The principle of utmost good faith requires full disclosure of medical history in insurance contracts, failure of which justifies claim denial.

JUDGMENT

(Dated this the 05^th day of November, 2025)

The petitioner had availed two health insurance policies from the 2^nd respondent company for a sum assured to the tune of Rs.10,00,000/-. Subsequently, the petitioner took another policy on 29.07.2022, namely, the Niva Bupa GCC Plan-Health Plus Policy, for a sum assured of Rs.25,00,000/-. The said policy comes under the category of group health insurance, known as a Group Master Policy, offering cashless treatment and coverage for various medical expenses. The petitioner had availed an overdraft facility of Rs.25,00,000/- from the 3^rd respondent Bank, and as part of the said loan, she was enrolled under the Group Master Policy.

2. While the said policy was in force, the petitioner was admitted to Aster Medicity, Kochi on 01.12.2022, for coronary angiogram, which showed CAD with Triple Vessel Disease, and PTCA was done on 03.12.2022. She was discharged on 05.12.2022. The petitioner thereafter raised a claim under the Niva Bupa GCC Plan-Health Plus Policy, which was rejected as per Ext.P4 on the following grounds:

“Non-disclosure-1.1. As per submitted documents, patient has a history of Hypertension from 1 year and basilar aneurysm - treated with stent-assisted coiling on 24.05.22 which is prior to policy start date. This was not disclosed to us at policy issuance stage. We regret the claim is not payable under non disclosure, policy clause 2(XIV).”

3. Aggrieved by the repudiation of the claim, the petitioner approached the 1^st respondent, Insurance Ombudsman, and a complaint was registered as KOC-H-031-2425-0206. The Ombudsman conducted a hearing and thereafter passed Ext.P8 award, directing the refund of the premium amount of Rs.1,83,254/- to the complainant. Challenging the said award, the petitioner has filed this writ petition.

4. A counter affidavit has been filed by the 2^nd respondent contending that the petitioner had submitted an enrollment form for the issuance of Niva Bupa GCC Plan-Health Plus Policy based on the disclosures made therein. The policy was valid from 29.07.2022 to 28.07.2027 for a base sum insured of Rs.25,00,000/-. It was a Group Policy, with the 3^rd respondent as the master policyholder. Ext.R2(a) is the enrollment form signed by the petitioner on 29.07.2022. In Ext.R2(a), sub-clause 3 deals with medical history. For all the questions where the petitioner was required to mark either ‘Yes’ or ‘No’, she had marked ‘No’ in all the columns, except one marked as ‘N’, indicating that she was in good health.

5. As mentioned earlier, the petitioner, however, was a patient of systemic hypertension and had an intracranial aneurysm and she had undergone stent-assisted coiling of the basilar aneurysm on 24.05.2022.

Though Ext.R2(a) was signed on 29.07.2022, the said material fact was suppressed. It is contended that, had the petitioner disclosed the true details, the company would not have issued the policy. Thus, the policy was obtained by suppression of material facts and also non-disclosure of pre- existing illness. Under the contract of insurance, the parties are bound to observe the principle of uberrima fidei (utmost good faith), which the petitioner failed to uphold.

6. As per Clause 5.14 of the policy conditions, it is specifically stated that the policy shall be void and all premiums paid thereon shall be forfeited to the company in the event of any misdescription or non-disclosure of material facts by the policyholder. Since there was non-disclosure of pre- existing disease, the rejection of the claim is valid. The Ombudsman has rightly held that the petitioner is not entitled to any claim amount.

Therefore, prayed that the writ petition be dismissed.

7. A counter affidavit was also filed by the 3^rd respondent, wherein it is averred that the petitioner had availed ove