An insurer cannot repudiate a health insurance claim for non-disclosure if the medical condition was not specifically queried in the proposal form. Writ courts will not interfere with factual findings of quasi-judicial bodies unless the decision exhibits gross illegality or perversity.

J U D G M E N T

The petitioner is a company engaged in General Insurance and this writ petition is submitted by the petitioner, challenging the award passed by the Permanent Lok Adalat for Public Utility Services, Ernakulam. Ext.P5 is the impugned award, which was passed on the complaint submitted by the respondent herein.

2. The reason for submitting the said complaint was that, according to the respondent, the claim made by the said respondent for reimbursement of the medical expenses for the treatment availed by him was repudiated by the petitioner. The respondent had availed a group health insurance policy issued by the petitioner, and Ext.P1 is the said policy. The said policy was valid from 16.12.2019 for a period of one year. On 16.06.2020, the respondent was admitted to Little Flower Hospital, Angamaly for chest discomfort and was diagnosed with CAD-effect angina and he was subsequently treated at Lisie Hospital, Ernakulam where, he underwent surgery and was discharged on 22.06.2020. Seeking reimbursement of medical expenses incurred, the respondent submitted a claim before the petitioner herein, which was repudiated by the petitioner on the ground that, the respondent failed to disclose chest pain and dyslipidemia (DLP) at the time of the proposal. The same was challenged by the respondent by submitting the complainant before the Permanent Lok Adalath at Ernakulam (For Public Utility Services) in O.P.No.92/2022, which resulted in Ext.P5 award, where the contentions raised by the petitioner were rejected and the petitioner was directed to pay an amount of Rs.33,00,000/- (Rupees Thirty-Three Lakh only) to the respondent, along with interest at the rate of 8% per annum from the date of submission of the claim. Challenging the said award, this writ petition is submitted by the petitioner.

3. I have heard Sri.K.J.Saji Isaac, the learned counsel appearing for the petitioner.

4. The main contention raised by the learned counsel for the petitioner is that, the Permanent Lok Adalath at Ernakulam (For Public Utility Services) ought to have rejected the complaint by holding that, the complainant/respondent is not entitled to make the claim, as the respondent failed to disclose the pre-existing illness in the proposal form, and thus, the repudiation of the claim made by the petitioner was strictly as per the terms and conditions of the policy.

5. However, after carefully going through the records, I do not find any justifiable reason to entertain the said challenge. This is because, the contention of the petitioner is mainly on the ground that, the respondent failed to disclose the pre- existing medical condition, i.e., chest pain and dyslipidemia (DLP) at the time of proposal. This contention is raised by the petitioner, mainly by placing reliance upon the executive health check-up done by the respondent at Rajagiri Hospital on 09.02.2019, where it was shown that, the petitioner was suffering from a mild dyslipidemia. Apart from the above, Ext.P4 treatment records were also relied on, where it is mentioned that, the petitioner was having chest pain and dyslipidemia for the past eight months. Ext.P4 was prepared on

10.06.2020.

6. However, on going through the findings entered into by the Permanent Lok Adalath, it can be seen that, those aspects were specifically discussed and considered, in the light of the documents relied on by the petitioner. Thereafter, the Permanent Lok Adalath came to a definite finding that, the petitioner failed to establish any sustainable grounds to invoke the right of