The court held that a claim cannot be denied based on a pre-existing condition unless there is evidence of treatment or symptoms within 48 months prior to the policy issuance.

JUDGMENT :

BASANT BALAJI, J.

The petitioner had availed a medical insurance policy to get insured in connection with an overseas journey to the United Kingdom and Dubai. The insurance policy was valid from 25.09.2019 to midnight of 10.11.2019. Ext.P1 is the policy issued, and as per the contract of the policy, an amount of 2,50,000 USD was covered towards accident (medical expenses), 25,000 USD towards personal accident, 1,000 USD towards loss of checked-in baggage, 100 USD for delay of checked-in Baggage, 250 USD towards loss of passport, 2,00,000 USD towards personal liability and 10,000 USD towards illness (medical expenses).

2. The petitioner was subjected to a medical examination, and a detailed investigation was conducted by a competent Doctor and Ext.P2 Medical Examination Report was produced before taking the policy. It is specifically noted that, there was no previous history of any operation or existing disability. When the petitioner was abroad, she fell ill due to fever and suffered difficulty to breath. An amount of Rs.1,77,894.57 (9007.32 AED) was spent for the treatment, and after returning, the petitioner has lodged a detailed representation and requested to extend the benefit of the health insurance policy as per Ext.P1. The 1^st respondent company, after due verification and investigation, had approved the claim submitted by the petitioner as per Ext.P3 for AED 9007.32 less USD 100. Ext.P3 is an email sent to the petitioner asking to produce certain documents. Thereafter, Ext.P4 letter dated 23.1.2020 was issued rejecting the petitioner’s claim on the grounds of pre-existing disease and related complications. The petitioner approached the Grievance Cell of the 1^st respondent and filed a complaint, but the complaint was dismissed, against which the petitioner approached the 3^rd respondent. The 3^rd respondent, also vide Ext.P7, rejected the complaint on the ground that there is a reference regarding the history of bronchial asthma in the discharge summary and that the petitioner has not disclosed the same while taking the policy. The petitioner challenges Exts.P4 and P7 in this Writ Petition.

3. A counter affidavit is filed by 1^st and 2^nd respondents, in which it is contended that the petitioner was aged about 74 years and was hospitalised at Mediclinic City Hospital, Dubai, from 23.10.2019 to 25.10.2019, as she felt difficulty in breathing. It was diagnosed as an infective exacerbation of Asthma and Respiratory failure. In the discharge summary, it is specifically noted that the patient had a history of bronchial Asthma. Ext.R1(b) is the copy of the discharge summary dated 25.10.2019. The respondents have also produced Ext.R1(c) proposal form in which, for query nos.2 and 5, the petitioner has stated that she doesn’t have any illness or disease up to the date of making the proposal or had an accident in the 12 months preceding the first day of insurance.

4. While submitting the proposal and obtaining the policy, the petitioner has suppressed vital facts regarding her existing disease and health conditions. The utmost good faith is required regarding the medical insurance policy, and the insurance contract in the instant case is void. The 1^st respondent has no liability under the contract. The policy was obtained by suppressing existing diseases and ‘pre-existing diseases’ which have been specifically defined in the policy. The policy issued in this case is not a general health policy, and coverage is intended for use by the insured person in the event of a sudden illness or accident arising when the in