Back
IN THE HIGH COURT OF KERALA AT ERNAKULAM
MR. JUSTICE HARISANKAR V. MENON, J
Star Health And Allied Insurance Company Ltd. – Appellant
Versus
Ananthan K. – Respondent
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 1st respondent therein pursuant to Ext.P1 policy dated 11.08.2017. The validity of the afore insurance was till 10.08.2018. The 1st 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 1st respondent and by Exts.P6 and P7 communications, repudiated the claims since, according to it, the treatment was for “pre-existing” disease. The 1st 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 fav
The court emphasized the duty of disclosure in insurance contracts, ruling that claims cannot be repudiated without sufficient medical evidence supporting pre-existing conditions.
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]
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....
Insurance claims cannot be denied arbitrarily on the basis of unrelated pre-existing conditions, as such actions violate the fundamental rights to medical treatment and fairness under Article 21 of t....
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 insurer cannot repudiate a life insurance claim based on non-disclosure of a previous policy if it failed to verify existing records, as this does not constitute material suppression.
Medical Examination – Insurance company is responsible for conducting a medical examination of the policyholder in advance.
(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....
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
