While upholding an order directing PNB MetLife India Insurance Company Ltd to pay ₹22.75 lakh to a policyholder’s family, the national consumer disputes redressal commission (NCDRC) dismissed the insurer’s appeal in a case involving alleged suppression of a pre-existing illness.
In
its order earlier this month, the NCDRC bench comprising presiding member Dr Inder Jit Singh and member justice Sudhir Kumar Jain ruled that the insurer failed to conclusively prove that the deceased insured had deliberately concealed a history of tuberculosis (TB) while purchasing the policy.
The bench says, "Assuming for the sake of argument that the deceased insured had in the past suffered from TB, if a person gets cured from such diseases with proper treatment, normally such persons will not feel the need of declaring such incidents of the past in the proposal form, notwithstanding that proposal form ask such questions for the entire life span of the insured. These are unilaterally drafted proposal forms seeking questions ever since the birth of the insured."
"After careful consideration of the orders of the state commission and other relevant records, we are of the view that PNB MetLife has not been able to discharge its burden beyond a reasonable doubt that the deceased insured was suffering from the diseases alleged to have been suppressed in the proposal form," NCDRC says.
The dispute arose after PNB MetLife repudiated a claim in June 2015, alleging that the insured had suppressed material facts regarding pre-existing ailments, specifically TB, at the time of filling out the proposal form in June 2014.
The complainant, Gitaben I Dantani from Gujarat, had approached the state consumer commission after the claim was denied.
In August 2025, the Gujarat state consumer disputes redressal commission partly allowed the complaint and directed PNB MetLife to pay ₹22.75 lakh with 8% interest from the date of filing, along with ₹7,000 as litigation costs.
Challenging this order, the insurer filed an appeal before NCDRC with a 26-day delay which was condoned. However, after examining the merits, the national commission dismissed the appeal and upheld the state commission’s findings.
NCDRC observed that while suppression of material facts can justify claim repudiation, the burden of proof lies squarely on the insurer.
The commission noted that PNB MetLife relied on certain certificates and hospital records to establish that the insured had TB prior to the policy issuance. However, these documents were found to be inconclusive and unreliable.
Significantly, information obtained under the Right to Information (RTI) Act from the concerned hospital indicated that no record of TB treatment for the insured existed.
NCDRC also pointed out that the insurer failed to examine the issuing authorities of the documents or produce independent medical records to substantiate its claims.
Endorsing the state commission’s reasoning, the NCDRC reiterated a key legal principle: “Suspicion, howsoever strong, cannot take the place of proof.”
It further observed that unless it is clearly established that the insured was aware of the disease and deliberately withheld that information, repudiation of the claim cannot be sustained.
The commission also examined documents cited by PNB MetLife, including a certificate indicating TB treatment in 2013. However, it noted that such references are part of unrelated documents, such as caste and income certificates, and could not be treated as reliable medical records.
Even where TB diagnosis was mentioned, there were no supporting treatment records establishing the duration or continuity of the illness, the bench observed.
NCDRC also made an important observation regarding insurance proposal forms, noting that many questions require disclosure of ailments over a person’s lifetime.
It added that even if a person had suffered from a disease in the past and recovered, they might not necessarily perceive a need to disclose such information—especially in the absence of clarity or awareness.
Concluding that PNB MetLife had failed to discharge its burden of proof, NCDRC held that there was no illegality or material irregularity in the state commission’s order.
“The state commission has passed a well-reasoned order and we do not find any reason to interfere,” the bench says, dismissing the appeal.
The ruling reinforces consumer protection in insurance disputes and underscores that claim repudiation must be backed by clear, credible and verifiable evidence rather than presumptions.
(Case No. NC/FA/133/2026 Date: 12 March 2026)
