Disclosure of pre-existing conditions is crucial for insurance claims; failure to disclose can lead to claim denial if conditions were treated or diagnosed within 48 months prior to policy inception.

JUDGMENT

(Dated this the 10^th day of March 2026)

Late Mahendra Singh Laxmidas Parekh had bought an overseas Mediclaim policy from the 2^nd respondent for the period from 14.2.2022 to 14.5.2022 for a sum of $50,000/- to cover accident and hospitalisation expenses during his stay overseas. The insured was hospitalised due to pulmonary oedema at Mediclinic Park View Hospital Dubai on 4.5.2022. The claim submitted by the petitioner for the expenses he met in the hospital was rejected by the 2^nd respondent Insurance company. Against the rejection, the petitioner approached the 1^st respondent by filing a complaint.

2. The 1^st respondent, after giving opportunity to the complainant as well as the respondent to file their versions, rejected the complainant’s claim on the ground that the claim falls under General Exclusion No.2, part B of the policy. The petitioner has filed this Writ Petition challenging the award of the 1^st respondent and for a direction to the 2^nd respondent to pay off the entire claim with 7.5% interest per annum.

3. The 2nd respondent filed a counter affidavit contending that the allegation that Mahendra Singh Laxmidas Parekh was hospitalised due to pulmonary oedema consequent on community acquired bacterial pneumonia resulted in sepsis, is not correct. In fact, he was admitted to the hospital with complaint of central chest heaviness. He was diagnosed for decompensated heart failure, pulmonary oedema, AKI, IHD, T2 DM, HTN and was treated for the same. He had a history of ischemic of heart disease (IHD), stenting was done in 2014. From the available records, it is established that the treatment due to pulmonary oedema with ACS with de-compensated heart failure with acute kidney injury with diabetes mellitus was caused due to pre-existing condition of hypertension and heart disease.

4. As per the policy condition, any declared or undeclared pre- existing disease is not covered under the policy and therefore, the rejection is in order. Heart failure is known to lead to pulmonary oedema, the ailment was due to complication of pre- existing heart disease. The Ombudsman had rightly rejected the claim as it comes under the General Exclusion No.2 of part B of the policy therefore, prayed for dismissal of the Petition with cost.

5. A reply affidavit is filed by the petitioner to the counter affidavit. It is stated that Ext.P1 policy is self contained and binding on the parties. Pre - existing condition is defined in the policy itself to mean as “any condition, ailment or injury, or related condition(s), for which the insured person had signs or symptom, and/or were diagnosed, and/or received medical advice/treatment, within 48 months prior to the commencement of the first policy issued by the insurer. Admittedly, the stenting was done in the year 2014 and hence, it has no relation with the present illness in 2022. The hospitalisation was due to pulmonary oedema consequent on community acquired bacterial pneumonia resulted in sepsis. Therefore, the allegation regarding pre-existing heart disease is false and was denied. The averment that hospital record shows that the insured has a known case of heart disease is absolutely false. There was no heart failure. The Insurance Ombudsman did not apply his mind to the facts of the case and definition of pre -existing disease in rejecting the claim. The petitioner has not suppressed any material facts in the proposal form. The patient had diabetes and the same is duly filled in the proposal form in the column for pre-existing disease. Stenting done in 2014 stands excluded as it was before 48 months of the date on which the policy was taken.

6. The counsel for the petitioner, Shri.P P J