Insured’s duty is to divulgepre-existing illness, says Karnataka HC, Legal News, ET LegalWorld – Legal Firms

BENGALURU: Mediclaim policy is a contract of good faith and repudiation of the claim due to suppression of pre-existing illness cannot be faulted, the high court observed in a recent judgment.

“Divulging pre-existing illness was a duty of the insured. Having not done so, the repudiation of the claim cannot be faulted with,” Justice M Nagaprasanna noted while dismissing a petition filed by a couple from Vidyaranyapura in Bengaluru.

He also pointed out that in Satwant Kaur Sandhu Vs New India Assurance Company case, the Supreme Court held that mediclaim is a non-life insurance policy meant to assure the policy holder in respect of certain expenses of hospitalisation and it is a contract of insurance falling under the category of contract Uberrimae fidei (utmost good faith) on the part of the assured.

He also noted that the insurance ombudsman, on looking at medical records of the first petitioner (wife) from 2012, had concluded they revealed a history of vertigo since pre-pregnancy and the suggestion at Columbia Asia Hospital or Baptist Hospital was that she might be suffering from Multiple Sclerosis (MS). The discharge summary of Baptist Hospital was ‘White Matter Disease of the CNS (central nervous system)” and based on this, the claim was rejected. The husband was the second petitioner in the case.

The judge added: “The petitioners’ counsel contended it is not a pre-existing illness. It had been further claimed it was diagnosed as Multiple Sclerosis only later. This submission goes against records and is unacceptable. Medical terminology cannot be fixed in terms of nomenclature though every diagnosis of the first petitioner related to Multiple Sclerosis.”

The couple had approached the court challenging the March 29, 2021 order of the insurance ombudsman, wherein the repudiation of the petitioners’ claim of December 14, 2020 was confirmed. They sought a directive to release their claim of Rs 28,43,684.

The claim was declined on the grounds that the patient had been diagnosed with MS since March 27, 2017, with the policy coming into effect only from April 29, 2017. The petitioners had availed a home loan from HDFC Ergo General Insurance Company. The loan came with Home Suraksha Plus dated April 29, 2017 and was valid for five years till April 28, 2022. The policy covered major medical ailments and the sum assured was Rs 56,87,368 jointly for both petitioners.

On August 10, 2020, doctors at Vikram Hospital diagnosed the wife with MS and started treatment immediately. After the treatment, the insurance claim was raised. The claim was repudiated by the insurer on December 14, 2020 on the ground that the claimant (wife) had been diagnosed with MS from April 27, 2017 itself and it was a pre-existing ailment which had not been divulged by petitioners when availing insurance.

The petitioners approached the insurance ombudsman, who on March 29, 2021 affirmed the repudiation and held petitioners guilty of non-disclosure of serious illness though they knew about it.

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