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IN THE HIGH COURT OF KARNATAKA AT BENGALURU
M. NAGAPRASANNA, J.
Mrs. Jaya Elizabeth Mathew W/O Mr.Preneesh Ommen – Appellant
Versus
Insurance Ombudsman For The State Of Karnataka – Respondent
Writ Petition No.14346 of 2021 (GM-RES)
Decided on : 21-10-2022
Loan - Insurance claim - Petitioners are wife and husband respectively. 1st respondent is Insurance Ombudsman and 2nd respondent is the insurer/HDFC Ergo General Insurance Company - Petitioners having a desire of building a house opted for home loan through 2nd respondent/Company - Loan came with “Home Suraksha Plus’ dated and was to be for a period of 5 years - Policy covered major medical illness and procedures to an amount of Rs.56,87,368/- jointly for both petitioners - On 10-08-2020, it appears that Doctors at Vikram Hospital diagnosed the 1st petitioner to be suffering from Multiple Sclerosis and started treatment immediately - After the treatment, insurance claim was made on the strength of the insurance coverage that was given by 2nd respondent/Company in its policy dated - Against said repudiation, petitioners approached Insurance Ombudsman challenging repudiation by 2nd respondent/Company - Insurance Ombudsman by an order dated affirms repudiation of the claim of petitioners and also holds that petitioners were guilty of their non-disclosure of information about serious illness notwithstanding it being in their knowledge - It is order of repudiation by 2nd respondent/Insurance Company and order of 1st respondent/Insurance Ombudsman that drives petitioners to this Court in subject petition.
Finding of Court : Those are not the facts in the case at hand, as it was held that husband of the petitioner therein had not died on account of pre-existing disease but he died for sepsis, pancytopenia, left loculated pleural effusion - Court would hold that clause with regard to preexisting illness was not applicable in factual matrix - Therefore, said judgment would not lend any assistance to the petitioners - Said judgment was tossed before Division Bench by Insurance Company which also comes to be dismissed - Finding of Division Bench which has only affirmed order of co-ordinate Bench would also lend no assistance to petitioners - Other two judgments relied on by learned counsel for petitioners would also become inapplicable, as they are distinguishable on facts obtaining in those cases without much ado - Facts therein would become distinguishable to the facts in case at hand - Claimant therein was suffering from myocardial infarction and it was a finding that cause of death was myocardial infarction due to Ventricular Fibrillation -Said judgment also is inapplicable to facts of the case at hand - In light of preceding analysis, no fault can be found with repudiation and order of Ombudsman affirming said repudiation and disallowing the claim. [Para 12 and 13]
Result : Petition undoubtedly meets its dismissal and is accordingly dismissed.
ORDER :
The petitioners are before this Court calling in question order dated 29-03-2021 passed by the 1st respondent/Insurance Ombudsman declining to accept the insurance claim of the petitioners, sought quashment of letter of repudiation dated 14-12-2020 issued by the 2nd respondent/Insurance Company and a consequential direction of issuance of a writ in the nature of mandamus directing release of an amount of Rs.28,43,684 being the Insurance claim of the petitioners.
2. Heard Sri Apoorv Khator, learned counsel for the petitioners and Sri S.Krishna Kishore, learned counsel for the 2nd respondent.
3. Shorn of unnecessary details, facts in brief, as borne out from the pleadings, are as follows:-
The petitioners are wife and husband respectively. 1st respondent is the Insurance Ombudsman and the 2nd respondent is the insurer/HDFC Ergo General Insurance Company (‘the Company’ for short). The petitioners having a desire of building a house opted for home loan through the 2nd respondent/Company. The loan came with “Home Suraksha Plus’ dated 29-04-2017 and was to be for a period of 5 years from 29-04-2017 to 28-04-2022. The policy covered major medical illness and procedures to an amount of Rs.56,87,368/- jointly for both the petitioners. On 10-08-2020, it appears that the Doctors at Vikram Hospital diagnosed the 1st petitioner to be suffering from Multiple Sclerosis and started treatment immediately. After the treatment, the insurance claim was made on the strength of the insurance coverage that was given by the 2nd respondent/Company in its policy dated 29-04-2017. The claim was repudiated by communication of the 2nd respondent dated 14-12-2020 on the ground that the 1st petitioner was diagnosed to be suffering from multiple sclerosis from 27-03-2017 and the ailment was a pre-existing ailment which had not been divulged by the petitioners while filling the form claiming such insurance. Against the said repudiation, the petitioners approached the Insurance Ombudsman challenging repudiation by the 2nd respondent/Company. The Insurance Ombudsman by an order dated 29-03-2021 affirms repudiation of the claim of the petitioners and also holds that the petitioners were guilty of their non-disclosure of information about serious illness notwithstanding it being in their knowledge. It is the order of repudiation by the 2nd respondent/Insurance Company and the order of the 1st respondent/Insurance Ombudsman that drives the petitioners to this Court in the subject petition.
4. The learned counsel appearing for the petitioners would contend that on 27-03-2017 the 1st petitioner had developed only giddiness and vomiting and was diagnosed as vertigo and the further diagnosis of the 1st petitioner was multiple sclerosis. It is for the first time the Doctors at Vikram Hospital opined that the 1st petitioner is suffering from multiple sclerosis. Therefore, the petitioners had no occasion to mention a problem that would occur in future when the insurance policy was taken. On these technical grounds the claim of the petitioners is rejected. The learned counsel would seek to place reliance on the co-ordinate Bench decision of this Court in MRS. SHIVAPRABHA JAYAPRAKASH SHETTY v. UNION OF INDIA – Writ Petition No.52434 of 2018 decided on 20-08-2019; Division Bench judgment of this Court in NATIONAL INSURANCE COMPANY LIMITED v. SHIVAPRABHA JAYAPRAKASH SHETTY – Writ Appeal No.3944 of 2019 decided on 19-02-2020; order of the High Court of Delhi in PAVAN SACHDEVA v. OFFICE OF THE INSURANCE OMBUDSMAN AND ANOTEHR – W.P.(C) 6304 of 2019 decided on 27-07-2020 and a decision of the Madras High Court in JASMINE EBENEZER ARTHUR v. HDFC ERGO GENERAL INSURANCE COMPANY LIMITED AND OTHERS – W.P.Nos. 22234 of 2016 and others decided on 6-06-2019.
5. On the other hand, the learned counsel for the 2nd respondent/Insurance Company enters appearance and files detailed stat
Point of Law : No fault can be found with the repudiation and the order of Ombudsman affirming the said repudiation and disallowing the claim. [Para 13]
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