Diagnosis for insurance claims must align with medical confirmation post-surgery, not just initial findings, especially concerning stipulated waiting periods.

JUDGMENT

Muralee Krishna S., J.

The 1^st respondent in W.P.(C) No.38249 of 2023 filed this writ appeal under Section 5 (i) of the Kerala High Court Act , 1958, challenging the judgment dated 29.08.2024 passed by the learned Single Judge in that writ petition.

2. According to the 1^st respondent, she had initially taken Ext.P1 Life Insurance Corporation’s (‘LIC’ in short) Cancer cover Policy dated 24.09.2019 for Rs.10,00,000/-. Since the 1^st respondent was abroad, she could not renew the same during the currency of the policy. Later, after reaching her native place, the 1^st respondent contacted the LIC of India and obtained a new policy from their office at Mavelikkara on 16.03.2021 by remitting the premium amount and completing all mandatory formalities. After five months, on 25.08.2021, the 1^st respondent happened to be hospitalised in Life Line Hospital at Adoor in Pathanamthitta District, on account of profuse bleeding. Having found that Haemoglobin (HB) was lower, two units’ blood were given and Dilation & Curettage (D&C) was conducted. The 1^st respondent was discharged on 28.08.2021. On the basis of the D&C report, she was advised to take expert opinion at Lake Shore Hospital, Ernakulam. Accordingly, she was admitted at Lake Shore Hospital on 09.09.2021 and underwent surgery to remove the uterus and the same was sent for investigation/biopsy. The biopsy result was obtained only on 28.09.2021, confirming that the 1^st respondent was suffering from the disease Carcinoma Endometriosis Grade II. Since the 1^st respondent has a valid cancer cover policy, she submitted Ext.P2 claim petition. In reply, the appellant issued Ext.P3 letter dated 22.11.2021 calling for treatment details of the 1^st respondent. The hospital has issued Ext.P4 certificate showing the details of the treatment undergone by the 1^st respondent. But the appellant rejected the claim of the 1^st respondent, stating the reason that the first diagnosis of ‘any stage of cancer’ was on 25.08.2021, which was during the waiting period of 180 days mentioned in Clause 8(G) of Part C, from the date of policy, i.e., on 16.03.2021. After receiving Ext.P5 rejection order dated 06.01.2023, the 1^st respondent submitted Ext.P6 complaint dated 17.02.2023 before the Manager, Grievance Redressal Office of the appellant at Kottayam. She further approached the Insurance Ombudsman by filing Ext.P7 petition dated 07.07.2023. But, by Ext.P9 award dated 29.09.2023, the Insurance Ombudsman rejected the petition, upholding the contention of the appellant. Hence, the 1^st respondent filed W.P.(C) No.38249 of 2023 under Article 226 of the Constitution of India seeking the following reliefs;

“1) To call for the originals of Exhibit P5 and Exhibit P9 and quash the same by a writ of certiorari;

2) To issue a writ of mandamus or any other writ order or direction commanding the respondents to disburse the monetary benefit due to major stage cancer to the petitioner's valid insurance policy No. 319261424 dated 16.03.2021;

3) To declare that petitioner is eligible and entitled to all the monetary benefit of major stage cancer, covered under the insurance policy No. 319261424.dated 16.03.2021;”

3. In the writ petition, the appellant, who is the 1^st respondent therein, filed a counter affidavit dated 17.01.2024, producing therewith Exts.R1 to R1(g) documents. By producing Ext.R1(b) copy of Ultrasound Scan Report dated 25.08.2021, Ext.R1(c) Histopathology Report dated 31.08.2021 and Ext.R1(d) MRI Report dated 01.09.2021 pertaining to the examination rega