The insurance policy's ambiguity necessitates interpretation favoring the insured, especially when the insurer wrongfully denies a claim despite evidence suggesting qualification under policy terms.

JUDGMENT

1) This an unfortunate case, where all three male members of the family passed away in a short span of 6 months leaving behind the family in penury. The widow’s claim towards insurance availed by her husband as a part of package of housing loan availed for purchase of their home, is repudiated by the Petitioner insurance company. Due to widow’s inability to repay the housing loan, the finance company has attached the flat for sale. The Insurance Ombudsman has allowed the claim preferred by the widow and has directed Petitioner to pay to her the claim amount of Rs.27,00,000/- vide impugned award dated 21 November 2022. Petitioner is aggrieved by the award dated 21 November 2022 and has filed the present petition.

2) Brief facts of the case are that Respondent No. 2 and her late husband dreamt of owning a house. They planned to purchase of Flat No. 704 on 7^th floor of building Sonadevi Residency situated at plot No. 1, 9/2a and 12/4, Survey No. 1 village Temghar, Bhiwandi, Dist. Thane (the Flat). The husband of Respondent No. 2 was working as a teacher in ABS International School. After negotiations, sale consideration of the flat was agreed at Rs.30,70,000/-. The duo registered an Agreement for Sale with the developer on 31 March 2017. Respondent No. 2 and her husband approached India Infoline Housing Finance Limited (IIFL) for disbursement of housing loan, which sanctioned a loan amount of Rs.27,00,000/- to the couple. However, in the sanction letter dated 24 June 2017, a condition was imposed for compulsory availing of insurance policy. The sanction letter stated that insurance premium of Rs.84,767/- was included in the loan amount. This is how total loan amount sanctioned to the couple was Rs.27,84,767/-, out of which Rs. 84,767 was debited and paid by IIFL directly to Petitioner while the balance amount was disbursed to the couple. The loan amount of Rs. 27,84,767 was repayable in 27 years through Equated Monthly Instalments (EMI) of Rs.22,631/-. After receipt of insurance premium of Rs. 84,767 from IIFL, Tata AIG General Insurance Company Limited (Petitioner) issued Group Credit Secure Insurance Policy in the name of Mr. Vishal Suryabhan Raut (husband of Respondent No. 2). The insurance policy included coverage for specified and defined critical illnesses for Rs.27,00,000/-. It is the case of Respondent No. 2 that insurance policy was never supplied to her or to her husband and it was internal arrangement between IIFL and the Petitioner.

3) In the year 2020, the husband of Respondent No. 2 secured a new job at Vapi, Gujrat and shifted along with his family in a licensed premises at Vapi. On 10 April 2021, the husband of Respondent No. 2 started suffering from fever and visited a doctor. Since there was no improvement in his condition, he was brought to Bhiwandi on 12 April 2021 and was hospitalized in Shree Saish Hospital, Bhiwandi for treatment. It is the case of Respondent No. 2 that her husband suffered from severe cardiac arrest on 15 April 2021 and passed away within 15 to 20 minutes. After securing a copy of the insurance policy, Respondent No. 2 lodged the claim by filling the claim form. On 15 July 2021, Petitioner requested for certain documents to process the claim and particularly called for Electrocardiogram (ECG) and other relevant reports. Respondent No. 2 informed the Petitioner on 16 July 2021 that ECG and other tests could not be conducted. Petitioner forwarded all medical papers of the deceased to Dr. Asrani, its panel medical professional, and based on the medical report, Petitioner repudiated the claim on 20 October 2021 on the ground of absence of any medical documents to substantiate the cause of death due to any critical illness as specified and defined under the insurance policy. On 06 November 2021, Respondent No. 2 produced letter of Dr. Rashmin Jain, who had treated the insured at the hospital certifying that the insured had suffered heart attack.

4) In the above background, Respondent No. 2