Sudip Ahluwalia, Member

This First Appeal has been filed by Appellant/Opposite Party - Insurance Company against the Order dated 22.04.2024 passed by the Ld. State Consumer Disputes Redressal Commission, Uttar Pradesh, Lucknow in Consumer Complaint No. 317 of 2019, whereby the Complaint filed by the Respondent/Complainant, was allowed and the Appellant was directed to pay the sum assured of Rs.75,00,000/- with interest @ 10% per annum from 12.04.2019 till actual realisation, besides compensation of Rs.2,00,000/- for physical harassment and mental agony and Rs.25,000/- towards costs of proceedings.

2. The relevant facts, in brief, are that the Respondent's husband, Late Shri Manoj Kumar Agarwal, was the Deceased Life Assured under HDFC Life Click 2 Protect 3D+ Policy No. 19458793. The Proposal Form was submitted on 14.07.2017 and the Policy was issued with effect from 28.07.2017 for a sum assured of Rs.75,00,000/- against an annual premium of Rs.38,204/- for a term of 19 years. In the Proposal Form, the Deceased Life Assured answered in the negative, inter alia, to questions as to whether he had ever suffered from heart disease or other specified ailments, whether he was then suffering from any illness, impairment or taking medication, and whether during the preceding five years he had undergone or been advised hospitalisation. The relevant questions were Nos. 12, 18 and 21, besides question No.23 relating to investigations.

3. Before issuance of the Policy, the Appellant had also caused the Deceased Life Assured to undergo medical investigations on 24.07.2017. These included Haemogram, biochemistry, routine urine examination, fasting blood sugar, HbA1C, HBsAg, HIV, lipid profile and TMT. The Respondent has relied upon these medical reports to contend that the Deceased Life Assured was found fit and healthy and that no abnormality relating to his heart was detected. It is, however, significant that no 2D Echocardiography was conducted at that stage. The Appellant itself has relied upon this circumstance in the present Appeal to contend that DCMP could not have been detected through the Tests undertaken in the course of the pre-Policy medical examination and that the responsibility of the Proposer to disclose material facts nevertheless continued.

4. The Deceased Life Assured was subsequently admitted to Medanta Hospital, Gurgaon in November 2018 and was diagnosed with Hepatitis-E. He unfortunately expired on 25.12.2018. The medical records relating to his last illness referred, inter alia, to septic shock with multi-organ failure, Hepatitis-E related acute-on-chronic liver failure and Dilated Cardiomyopathy with severe Left Ventricular Dysfunction. Thereafter, the Respondent lodged a claim under the Policy.

5. The Appellant appointed Eagle Eye Consultants Pvt. Ltd. for investigation of the Claim. The investigation Report dated 15.03.2019 stated, according to the record, that the pre- medical records could not be traced despite efforts. Thereafter, the Claim was repudiated by letter dated 12.04.2019. The basis of repudiation was that the Deceased Life Assured had allegedly been taking treatment for Dilated Cardiomyopathy with poor Left Ventricular Function prior to submission of the proposal dated 14.07.2017 and that the same had not been disclosed in the Proposal Form. The Appellant specifically referred to the negative answers furnished against questions Nos.12, 18 and 21 and stated that, had the relevant information been disclosed, the proposal could have been declined.

6. Aggrieved by the repudiation, the Respondent approached the Ld. State Commission by filing Consumer Complaint No.317 of 2019. The Respondent maintained that there had been no suppression of any material fact and that the medical records relied upon by the Appellant were fabricated. She also relied upon the medical examination conducted by the Appellant before issuance of the Policy and contended that nothing abnormal had been detected therein. It was further contended that the death of the Deceased Life Assured was primarily attributable to Hepatitis-E related acute-on-chronic liver failure and septic shock and that the cardiac condition mentioned in the later medical records had no bearing upon the alleged suppression at the time of obtaining the Policy.

7. The Appellant, on the other hand, relied upon the Proposal Form, the repudiation letter and the medical records said to have been obtained during investigation. The Appellant's evidence before the Ld. State Commission included the Affidavit of its Legal Manager, Shri Sudhir Kumar Singh, who stated that during investigation it was established that the Deceased Life Assured had been admitted at Regency Healthcare, Kanpur and had been treated for DCMP with severe left ventricular dysfunction, including an alleged ejection fraction of 15-20%. The relevant Discharge Summaries were placed on record.

8. The Ld. State Commission, vide the impugned Order dated 22.04.2024, allowed the Complaint. The principal consideration which weighed with the Ld. State Commission was that the Appellant had itself conducted medical investigations before issuing the Policy and that the material subsequently relied upon by the Appellant did not, in its view, satisfactorily establish the alleged suppression. The Ld. State Commission accordingly directed payment of the sum assured with interest and compensation as noticed above.

9. When the present Appeal came up before this Commission on 04.06.2024, Notice was issued to the Respondent and, subject to deposit of 50% of the decretal amount with the Ld. State Commission, operation of the impugned Order was stayed. The Appellant was also directed to pay Rs.7,500/- to the Respondent/Complainant towards travel and allied expenses.

10. Thereafter during the pendency of the matter, the principal controversy before this Commission came to be narrowed down to the authenticity and evidentiary value of the Regency Hospital records. Vide Order dated 27.10.2025, this Commission recorded that the very basis of repudiation was the assertion that the Deceased Life Assured had been suffering from DCMP with an ejection fraction of 15-20% and that the Respondent had disputed the existence and genuineness of the relevant medical record. It was further noticed that the original Investigator's Report dated 15.03.2019 did not refer to the disputed Regency record, whereas the Appellant relied upon subsequent correspondence and material to explain how the said record had come to its knowledge. In the interest of justice, and treating the Appeal as a continuation of the original proceedings, this Commission granted the Appellant one opportunity to bring before it the person who had first come to know of the treatment of the Deceased Life Assured at Regency Hospital and to disclose on oath how such information had been obtained. The Appellant was further required to summon the original records of Regency Hospital for verification.

11. Pursuant to the aforesaid direction, an affidavit of Shri V. Kaniraj, Manager-Claims of the Appellant, was filed. He stated that he had been posted as Deputy Manager-Claims in 2019 and that the matter had been assigned to him after the Investigation Report dated 15.03.2019. He stated that, during an industry check, he discovered that the Deceased Life Assured had a health Insurance Policy with ICICI Lombard and that further enquiry disclosed treatment at Regency Hospital, Kanpur. According to him, an email dated 31.03.2019 was addressed to Shri Sher Singh of ICICI Lombard seeking the medical records and Discharge Summaries relating to the treatment of the Deceased Life Assured. He further stated that the concerned Officer of ICICI Lombard confirmed the details and supplied the Discharge Summaries relating to the periods 13.11.2016 to 15.11.2016, 15.12.2016 to 19.12.2016 and 05.04.2017 to 12.04.2017. The email correspondence forming part of the record has also been placed on record before by us.

12. Thereafter, vide Order dated 18.11.2025, this Commission, in view of the directions contained in the Order dated 27.10.2025, directed that the original relevant records of Regency Hospital Limited be summoned.

Pursuant thereto, Summons were served upon the Medical Records Keeper/Nodal Officer of Regency Hospital.

13. On 14.05.2026, Mr. Maneendra Kumar, Associate (Legal Affairs) of Regency Hospital Limited, Kanpur appeared before this Commission and produced authenticated copies of the three Discharge Summaries pertaining to the alleged hospitalisations of the Deceased Life Assured for the periods 13.11.2016-15.11.2016, 15.12.2016-19.12.2016 and 05.04.2017-12.04.2017. When asked about the original records, he stated that the records maintained by the Hospital were destroyed after five years in accordance with the applicable rules and, consequently, only print-outs of the soft copies available in the Hospital system could be produced under authentication. This Commission accordingly directed the competent Officer of the Hospital to file an affidavit stating the Rules under which such records were destroyed, and the period after which they were liable to be destroyed. The Respondent was also specifically directed to file an affidavit stating whether the Discharge Summaries relied upon by the Appellant were forged and whether the Deceased Life Assured had ever been admitted in the Hospital on the dates mentioned therein.

14. In compliance with the aforesaid Order, the competent Officer of Regency Hospital Limited filed an Affidavit through Shri Yogi Srivastava, Company Secretary and Compliance Officer. The Affidavit explains that, under Regulation 1.3.1 of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, as continued under the National Medical Commission Act, 2019, and Rule 30 of the U.P. Clinical Establishments (Registration and Regulation) Rules, 2016, indoor patient medical records were maintained for the prescribed minimum period, while the Hospital's internal policy contemplated retention of original indoor patient records for five years. It was further stated that the records in question related to the years 2016 and 2017 and that, by the time the Hospital first came to know of the present litigation in November 2025, the original physical records had already ceased to be available. The Affidavit further stated that soft/scanned copies of the available documents had already been placed on record.

15. The Respondent also filed the Affidavit directed by this Commission, specifically denying that her husband had ever been admitted in Regency Hospital on the aforesaid dates and alleging that the Discharge Summaries relied upon by the Appellant were forged. She also pointed out that, according to the Appellant's own Affidavit, the diagnosis recorded in relation to the admission between 13.11.2016 and 15.11.2016 was 'fracture of one rib', whereas the disputed Discharge Summary contained reference to other cardiac ailments. It was further contended that the original Investigation Report did not refer to the disputed records and that the documents were subsequently manufactured for the purpose of repudiating the Claim.

16. Heard Ld. Counsel appearing on behalf of both the parties and perused the material placed on record.

17. The first question which arises for consideration is whether the alleged suppression is of such nature which could justify repudiation of a Life Insurance Claim. There can be no dispute with the settled proposition that a Contract of Insurance is a contract uberrimae fidei. The Proposer is under an obligation to disclose material facts within his knowledge which may influence the decision of a prudent Insurer. In 'Satwant Kaur Sandhu v. New India Assurance Co. Ltd.', (2009) 8 SCC 316, the Hon'ble Supreme Court held that where information is specifically sought in a Proposal Form, the Assured is under a solemn obligation to make a true and full disclosure of the information within his knowledge. Similar principles were reiterated in 'Life Insurance Corporation of India v. Asha Goel', (2001) 2 SCC 160, and 'Reliance Life Insurance Co. Ltd. v. Rekhaben Nareshbhai Rathod', (2019) 6 SCC 175.

18. In the present case, the Proposal Form specifically required disclosure of any previous heart disease, current illness and hospitalisation during the preceding five years. The answers furnished by the Deceased Life Assured were in the negative. There is, therefore, no ambiguity in the questions which were asked. The alleged hospitalisations at Regency Hospital, if accepted, were not remote or insignificant events. They were three separate admissions, the last of which occurred between 05.04.2017 and 12.04.2017, i.e., only about three months before submission of the proposal on 14.07.2017. Consequently, if the medical history recorded in those documents is accepted, the negative answers to questions Nos.12, 18 and 21 would constitute non-disclosure of facts directly relevant to the underwriting of the risk.

19. It is true that the Respondent has challenged the genuineness of the Regency records and that the original physical records are no longer available. It is equally true that the initial Investigation Report dated 15.03.2019 did not refer to these records and that the Appellant's subsequent evidence indicates that the records were obtained only after further enquiry. We have carefully considered these circumstances. However, the fact that the original physical records could not ultimately be produced does not, by itself, render the Discharge Summaries worthless, particularly when the Hospital itself has explained on Affidavit that the records of the relevant period had ceased to be available by reason of the applicable record-retention regime.

20. More importantly, this Commission itself had, vide its Order dated 27.10.2025, identified the provenance of the Regency records as the central controversy and had afforded the Appellant one specific opportunity to place before it the relevant material. Pursuant thereto, the Appellant filed the Affidavit of Shri V. Kaniraj explaining the manner in which the Regency treatment came to its notice and produced the relevant correspondence with ICICI Lombard. Thereafter, pursuant to the Summons issued by this Commission, a representative of Regency Hospital appeared and produced authenticated copies of the three Discharge Summaries. The Hospital subsequently explained on Affidavit why the original physical records were no longer available. Thus, the record before us is materially different from a case where the Insurer merely produces an unverified document from an unknown source.

21. We have also examined the contents of the Discharge Summaries themselves. The Respondent has relied upon the fact that the admission from 13.11.2016 to 15.11.2016 is also reflected in the Appellant's correspondence as involving fracture of one rib. In our view, this circumstance does not necessarily undermine the medical record. A patient admitted with an injury may simultaneously be found to have underlying medical abnormalities during the course of examination and treatment. The presence of a rib fracture, therefore, is not inconsistent, by itself, with the presence of other medical findings recorded during the same hospitalisation. On the contrary, the coincidence of the hospitalisation, the injury and the other medical entries in the documents provides contextual consistency rather than a basis, by itself, for discarding the record.

22. We are conscious that there are certain discrepancies in the correspondence exchanged with ICICI Lombard, particularly as regards the precise details contained in the communication dated 26.12.2019 and the three admissions referred to in the Affidavit of Shri V. Kaniraj. These discrepancies have been considered. However, the standard applicable in the present proceedings is not that applicable to a criminal prosecution or to a full-fledged civil trial concerning allegations of fabrication of medical records. The consumer jurisdiction is required to decide the dispute on the basis of the material placed before it and on the touchstone of preponderance of probabilities. We are not required, in the present proceedings, to undertake an elaborate forensic examination of every minute aspect of the Hospital's record-generation process, the internal electronic trail, the identity of every person who handled the record, or the precise chain by which every electronic copy came to be preserved.

23. Upon consideration of the entire material, the disputed Discharge Summaries do not, to us, appear to be manufactured documents. This conclusion is fortified by the subsequent appearance of the Hospital's representative before this Commission, production of authenticated copies of the relevant Discharge Summaries, and the Hospital's subsequent explanation as to the non-availability of the original physical records. The Respondent's denial of the hospitalisation and allegation of forgery have certainly been taken into account; However, on the material presently before us, we are unable to accept that allegation as sufficient to displace the cumulative evidentiary value of the documents.

24. The fact that the Appellant had itself conducted a medical examination before issuance of the Policy also does not assist the Respondent to the extent contended. The tests conducted on 24.07.2017 did not include 2D Echocardiography. More importantly, the obligation of disclosure under the Proposal Form is not replaced by the Insurer's medical examination. A Proposer cannot, after giving a specific negative answer to a question regarding previous hospitalisation or heart disease, contend that the Insurer ought independently to have discovered the concealed history. As held by the Hon'ble Supreme Court in "Satwant Kaur Sandhu" (supra) and "Rekhaben Rathod" (supra), the duty to disclose facts within the knowledge of the Proposer is distinct from the medical assessment subsequently undertaken by the Insurer.

25. It is material that the three Discharge Summaries from the Regency hospital relate to hospitalisations which admittedly, on the face of the documents relied upon by the Appellant, occurred before the proposal dated 14.07.2017 and contain material medical information relating to the Deceased Life Assured. The last of these hospitalisations was only about three months before the proposal. When juxtaposed with the express negative answers furnished to questions concerning heart disease, illness and hospitalisation, the inference of suppression of material medical history becomes more probable than the contrary explanation.

26. The position is also supported by Section 45 of the Insurance Act, 1938, which, in the applicable statutory framework, permits a life Insurance Policy to be called in question within the prescribed period on the ground of an incorrect statement or suppression of a fact material to the expectancy of the life Insured. The statutory explanation places the burden upon the Insurer to show that the suppressed fact had a direct bearing on the risk and that, had the Insurer been aware of it, the Policy would not have been issued. The repudiation in the present case was within three years of issuance of the Policy. The Appellant's case is that disclosure of the relevant cardiac history would have led to declination of the proposal. The material concerning repeated hospitalisation and serious cardiac findings, particularly the alleged severe LV dysfunction and the proximity of the April 2017 admission to the proposal, is sufficient, on a preponderance of probabilities, to establish that the suppressed information had a direct bearing upon the underwriting of the risk.

27. The decision of the Hon'ble Supreme Court in 'Bajaj Allianz Life Insurance Co. Ltd. v. Dalbir Kaur', Civil Appeal No.3397 of 2020, decided on 09.10.2020, is also instructive. There, the Hon'ble Apex Court upheld repudiation where the Insurer was able to establish from medical records that a serious pre-existing medical condition had not been disclosed in the Proposal Form. The underlying principle is that where the medical record reliably establishes a material pre-existing condition and the Proposal Form contains a specific incorrect answer concerning such condition, the Insurer is entitled to act upon the suppression. The present case, in our view, falls within that principle once the Regency Discharge Summaries are considered together with the other evidence now brought on record.

28. The Respondent has relied upon the fact that the initial Investigator's Report did not refer to the Regency records and has contended that the records were procured subsequently. This circumstance was specifically noticed by this Commission in its Order dated 27.10.2025 and was the reason why the Appellant was required to establish the source of the subsequent material. The subsequent evidence, including the Affidavit of Shri V. Kaniraj, the correspondence with ICICI Lombard, the appearance of the Regency Hospital representative and the Hospital's affidavit explaining the destruction of the original records, sufficiently addresses that concern for the purposes of the present Consumer proceedings. The subsequent discovery of evidence during investigation does not, by itself, render such evidence inadmissible or unreliable.

29. We are also unable to accept that the reference in the first Discharge Summary to 'fracture of one rib' necessarily negates the other medical findings appearing in the Discharge Summary. The fact of a rib fracture is not mutually inconsistent with a finding of an underlying cardiac disorder. The Respondent's reliance upon this circumstance, therefore, does not create such a contradiction as would render the entire document improbable.

30. It is necessary, however, to make one aspect of the present decision clear. We have reached the aforesaid conclusion on the basis of the standard of preponderance of probabilities applicable to the adjudication of the Consumer dispute before us. We have not undertaken, and are not required to undertake, a detailed forensic adjudication of the authenticity of each electronic or medical record, the exact manner in which the Hospital's internal records were generated or preserved, or the question whether any individual document could, after a full trial with oral and documentary evidence, be proved or disproved in accordance with the stricter evidentiary standards applicable to a regular Court Trial. The present proceedings cannot be converted into an elaborate trial for determination of every disputed question surrounding the historical hospital records.

31. Consequently, our finding is that, on the balance of probabilities, the Deceased Life Assured had undergone the aforesaid hospitalisations before submission of the proposal and that the medical information reflected in the Regency Discharge Summaries was material information which was not disclosed in the Proposal Form. The answers furnished against questions Nos.12, 18 and 21 were therefore incorrect in material respects. The repudiation of the Claim on the ground of suppression of material medical history was consequently justified.

32. The impugned Order dated 22.04.2024 passed by the Ld. State Consumer Disputes Redressal Commission, Uttar Pradesh, Lucknow in Consumer Complaint No.317 of 2019 cannot, therefore, be sustained. The Complaint filed by the Respondent/Complainant is liable to be dismissed.

33. Before parting, we deem it appropriate to clarify that the observations made herein are confined to the adjudication of the Consumer dispute before this Commission. In particular, we have not recorded any final or conclusive finding in relation to any allegation of forgery or fabrication of the medical records in question, nor have we undertaken a determination of any issue which may require a detailed trial of evidence beyond the scope of the present proceedings. If the Respondent/Complainant considers that she has any independent remedy available to her in accordance with law, including a remedy before a competent Civil Court in respect of any matter arising out of the medical records or the Insurance contract, it shall remain open to her to pursue the same in accordance with law. Any such court or other competent Forum shall decide the matter independently on the evidence and law before it and shall not be influenced by any observation made in the present Order beyond the findings necessary for disposal of this Consumer Appeal.

34. Accordingly, the present First Appeal is allowed. The Order dated 22.04.2024 passed by the Ld. State Consumer Disputes Redressal Commission, Uttar Pradesh, Lucknow in Consumer Complaint No.317 of 2019 is set aside and the Consumer Complaint is accordingly dismissed.

35. Since the impugned order passed by the Ld. State Commission is being set aside and the Consumer Complaint itself is being dismissed, the amount, if any, deposited by the Appellant before the Ld. State Commission pursuant to the Order dated 04.06.2024 passed by this Commission shall be refunded to the Appellant in accordance with law and after completion of the necessary formalities.

36. Pending application(s), if any, also stand disposed off as having been rendered infructuous.