An insurer cannot deny a claim based on uncommunicated policy conditions, emphasizing the necessity for clear disclosure of exclusions to the insured.

JUDGMENT

The prayers in the writ petition are as follows:

“(i) Declare that the first respondent was not entitled to any relief under the policy as claimed in Exhibit P1 Original Petition.

(ii) Issue a writ of certiorari or any other appropriate writ, order or direction of the nature of mandamus quashing Exhibit P6 as grossly illegal and wrong."

2. Heard the learned counsel for the petitioners and the learned counsel appearing for the 1st respondent. The writ petition is filed challenging Ext.P6 order of the Permanent Lok Adalath on the ground that the finding to the effect that the 1st respondent is entitled to the payment of an amount of Rs.14,736/- towards medical bills which were liable to be reimbursed by the petitioner in terms of Ext.P1 policy as illegal. It is submitted by the learned counsel appearing for the petitioners that the 1st respondent had preferred Ext.P1 claim before the Peramanent Lok Adalat and produced Ext.P2 which was a copy of the Senior Citizens Red Carpet Insurance Policy. It is stated that the 1st respondent was insured for medical benefits to the extent of Rs.2,00,000/- by the policy. It is submitted by the learned counsel for the petitioners that Ext.P3 contained the conditions attached to Ext.P2 policy which were not produced by the 1st respondent.

3. The policy conditions specifically provided for Exclusions. Clause 5 of the Exclusions provided that 50% of each claim arising out of pre-existing diseases and 30% in all other claims are to be borne by the insured. Clause 14 thereof provided the charges incurred at hospital or nursing home primarily for diagnostic, X-ray or laboratory examinations not consistent with or incidental to the treatment of ailment, for which confinement is required are also excluded. Pursuant to Ext.P1 complaint, written statement of defence was filed by the petitioners before the Lok Adalath as Ext.P4. It is stated therein that the claim preferred by the 1st respondent had initially been repudiated by the petitioners based on Clause 14 of the Exclusions. However, it is submitted that the issue was reconsidered and out of total bills of Rs.14,736, the petitioners had already made a payment of Rs.9,919/- on 15.10.2014 which was not accepted by the 1st respondent. Lok Adalath, considering the contentions raised on either side, accepted the contentions raised by the 1st respondent that the terms and conditions of the policy which are contained in Ext.P3 were not served on the 1st respondent and therefore, the petitioners could not repudiate the claim of the respondent on the basis of the conditions contained in Ext.P3. In the above circumstances, there was a direction to the petitioners to pay an amount of Rs.14,736/- which was the bill amount in full to the petitioners.

4. The order of the Permanent Lok Adalath is challenged in this writ petition on the ground that the finding of the Lok Adalath to the effect that the policy conditions had not been served on the 1st respondent was perverse and unsupported by any evidence. It is further stated that the coverage of the policy is also provided in Ext.P3 and not in Ext.P2 and the stand taken by the 1st respondent before the Lok Adalath that she was not covered by the exclusions contained in Ext.P3 would also mean that she does not entitled the coverage. It is further stated that the payment made by the petitioner was in strict conformity with the conditions contained in the policy and therefore the finding of the Lok Adalath was unsustainable.

5. The learned counsel appearing for the 1st respondent contended that the claim filed by her before the Lok Adalath was on the specific ground that the conditions of the policy which have been relied on by the petitioner for repudiating the claim raised by her had not been served on her. It is submitted that it was only after a lawyer notice was issued that a partial payment was attempted to be made to the respondent. Since the policy document which was handed over to the respondent did not