence about the precise date of onset of the diseases, the condition could not be said to pre-date the proposal. The Commission held that this overlooks the specific medical history on the record. The absence of separate records of the 2008 treatment, and the fact that the treating doctor was not examined, are relevant to corroboration but do not cancel the entry itself.

The Commission was careful to mark the distinction that makes this case different from many repudiations. This is not a case where the insurer infers a pre-existing disease from the cause of death and asks the forum to complete the chain. Here the hospital's own record contains a specific reference to significant cardiac treatment substantially preceding the proposal.

It was equally careful about where the burden sits. Establishing false representation or suppression of material facts rests on the insurer. But once the insurer produces cogent documentary evidence that a specific answer in the proposal form was contrary to the known medical history of the proposer, the question falls to be decided on the whole of the evidence, and not by demanding proof of the precise date of onset of the disease in every case.

The Commission also separated two documents the District Forum had run together. That Forum had observed that the face sheet established only the insured's admission to the cardiology department on 3 April 2012 and said nothing about the duration of his illness. The Commission accepted that about the face sheet — and pointed out that the death summary is a different document, and does record the earlier therapy.

On that footing the non-disclosure was not a technical omission. The negative answers given to specific questions about previous heart disease, cardiac treatment, hospitalisation and other ailments were inconsistent with the medical history the hospital later recorded, and the condition concealed was a significant pre-existing cardiac condition material to the insurer's assessment of the risk.

Why revision was available at all

Revisional jurisdiction over concurrent findings is narrow, and the Commission addressed that directly rather than assuming it away.

The Commission said so itself: jurisdiction under Section 21(b) is revisional, not appellate, and is not an occasion to re-appreciate every piece of evidence. Ordinarily concurrent findings of fact do not warrant interference unless there is a jurisdictional error, a material irregularity, or perversity in the appreciation of evidence.

The gateway it used is the last of those. The State Commission, in dismissing the appeal, did not advert to the entry in the death summary at all, and proceeded on the footing that the record established no prior disease and no concealment. A concurrent finding that does not adequately deal with a material piece of documentary evidence relied on by the party against whom it is made is a finding that calls for examination in revision.

On the substantive law it applied settled principles. A contract of insurance is one of utmost good faith, and the proposer is under a duty to make full and true disclosure of material facts within his knowledge, particularly where the proposal form puts specific questions about health and previous medical history. What counts as material depends on the nature of the contract, the risk to be covered and the information the insurer has asked for. Where a specific question is asked, a truthful answer is required. The Commission relied on the Supreme Court's decision in Mahaveer Sharma v. Exide Life Insurance Company Limited, which discusses Satwant Kaur Sandhu, where suppression of a material fact about the health of the insured justified repudiation.

Outcome

The revision petition was allowed. The order of the State Commission of 25 October 2017 in First Appeal No. 504 of 2014 and the order of the District Forum of 12 February 2014 in Consumer Complaint No. 318 of 2013 were both set aside, and the consumer complaint stands dismissed.

There is no order as to costs, and the pending applications, including one for condonation of delay, were disposed of. The matter had been reserved on 2 September 2026 and was pronounced on 12 October 2026 — thirteen years after the claim was first made.