A claim cannot be denied if the diagnosis occurred after the policy's waiting period, regardless of prior health disclosures.

JUDGMENT

The Writ Petition has been filed praying to quash Exts.P5 and P9 and praying for a direction to the respondents to disburse the monetary benefits due under the valid Insurance Policy No.319261424 dated 16.03.2021. The petitioner had taken an insurance policy, which is titled “LIC’s Cancer Cover” on 24.09.2019. Ext.P1 is a copy of the policy. Due to non-payment of the premium, the policy lapsed on 17.09.2020. It is stated that the petitioner was abroad during the year 2021, and on 16.03.2021, the petitioner took another policy, No.319261424, from the Mavelikkara office of the LIC with coverage of Rs.20,00,000/-. On 25.08.2021, the petitioner was admitted to the Lifeline Hospital on account of profuse bleeding. Finding that the HB count was low, 2 units of blood were infused. The petitioner was discharged on 28.08.2021. A Dilation and Curettage (D & C) procedure was performed, and on the basis of the report, the petitioner was advised to obtain an expert opinion from Lakeshore Hospital, Ernakulam. The petitioner was admitted at Lakeshore Hospital on 09.09.2021, wherein surgery was performed to remove her uterus. A sample was taken and sent for further investigation/biopsy report. The biopsy result was obtained on 28.09.2021, wherein it was stated that the petitioner was suffering from carcinoma endometriosis grade II. Since the petitioner had valid insurance cover, she had submitted a letter on 19.11.2021 before the 1^st respondent. The petitioner has stated that the original of the policy document is with the 1^st respondent. On 22.11.2021, the 1^st respondent issued a reply to the petitioner informing her about the details that are required for processing a claim form. The petitioner submits that all the required documents were submitted before the 1^st respondent. On 06.01.2023, the 1^st respondent issued a letter to the petitioner stating that, after going through the records, it is seen that the petitioner was diagnosed with cancer on 25.08.2021 and since the diagnosis of illness under the policy had arisen during the waiting period of six months prescribed in the policy, the claim is inadmissible and that the policy would be terminated with immediate effect as per policy conditions of Part C of 8(G). The petitioner sent a reply on 17.02.2023 stating that the diagnosis did not happen within the waiting period and the report regarding the malignancy was received only on 28.09.2021, after the waiting period. It was hence requested that the claim be processed and allowed. The petitioner submitted a complaint before the Manager, Grievance Redressal Office, LIC, Kottayam, a true copy of which is produced as Ext.P6. The petitioner had also approached the 2^nd respondent Insurance Ombudsman by filing a petition on 07.07.2023, true copy of which is produced as Ext.P7. The claim was rejected by the Ombudsman upholding the contention of the 1^st respondent. The order of the Ombudsman has been produced as Ext.P9. The petitioner has challenged Exts.P5 and P9.

2. The 1^st respondent has filed a counter affidavit. Along with the counter affidavit, the 1^st respondent has produced the policy as Ext.R1 and the discharge summary from the Lifeline Hospital, where the petitioner was first admitted as Ext.R1(a). It is contended that at the Lifeline Hospital, the petitioner had undergone an ultrasound (abdomen) on 25.08.2021, wherein endometrial malignancy was suspected and advised to correlate pathologically. A Histopathology sample was taken on 27.08.2021, and a report was obtained on 31.08.2021, which showed fragments of moderately differentiated endometrioid carcinoma. So also, an MR imaging done on 01.09.2021 als