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IN THE HIGH COURT OF KERALA AT ERNAKULAM
BASANT BALAJI
Kumud Mahendra Parekh – Appellant
Versus
National Insurance Company Ltd., Represented By Regional Manager – Respondent
| Table of Content |
|---|
| 1. insurance policy details and claim origin. (Para 1 , 2) |
| 2. claims of pre-existing conditions and responses. (Para 3 , 5) |
| 3. court's analysis of policy terms and conditions. (Para 4 , 6 , 7) |
| 4. definition and relevance of pre-existing conditions. (Para 8 , 11 , 12) |
| 5. judicial interpretation of insurance claims and obligations. (Para 9 , 10) |
| 6. final order granting claim and directing compliance. (Para 14) |
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 Ex
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.
The rejection of an insurance claim based on alleged pre-existing conditions must be substantiated by evidence showing treatment or symptoms within the specified period prior to the policy issuance; ....
Disclosure of pre-existing conditions is crucial for insurance claims; failure to disclose can lead to claim denial if conditions were treated or diagnosed within 48 months prior to policy inception.
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 court emphasized the duty of disclosure in insurance contracts, ruling that claims cannot be repudiated without sufficient medical evidence supporting pre-existing conditions.
Travel Medical Policy – Repudiation of claim – When the insured was thoroughly examined by doctor of insurance company before approval of the insurance policy, repudiation on ground of non-disclosure....
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....
Proof - The Appellants further asserted that the Respondent also had history of asthma but no evidence has been placed by them to substantiate the same.
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