IN THE HIGH COURT OF JUDICATURE AT BOMBAY CIVIL APPELLATE JURISDICTION WRIT PETITION NO.18745 OF 2024 Prakash Mehta ...Petitioner -Versus-

1. The Insurance Ombudsman for State of Goa and Mumbai Metropolitan Region

2. Care Health Insurance Ltd. ...Respondents ______________________________________________________________________ Mr. Akshay Patil with Ms. Girija Balkrishnan, Mr. Jarin Doshi and Ms. Devika Mahadekar i/b. M/s. Malvi Ranchoddas & Co. for the Petitioner.

Mr. Rajesh Kanojia with Ms. Deepika Prabhala, Ms. Sangita Upadhyay i/b.

M/s. Res Juris for Respondent No.2.

_____________________________________________________________________

CORAM: SANDEEP V. MARNE, J.

Judgment Reserved on: 5 May 2025.

Judgment Pronounced on: 9 May 2025.

JUDGMENT :

1) Rule. Rule is made returnable forthwith. With the consent of the learned counsel appearing for parties, the Petition is taken up for final disposal.

2) The Petitioner has filed the present Petition challenging the Award dated 10 June 2024 passed by the Insurance Ombudsman, Mumbai, thereby rejecting the complaint preferred by him, in which he had challenged repudiation of claim by the second Respondent- Insurance Company. The claim of the Petitioner was towards expenditure incurred by him towards medical treatment of Rs.17,77,147/-.

3) Briefly stated, facts of the case are as under:-

Petitioner had secured Health Insurance Policy from M/s. Royal Sundaram General Insurance Company Ltd. (Royal Sundaram) having policy cover of Rs.3,00,000/-, which commenced from 3 September 2003. Under the policy, Petitioner and his wife were covered under health insurance. Policy was renewed every year till 2020 and with no-claim bonus, the insurance cover had gone up to Rs. 4,50,000/- over the period of years. Petitioner was persuaded to port the health insurance policy from Royal Sundaram to Care Health Insurance Ltd. (Respondent No.2) with offer of provision of normal floater insurance cover of Rs. 5,00,000/- for himself and his wife. He was also persuaded to enhance the policy cover known as ‘top-up’ cover by Rs. 50,00,000. Accordingly, with porting of the policy, Petitioner and his wife were given normal policy cover of Rs.5,00,000/- and under the top-up plan, the policy cover was enhanced to Rs.55,00,000/- jointly for the benefit of the Petitioner and his wife. Petitioner paid aggregate premium of Rs.13,23,634/- to the second Respondent, which issued Health Policy No.33902486 for a period of three years commencing from 29 September 2021 to 28 September 2024. Petitioner was diagnosed with tumour in his abdomen in July-2022 and was subjected to several diagnostics tests including biopsy. The diagnostics revealed that he was suffering from Non-Hodgkin’s Lymphoma (cancer) and was advised to undergo chemotherapy and radiation therapies. He was admitted in Breach Candy Hospital for the purpose of biopsy on 22 July 2022 and for the purpose of chemotherapy on 3 August 2022. Petitioner submitted a Claim Form on 18 August 2022. However, he received claim denial letter dated 3 September 2022 by which Respondent No.2 stated that the claim was not payable as per policy terms and conditions citing the reasons of (i) non-disclosure of habit of daily drinking alcohol at the time of policy inception and (ii) non-disclosure. Similar letter was received by the Petitioner on 4 September 2022. On 5 September 2022 one more claim denial letter was received by the Petitioner in which following two reasons were stated for denial of claim:

(i) Denial non-disclosure of habit of daily drinking alcohol at the time of policy inception.

(ii) Non-disclosure of material facts /pre-existing ailments at time of proposal.

4) Petitioner underwent chemotherapy on medical advice on 5 occasions between September-2022 to November 2022. He also underwent radiation between 26 December 2022 to 20 January 2023 in Sir H. N. Reliance Hospital. In connection with his medical treatment, he submitted total 7 claims as under :

5) Six additional claims submitte