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 the Constitution.

JUDGMENT :

P.M. MANOJ, J.

The above captioned writ petitions are preferred against the denial of the full claim and the complete rejection of the subsequent claim by the respondent insurance company, and seeking a direction to quash Exts.P8, P14 and P15.

2. It is the case of the petitioner that he is the policyholder under a policy (LIC’s health plus plan table 901) valid up to 31.03.2024, which commenced on 31.03.2008. It covers medical treatment for the petitioner along with three other family members, namely his wife and two children, as evident from Ext.P1 insurance policy.

3. Due to hospitalisation of his wife, the petitioner submitted a claim petition for a sum of Rs.60,093/- along with supporting documents on 02.05.2016. She was hospitalized from 12.04.2016 to 22.04.2016. Then, the petitioner was directed to provide the history and duration of the hysterectomy, as certified by the treating doctor, along with the first consultation paper. In this regard, two communications were effected on 27.05.2016 and 11.06.2016. The petitioner also received a communication to provide the previous treatment papers of implantation done and the placement of DJ Stent, and the treatment details of the hysterectomy of March 2016 by communication dated 26.09.2016, that is Ext.P4.

4. It was responded to by a reply dated 12.10.2016. Even thereafter, a similar communication was issued to the petitioner on 08.11.2016. That was also responded to by the petitioner, and requested not to drag the issue. Even then, the claim of the petitioner was not acted upon. He preferred a reminder on 25.01.2017 along with a certificate issued by the Urologist. Then the 1^st respondent sanctioned the claim, which was limited to Rs.5,600/- against a claim of Rs.60,093/-, stating that “the benefits under the policy are not directly related to actual expenses incurred by you. The benefits are calculated based on the initial Daily Benefit opted by you in the proposal forms, on the life of the beneficiary referred above and the period of hospitalization and type of surgery eligible as per the Policy Terms and Conditions as elaborated in conditions and privileges referred to in the policy Document.”

5. The said order dated 04.02.2017 issued by the 1^st respondent was initially challenged in W.P.(C) No.13244 of 2017, which is a document marked as Ext.P8 in both the writ petitions. The petitioner also preferred a petition to review the said order, which is produced as Ext.P9 in that writ petition and sought for quashing Ext.P8 and expeditious disposal of Ext.P11, the claim petition. During the pendency of the said writ petition, the petitioner's wife continued treatment at Vedanayagam Hospital Ltd., Coimbatore. She was admitted there between 01.08.2016 and 24.08.2016, during which an expenditure of about Rs.1,80,000/- was incurred.

6. Then the petitioner preferred another claim petition for the said amount on 22.09.2016. This was during the pendency of the earlier writ petition as mentioned above. Then the respondents issued a communication dated 28.04.2017, directing the petitioner to produce the following details.

1. The history, duration and treatment papers of hernia repair done in past, certified by the treating doctor.

2. The certificate from the treating doctor as to whi