IMPORTANT POINT
The court emphasized the duty of disclosure in insurance contracts, ruling that claims cannot be repudiated without sufficient medical evidence supporting pre-existing conditions.

JUDGMENT :

[WP(C) Nos.15775/2019 and 33986/2019]

These two writ petitions are filed by Insurance Companies engaged in the business of Health/Allied Insurance seeking to challenge orders issued by the Insurance Ombudsman, Kochi, in favour of the party respondents in these writ petitions.

2. The petitioner in W.P(C) No.15775 of 2019 had extended an insurance coverage to the 1^st respondent therein pursuant to Ext.P1 policy dated 11.08.2017. The validity of the afore insurance was till 10.08.2018. The 1^st respondent obtained treatments at Najath Hospital, Aluva and Sunrise Hospital, Kakkanad, from 12.09.2017 and was discharged on 30.09.2017. He submitted two separate claims for hospitalization at Najath Hospital and Sunrise Hospital. The petitioner relied on the discharge card/summary from the respective hospitals and referred to the terms of the insurance proposal submitted by the 1^st respondent and by Exts.P6 and P7 communications, repudiated the claims since, according to it, the treatment was for “pre-existing” disease. The 1^st respondent, in such circumstances, submitted a complaint before the Insurance Ombudsman and the Ombudsman by Ext.P11 dated 29.03.2019 decided the matter in favour of the 1^st respondent holding that the petitioner has only relied on a “passing remark in the discharge summary” for repudiating the claim which according to the Ombudsman was not supported by any medical evidence. In the light of the afore, the petitioner was directed to pay Rs.1,77,000/- to the 1^st respondent herein.

3. In W.P(C)No.33986 of 2019, the 2nd respondent’s wife, availed a Travel Care Policy for the period from 18.07.2016 to 20.11.2016. On the basis of the afore, the insured went abroad. While she was in London, she was admitted to a hospital on 23.10.2016 for treatment and she passed away on 29.10.2016, as evidenced by Ext.P2 Death Certificate and Ext.P3 post-mortem report. The husband - 2^nd respondent - raised a claim before the petitioner on the basis of the Travel Care Policy obtained by the wife. The petitioner, by Ext.P5, repudiated the claim, placing reliance on the past medical history of the deceased. In such circumstances, the 2^nd respondent presented a complaint before the Insurance Ombudsman and by Ext.P8, the Ombudsman decided the issue in favour of the 2^nd respondent holding that the “insured died due to an accidental injury by a fall”.

4. It is in the afore circumstances that the respective petitioners have filed the captioned writ petitions.

5. I have heard Sri.Harish Gopinath, the learned counsel for the petitioner in W.P(C) No.15775 of 2019 and Sri.Hari Kumar G. Nair, the learned counsel for the petitioner in W.P(C) No.33986 of 2019. The respective party respondents were represented by Sri.Rajesh S.Subrahmanian and Sri.G.Biju, the learned counsel.

6. The issue arising for consideration in these writ petitions is whether the findings contained in the respective awards of the Insurance Ombudsman are sustainable or not.

7. In both cases, the Insurance Company sought to repudiate the claims on the allegation of “pre-existing” diseases, which were not disclosed while obtaining the policies. I notice that the petitioners have extended the Insurance Policies based on certain printed format policies and considerable reliance is being placed on the various clauses contained in the afore policies.

8. In this connection, I notice the judgment of the Apex Court in Manmohan Nanda v. United India Assurance Co. Ltd. and Another [ (2022) 4 SCC 582 ] That was a case where the appellant travelled abroad for attending a wedding after obtaining mediclaim policy. The policy was issued after a proper medical examination, wherein it was recorded that the appellant had Type II Diabetes alone. No other adverse medical conditions were recorded/found. In the medical examination, there are two specific queries about possible illness/disease. The doctor who examined the appellant noted the same as “normal”. The doctor further noted that there was no c