Back
IN THE HIGH COURT OF KERALA AT ERNAKULAM
SHAJI P.CHALY, J.
Mereeta Jesudas, D/O Jesudas Dinesh N Bangera – Appellant
Versus
Religare Health Insurance Company Ltd. – Respondent
W.P.(C). No. 7208 of 2021
Decided on : 03-03-2023
Constitution of India,1950 - Article 226 - Insurance claim - Repudiation of the claim - Whether hospitalized or not since it was mandatory for issuance of policy which resulted in alteration of risk covered policy and premium amount - Held, Insurance Company cannot later turn around and repudiate the claim stating that there was suppression of preexisting disease unless established by a proof otherwise. Since the award of the Ombudsman and the repudiation of the claim by the insurer are patently unfair, illegal, arbitrary, irrational, and was passed without taking into account the basic background requirements for analyzing the claim raised by the policyholder, interference is required to the repudiation of the claim by the Insurance Company as well as the award of the Ombudsman, exercising the power of discretion conferred under Article 226 of the Constitution of India - Documents produced by petitioner including discharge summary it is quite clear and evident that it was due to a sudden illness insured was admitted in hospital and diagnosed that he suffered brain hemorrhage - These aspects are quite clear and evident from Exhibit R1(e) discharge summary issued by Hospital and Research Centre - Court of considered opinion that it was being satisfied with medical examination conducted and materials furnished by insured that Insurance Company had issued policy - Writ Petition is Allowed.
JUDGMENT :
Petitioner, daughter of one late Jesudas Dinseh N Bangera, who was holding a health insurance policy issued by the first respondent company, has filed this writ petition challenging Exhibit P10 award No. 10/KOC/A/HI/0304/2020-2021 dated 16.12.2020 passed by the Insurance Ombudsman, Kochi in Complaint No. KOC-H-037-2021-0414; whereby the repudiation of the claim of the petitioner by the first respondent Insurance Company is upheld by the Ombudsman.
2. Brief material facts for the disposal of the writ petition are as follows:
Petitioner's father has purchased a Health Insurance policy from the first respondent with the plan name “CARE”, having policy No.14048706 valid from 00.00 Hrs on 09.04.2019 to the midnight of 08.04.2020. The petitioner and the second respondent were joint policy holders along with their father.
3. The case of the petitioner is that the policy was issued after satisfying that all the policy holders have no pre-existing diseases. Anyhow, Sri.Jesudas died on 10.07.2019 while undergoing treatment due to sudden illness. Thereupon, the petitioner lodged a claim for the reimbursement of the medical expenses and she has submitted all the required documents to the first respondent company. But, the Insurance Company rejected the claim as per letter dated 15.11.2019 assigning a reason that ‘there is suppression about pre-existing ailment at the time of purchasing the insurance policy’.
4. According to the petitioner, the claim for reimbursement with all the required documents she submitted clearly stated that Sri. Jesudas had no previous ailments and he was hospitalized due to sudden brain hemorrhage on 09.06.2019. The petitioner has claimed that a total amount of Rs.10,48,499/-has been spent for the treatment of late Jesudas and according to the petitioner, the first respondent is liable to reimburse the same to the petitioner.
5. Anyhow, the claim raised by the petitioner was dismissed by the Ombudsman stating that there is suppression of material facts which disqualifies the petitioner from securing claim from the company. According to the petitioner, the order passed by the Insurance Ombudsman is arbitrary and illegal liable to be interfered with by this Court in a writ proceeding under Article 226 of the Constitution of India.
6. The first respondent company has filed a detailed counter affidavit virtually admitting the policy held by late Jesudas. Among other contentions, it is submitted that the Insurance Ombudsman has considered the issues raised by the petitioner and has arrived at the conclusions after verifying all the documents submitted by the petitioner and therefore, on facts, the petitioner has not established a case for interference with the order of the Ombudsman in a writ proceeding.
7. The first respondent has also raised certain technical pleas with respect to the locus standiof the petitioner and submits that the second respondent, who is the nominee in the Medical Insurance Policy, alone has the locus standito file the writ petition. But, the fact that the petitioner was a co-insured in Exhibit P1 policy, is admitted. It is also stated that the insurance policy being contractual in nature, both parties are under an obligation to obey/fulfill all the terms and conditions of the same in the strict sense of the agreement executed by and between the parties.
8. It is further submitted that late Jesudas had made a proposal online for taking the policy and forwarded an online proposal to the respondent, as is evident from Exhibit R1(c). It is the case of the Insurance Company that it had requested the petitioner to give past medical history or any ailments, and also the details, if the proposed persons had suffered from any disease/illness, irrespective of whether hospitalized or not, since it was mandatory for the issuance of policy which resulted in the alteration of risk covered under the p
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]
The materiality of a fact is determined by the circumstances of each case and is a question of fact. A fact to be material has to have a direct bearing on the cause of death, and mere proximity to th....
The court emphasized the duty of disclosure in insurance contracts, ruling that claims cannot be repudiated without sufficient medical evidence supporting pre-existing conditions.
Insurance – Repudiation of death claim – If insured had not been found to be medically deficient as on date of proposal form then question of any allegation about past disease has to be viewed accord....
Insurers cannot reject claims on trivial grounds or without substantial evidence of pre-existing conditions, as it violates the insured's fundamental rights and undermines the principles of good fait....
(1) Full Knowledge – DLA had the full knowledge of pre-existing ailments at the time of filling the proposal form and there was a nexus with preexisting disease and the cause(s) of death.(2) Proposal....
Medical Examination – Insurance company is responsible for conducting a medical examination of the policyholder in advance.
An indispensable Tool for Legal Professionals, Endorsed by Various High Court and Judicial Officers
Please visit our Training & Support
Center or Contact Us for assistance
Scan Me!
India’s Legal research and Law Firm App, Download now!
For Daily Legal Updates, Join us on :
Back to top
