State Consumer Disputes Redressal Commission
Heera Ben Selarka vs General Manager Birla Sun Life ... on 11 March, 2026
IN THE NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION
AT NEW DELHI
NC / FA / 393 / 2014
(Against order dated 30.04.2014 in Consumer Complaint No. 02/11
of the State Consumer Disputes Redressal Commission, Chhattisgarh)
HEERA BEN SELARKA ... APPELLANT
Versus
GENERAL MANAGER BIRLA SUN
LIFE INSURANCE COMPANY LTD. AND ORS. ... RESPONDENTS
BEFORE:
HON'BLE MR. JUSTICE A. P. SAHI, PRESIDENT
HON'BLE MR. BHARATKUMAR PANDYA, MEMBER
For the Appellants : Mr. Mishal Vij, Advocate
For the Respondents : Appearance not marked
Dated : 11.03.2026
ORDER
1. This Appeal has been filed by the Complainants who lost the battle before the Chhattisgarh State Consumer Disputes Redressal Commission in Consumer Complaint No. 02 of 2011. The Complaint was dismissed on 30.04.2014 holding that the insured had suppressed the material fact of a pre-existing ailment while acquiring a life insurance policy from the Respondent Birla Sun Life Insurance Company.
2. The Appellants / Complainants are the legal heirs of Late Mr. Saurabh Selarka who had been insured under a Dream Plan Life Insurance Policy. He unfortunately died on 02.12.2009 after 81/z months of acquiring the policy.
3. The claim was set forth in respect of the risks and benefits under the policy where the coverage was Rs.48,92,000/- and had been issued on 28.03.2009. The Insurance Company appointed a claim investigator, Mr. Sanjay Aggarwal who made enquiries and on the basis of such investigation the claim was repudiated on 04.03.2010. The letter of repudiation is extracted herein under:
"Birla Sun Life Insurance 4th March 2010 Smt. Hiraben Selarka Sona Enterprise Mahavir Gosa la K.K. Road, Moudhapara Raipur-492 001 Chhattisgarh Dear Smt. Selarka Re: Death Claim under Policy No.002684132 on the Life of Late Mr. Saurabh Selarka This has reference to your claim dated 25th December 2009, for the benefit under the above policy. We have carefully examined the same; but have decided to repudiate our liability under the policy for the following reasons:-
The above policy was issued on 28th March 2009 on the basis of an application for insurance dated 16th March 2009 submitted by Mr. Saurabh Selarka ('the Life Assured') on his own life under the Company's "Dream Plan" of insurance. In the said application Questions numbered (IX) (D) 2(a) & (h) were replied by the Life Assured in negative. For your ready reference, we are reproducing below the aforesaid questions and the replies thereto in the application for insurance:
"(IX) MEDICAL AND PERSONAL HISTORY OF THE LIFE TO BE INSURED (D) MEDICAL INFORMATION
2. Within the past 5 years, have you:
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a) Consulted any doctor or other health practitioner except for common influenza lasting less than 4 days?...... No.
3. Have you ever had or sought advice for the followinci:-
a) Chest Pain, high blood pressure, stroke, heart attack, heart murmur or other heart disorders?..... .No
h) Dizzy/fainting spells, epilepsy, paralysis, nervous or mental/emotional disorder?. .... No. Further, in the medical examiner's Report dated 9th March 2009 (the "MER"), the Life Assured had replied in negative to the following questions:
Parti
3. Within the past five years, have you:
(a) Consulted any doctor or other health practitioner?
........ No. 4 Have you ever had or sought advice for
a) Chest pain, High Blood Pressure, stroke, heart attack, heart murmur or other heart disorder?........ No.
h) Dizzy/fainting spells, epilepsy, paralysis. nervous or mental/emotional disorder?. ..... No. However, our investigations have established that the Life Assured was suffering from hypertension, vertigo and was taking treatment for the same prior to the application for insurance and Medical Examiner's Report. Hence, we are satisfied that the aforesaid replies in the application for insurance and Medical Examiner's report are false. We also note that the Life Assured has died due to complications of the above mentioned ailments.
Further our investigations have also established that the Life Assured had grossly overstated his income in the application for insurance. Hence the reply to question No.1 (F) in the application for Insurance is false.
If the true and correct facts pertaining to Life Assured's past medical history and annual income were disclosed at the proposal stage, the company would have not issued the Policy on the existing terms.
Since the Company has been misled to issue the Policy, we are, hereby repudiating our liability under the aforesaid Policy. However, we have received the premium amounting to Rs.2.921.70 (Rupees Two Thousand Nine Hundred Twenty One and Raise Seventy only), subsequent to the date of death, which is being refunded herewith, vide our Cheque No.404687 dated 4 March 2010.
If you feel that your case deserves further consideration, you may register your dissatisfaction regarding the same, justifying the grounds for reconsideration, with the Claims Redressal Machinery at the following address:-
Birla Sun Life Insurance Co. Ltd.
4th Floor, Vaman Centre Makhwana Road, Near Marol Naka Off Andheri-Kurla Road, Andheri (East) Mumbai-400 059 Yours sincerely Sd/- illge.
Authorized Signatory ForBirla Sun Life Insurance Co. Ltd."
4. The repudiation letter records that on investigations it was found that the insured was suffering from Hypertension and Vertigo and was being treated, and that he died due to complications of the above ailments.
The second ground taken is that the assured had over stated his income in the application for insurance and therefore his reply was incorrect while filling up of the proposal form.
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5. The State Commission examined the issues and the material collected by the investigator was also assessed. The said material included a certificate issued by one Dr. Ashish Dubey dated 17.02.2010. The same is extracted herein under:
ANNEXURE A-1 MM HOSPITAL (Medical Nursing Home & ICCU) Dr AMhnSl?MDd be\ Dr- Sandhya Dubey M.D. (Medicine) Consultant Time: M.D, (Medicine) sSEstliEdnr. & «• o?fn£9: 10,0 2 P'nf'- 8 EveninS 6 t0 8:30 No.8953 94252^02393 Consult'n9 Physlclan Sunday clo5ed Specialist Medicine 8 Consulting Physician . ..------ -------- ■■■ ______ _ ______ M: 98271-48222 2°!Lal8lnl Complex, Main Road. Fafadih. RalpuM92009 (C.G.) Ph; 2523958. 252777G. (R> 2529898_______ Dated: 17.02.2010 Certified that Shri Saurabh Selarka 30 years of age was suffering from hypertension with vertigo and was under my treatment from 10.02.2009 to, 15.02.2009. He was advised rest for same for complete recovery.
Sd/- illge.
Ashish Dubey M.D. (Medicine) Consulting Physician Fafadih, Raipur (C.G.) Seal Certified to be a true copy Seal //True Copy// Y\ __ ' -6-
6. Relying on the said certificate, and holding that the testimony of Dr. Ashish Dubey in support of the said document it was evident that the insured had suppressed his pre-existing diseases of hypertension and vertigo and the same being a material fact, the claim was rejected by the State Commission. Accordingly the repudiation letter was upheld.
7. The State Commission also commented upon the sharp increase in the insured amount which was initially for Rs. 1,08,200/- that was enhanced to Rs.48,92,000/-. The State Commission doubted the same and treated it to be suspicious.
8. Assailing the order learned Counsel for the Appellant contends that both the grounds are untenable inasmuch as even though the State Commission has noticed the testimony of Dr. Ashish Dubey but it has ignored the inconsistencies and the admissions therein which render it totally uncreditworthy. The contention is that the certificate of Dr. Ashish Dubey was a procured and generated document obtained by the investigator of the Insurance Company and could not have been relied on in view of the answers given on affidavit by Dr. Ashish Dubey.
9. On the question of the increase in the amount insured, learned Counsel submits that it was done consciously and the Insurance Company has charged the premium for the same. There was no reason to doubt or suspect the increase inasmuch as neither the insured was unhealthy nor was he possessed of any poor health conditions. To the contrary he was a NCC cadet and had an athletic built. His unfortunate death was nowhere connected with any pre-existing disease. It has also been urged that there was no reason to suspect the enhancement inasmuch as even if the Income Tax Returns were not very substantial according to the State Commission, yet it is undisputed that he was the son of a businessmen and was capable of supporting the payment of a premium of Rs. 1460.85/- per month which was being regularly deposited. Thus there was no reason for the State Commission to have suspected the status of the insured whose father was an established businessman. The State Commission had therefore completely erred in recording the conclusions contrary to the evidence on record.
10. Learned Counsel for the Insurance Company has however supported the findings recorded in the Impugned Order of the State Commission and has urged that even if the statements of Dr. Ashish Du bey on examination may appear to be not acceptable, the certificate issued by him could not be disputed by the Complainants and as such the repudiation is justified on both counts and findings recorded by the State Commission do not suffer from any infirmity.
11. Having heard learned Counsel for the Parties, we may point out that the burden of proof to establish the fact of any pre-existing disease is on the Insurance Company and the law on this count is no longer res Integra as explained by the Apex Court in the case of Mahakali
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Suiatha versus Branch Manager, Future Generali India Life Insurance Company Limited and Anr. reported in C2024} 8 SCC
712.
12. Applying the ratio thereof we have examined the evidence on record particularly the statement of Dr. Ashish Dubey which is extracted herein under:
"7. Dr. Ashish Dubey, S/o SH. M.M. Dubey, age 50 Years, Coordinator, M.M Hospital; Jai Laxmi Complex, Main Road; Fafadih, Tehisi & D/stb Raipur;. (CG)gives following answer in reply to question on the demand of complainant Smt Hera Ben Seiarka in the form of affidavit.
1. Whether the Certificate dated17-02-2010 given in relation to Saurabh Seiarka in your hand writing?. Answer- Yes
2. Whether Saurabh Selafka was your regular patient before his. death on 02-12-2009?
Answer-No
3. Whether you are family doctor ofSaurabh Seiarka? Answer-No. 4 Whether you known to family members ofSaurabh Seiarka? How many total family members in the family of Saurabh Seiarka?
Answer-No.
5. Whether you have diagnose/treated any family members of Saurabh Se/arka, when and for how much time? Answer-I have not diagnose/treated any family members of Saurabh Selarka.
6. To whom and when you have issued the said certificate Exh-E dated17-02-2010 related to Saurabh Seiarka? Answer- one person came to me as Saurabh Seiarka and demanded the said certificate Exh-E dated 17-02-2010 from me.
7. Whether it is correct: that the name of that person has not been mentioned in that certificate? Answer-yes, it is correct.
8. Whether the said certificate has given by you on the demand of Investigator Saniav Kumar Bir/a Sun Life Insurance Co. ltd. ? whether the said demand was written? Answer-No.
9. Whether it is correct that you have not diagnosed the deceased Saurabh Seiarka any time while admitting in your Hospital i.e. M.M. Hospital for any disease. Answer- Yesr it is correct.
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10. Whether you have charged any fees from Sanjay Kumar or Birfa Sun Life Insurance Co, Ltd in respect of issuing the said certificate? If yes, then whether you have given a receipt? If no then, how much fees charged by you? Answer- No.
11. Whether without charging any fees/ how much and to whom these types of certificates had been issued by you and till today? Answer- Not Remember li?. Whether the facilities of ICCU and Medical Nursing home has been provided by you as mentioned in the certificate? Answer-Yes
13. Whether deceased Saurabh Seiarka has ever taken services of your Hospital or ICCU?
Answer-No.
14. Whether there is medical store in your Nursing Home? Answer-Yes
15. As you have mentioned in your certificate that you have diagnosed/treated the deceased Saurabh Seiarka from 10-02- 2009 till 15-02-2009, Have you registered him in vour Nursing home, if No, then, you have violated the medical Rules & regulations.
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Answer-Registration not done; only admitted patient would be registered in our Nursing home.
Whether you have not mentioned the registration Number in your certificate dated 17-02-2010 regarding the treatment of deceased Saurabh Seiarka? Whether It is Correct? Answer-Yes.
17. Whether deceased Saurabh Seiarka come to your Hospital from 10-02-2010 to 15-02-2010' dailyor come only for one day? Answer, Never Came.
18. Whether you have conducted any test on the deceased Saurabh Seiarka?
Answer- No, nothing test has been performed.
19. How much biood pressure of deceased Saurabh Seiarka was recorded.between 10-02-2009to 15-02-2009 and when you have recorded the same?
Answer-1 have neither conducted nor recorded the biood pressure of deceased Saurabh Seiarka.
20. Whether in your certificate the disease of vertigo has been mentioned? In this disease, one attendant always be with the patient whether there was any patient with Saurabh Seiarka? Have you advised for conducted the, ENT test to deceased Saurabh Seiarka?
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Answer- Yes, mentioned. Nobody was came, no advise was given.
21. Whether you have conducted the test of blood Sugar, Kidney Function, Lipid Profile in your Nursing Home? What was the report: of the same? Is there any document for the same? Answer-Not done, no document was there.
22. What are the medicines had been prescribed by you to the deceased Saurabh Seiarka?
Answer-Neither medicines was given nor prescribed.
23. Whether the patient had purchased the medicines from the medical store of your Nursing Home? In this respect, show the copy of the bill?
Answer- No medicines: was purchased therefore no bill was there.
24. Till today how many patients you have treated? How many patients are alive? How many of dead and from which disease they are dead? Whether you have advised the deceased Saurabh Seiarka to consult any special Doctor?
Answer- Not remembers. No advice has been given to deceased Saurabh Seiarka
25. To whom you have issued the certificate Exh E dated 17-02-20107
- 13- Answer- One person came to me as Saurabh Selarka and demanded the said certificate Exh-E dated 17-02-2010 from me and I had issued the same.
26. The person who had come to you for such certificate. what did he toldyou about the purpose for issuance ofthe same? Answer- He told me that I required the said certificate Exh-E dated 17-02-2010 for the purpose that his comoanY entrusted him heavy work so for removing the burden ofsuch heavy work he required the same.
27. What is the legal value of such certificate Exh-E dated 17-02- 20107 Answer that certificate does not bear any legal value. I came to know from the documents that the certificate Exh-E dated17-02-2010 issued bv me has been taken bv one Sh. Saniav Aaaarwai, claim investiaator for M/s Birta Sun Life Insurance company while misleading me as Saurabh Selarka.
28. Whether the certificate in respect, of treatment by deceased Saurabh Selarka from dated 10-02-2009 to 15-02-2009 has been issued after 1 year 2 days? Whether it is correct? Answer- Yes, and That's why the certificate is false.
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29. Whether at the time of giving certificate on 17-02- 2010, you have been informed that the Saurabh Seiarka had died?
Answer-No.
30. Whether it is correct that you are not competent to diagnose the hypertension and vertigo as mentioned in the certificate Exh- E dated 17-02-2010 as you are not qualified for that disease?
Answer - Yes.
31. Whether it is correct that deceased Saurabh Seiarka has never met you during his lifetime and you have never diagnose or conducted any treatment on deceased? Answer-Yes
32. Whether it is correct that vou have issued the said false certificate to Investigator Saniav Kumar of Biria Sun Life Insurances Co^ LtdJust to avoid the ciaim. of the complainant. Answer- No, Saniav Kumar had obtained the said certificate bv misted me as Saurabh Seiakarwhich is totally a false certificate.
33. Whether it is correct: that on every Sunday you dinic/hospitai is dosed and if yes then on 15702/2009 it was Sunday, then
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where you treated the deceased Saurabh Selerka on that day being a Sunday?
Answer It is correct that on Sunday my client remains closed being a holiday. It is also correct that I have never ADDITIONAL STATEMENT Saniav Agarwal himself bv personifying himself to be the deceased Saurabh Seiarka appeared before me and give me false information saving that he needs the certificate for a private iob and accordingly he obtained the certificate on 17.02.2010. Having satisfied with the perusal of the documents made available by Smt. Heera Ben Seiarka. I have found that the certificate issued bv me on 17.02.2016 has no legal force. The forged certificate obtained bv the forged persons does not keep any utility. I beg pardon from this Hon'hie Commission for the aforesaid forged certificate and I assure this Hon'bie Commission that in future I will not commit such wrong. From the certificate obtained by Sanjay Agarwal, it appears that he had obtained the certificate for undue benefit to the Biria Sun Life Insurance Company. Therefore, I humbly submit before this Hon'bie Commission that Sanjay Agarwal may be punished as per taw.
Accordingly this affidavit in the form of questionnaire is submitted before this Hon'bie Commission.
Sd/-illge.
Deponent -16- VERIFICATION:
lf deponent verify that Dr. Ashish Dubey S/o Late Sh. M. M. Dubey, Aged 50 years; Director NLM. Hospital, Jai Laxmi Complex, Main Road, Fafadih, Teshii& District-Raipur (C.G.) that the contents of the questionnaire from para 1 to 35 and the additional statement are true to. my best of knowledge, and the same has read over to me and I admitted the same to be true. Verified today at Raipur.
Sd/-iHge.
Deponent Place: Raipur (C. G.) Dated: 19.12.2011"
13. A perusal of the said statement of Dr. Dubey in relation to the certificate dated 17.02.2010 issued by him and relied upon by the investigator speaks volumes of the incongruity and inconsistency on a plain reading of the questions and the answers given by him. At the outset while answering Question No.-l he accepts having issued the certificate but while answering the other questions particularly question No.-6 he has stated that one person came to him posing to be Mr. Saurabh Selarka and demanded the said certificate. In the other questions he has admitted that he had neither diagnosed Mr. Saurabh Selarka at any time admitting him in his hospital for any disease. He has not even admitted having charged fees or prescribed medicines. He has then while answering question No. 17 stated that Mr. Saurabh Selarkar never came to his hospital. While answering question No.-18 he states that no tests have been performed and while answering question No.-19 he has stated that he has neither conducted nor recorded the blood pressure of the deceased.
14. It is surprising that without even measuring the blood pressure of the deceased it was certified that he was suffering from hypertension. This entire answer given by Dr. Ashish Dubey therefore belies his own certificate. He has also indicated that there were no reports of either blood sugar or any other tests before him nor he had prescribed any medicines. In fact the reading of the entire affidavit of Dr. Ashish Dubey culminates in the truth of the matter while answerting question No.-27 where he states that the certificate was obtained by Mr. Sanjay Aggarwal the claim investigator for the Insurance Company while posing as Mr. Saurabh Selarka. This admission is the last nail in the coffin which establishes that the certificate had been procured by Mr. Sanjay Aggarwal, the investigator which again stands confirmed while answering question No. 32 extracted herein above. To say the least the additional statement thereafter categorically records that Mr. Sanjay Aggarwal impersonated himself as Mr. Saurabh Selarka which was obtained by him on the pretext of a private job.
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15. Applying the priciples of any prudent rule of evidence this entire testimony unravels the manner in which the Insurance Company has attempted to procure evidence in order to defeat a valid claim. We thoroughly deprecate the practice of the Insurance Company and we find that the Insurance Company through this dubious method had succeeded in repudiating the claim which is clearly based on a fake and procured evidence.it is not only uncreditworthy but is also unethical.
16. Learned Counsel for the Insurance Company urged that this being a disputed question of fact should not be made the basis of any order in a summary jurisdiction. We reject this argument outright keeping in view the fact that this is a Complaint that was filed under a Consumer Protection Act, 1986 where the provisions Section 13(4) empower the Commission to examine witnesses on oath. Not only this, the Commission enjoys an inquisitorial jurisdiction as well and therefore the least that was expected from the State Commission was to have assessed the aforesaid affidavit on oath tendered by Dr. Ashish Dubey while he was examined on specific questions raised. These were interrogatories which were answered consciously and therefore could not have been cast aside to believe the certificate of Dr. Ashish Dubey or base findings thereon. For all the reasons herein above we therefore find that the findings of the State Commission about the pre-existing diseases of the insured are perverse and based on no evidence. The
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Insurance Company has failed to pass muster the tests led down by the Apex Court in the case of MahakaHSuiatha (Supra).
17. We have already mentioned above that the doubt that has been expressed about the increase in the insured amount as suspicious is unfounded because the monthly premium of Rs. 1460.85/- was paid regularly. Not only this the Income Tax Return as indicated and discussed by the State Commission in Paragraph No. - 14 of the Impugned Order does not raise such a doubt so as to discard the status of the insured capable of paying the premium. In addition thereto it is undisputed that the father of the insured was an established businessman and therefore to doubt the annual income of the deceased and to state that it was not possible for him to procure the insurance policy and pay its premium is a totally misconceived presumption. We do not agree with the findings so recorded by the State Commission as they appear to be ipse dixit
18. Thus on both grounds the Impugned order dated 30.04.2014 passed by the Chhattisgarh State Commission is set aside. The Complaint of the Appellants being Consumer Complaint No. 2 of 2011 is allowed. The repudiation letter dated 04.03.2010 is declared to be invalid for the reasons given herein above and we hold that the Complainants are entitled to the payment of the benefits of the insured amount under the Death claim policy No. 002684132. The payment of the entire insured
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amount together with 6% interest thereon shall be payable to the Complainants within two months from today. The interest on the said amount shall be payable from 04.03.2010 which is the date of repudiation till the date of actual, payment.
19. The Insurance Company shall make the payments within the aforesaid period and in the event of any default the rate of interests would stand enhanced to 9%. The amount shall be deposited with the State Consumer Disputes Redressal Commission, Chhattisgarh for being disbursed to the Complainants in accordance with law.
20. The Appeal is accordingly allowed.
Sd/-
( A.P. SAHI, J-) PRESIDENT Sd/-
Mss/Mukesh Kumar(CC)/C-l/21 .............