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Judgment
Vinod K. Sharma, J.—The Petitioner has approached this Court, with a prayer for issuance of a Writ, in the nature of Certiorari, for
quashing the order dated 25.04.2008, vide which the medical claim of the Petitioner under the Insurance Policy stands repudiated by the
Respondent company.
The Petitioner was insured under the Scheme of Medical Claim Policy in the year 2001, and the policy was subsequently renewed regularly.
The policy was in force from 01.12.2008 to 30.01.2009.
The policy taken out by the Petitioner was to cover unexpected hospital expenses, sudden illness, injury, disease and other domiciliary
hospitalization.
It is the case of the Petitioner, that the Petitioner felt Chest pain on 03.08.2007, and accordingly, approached his family Doctor, who advised
the Petitioner to undergo a test of Coronary Angiogram. As per the result of the Angiogram, the Petitioner was advised to undergo a bye-pass
surgery. The Petitioner was in the very serious state at that time.
The case of the Petitioner, is that it was only after hospitalization, that he had come to know that he had pre-existing disease called ""Diabetic
Mellitus"". The Petitioner, after undergoing surgery, filed the claim with the Insurance Company.
As the Petitioner was denied cash less hospitalization, the Petitioner filed W.P. No. 8331 of 2007. On notice, the Insurance Company took a
stand, that the Petitioner had approached this Court, without raising claim with the Insurance Company. In the counter affidavit, the Respondents
had undertaken to consider the claim of the Petitioner when submitted. The Petitioner, was directed to submit his claim by supporting documents to
the Insurance Company, within a period of one week of the receipt of a copy of the order, with a direction to be considered it in the terms of
Medical Claim Policy taken out by the Petitioner.
The Petitioner accordingly filed the claim, vide the impugned order, the claim of the Petitioner stands rejected.
The impugned order reads as under:
Dear Insured,
Subject: Liability Under Your Policy
We confirm receipt of your claim as per the reference given above. We state our inability to admit liability due to the following:
Clause Description
4.1 All diseases / injuries which a re pre-existing
when the cover incepts for the first time. For the
purpose of applying this condition, the date of
inception of the initial mediclaim policy taken
from any of the Indian insurance Companies
shall be taken, provided the renewals have been
continuous and without any break.
The insurance policy was taken for the first time on 06.11.2011, in 2003 the policy was renewed on 01.12.2003 with a break, hence this policy is
to be considered as fresh policy and continuous policy coverage is taken from this date only as per Insurance rule. The Diabetes Mellitus of over
six years has a definite bearing to this claim as hypertension and diabetes mellitus are considered to have damaging effects especially on the blood
vessels of the vital organ like heart, Kidney and eyes. Diabetes Mellitus being pre-existing and a major life long ailment related to damage of the
coronaries is a complication of the pre-existing ailment as per the Insurance Policy Clause 4.1. Therefore, we express our inability to admit this
liability under this claim as the claims falls under Clause 4.1 of the policy (pre-existing ailment with related complicates) and the non-disclosure
clause of the policy.
In case you have further facts or information to substantiate your claim, please forward the same to us.
The Petitioner challenged the impugned order on the ground that the stand taken by the Insurance Company, is contrary to the earlier stand
taken before this Court, as at that time, the eligibility was not disputed.
The contention of the learned Counsel for the Petitioner is, that the stand of the Respondents now is an attempt to deny the claim of the
Petitioner under the Medical Claim Policy.
It is also the contention of the learned Counsel for the Petitioner, that the reasons recorded, are wrong, as the Petitioner did not suppress any
material from the Insurance Company, while taking out the Medical Claim Policy.
The case of the Petitioner, is that in Column 17, it was categorically mentioned that Petitioner suffers from ""Diabetus Meletus"", which at the
time of renewal, was again reasserted.
Learned Counsel for the Petitioner placed reliance on the judgment of the Hon''ble Supreme Court in the case of LIFE INSURANCE
CORPORATION of INDIA and OTHERS v. ASHA GOEL (SMT) and Anr. (2001 (2) S.C.C. 160) to contend that the writ petition against the
Insurance Company was competent.
It is also the contention of the learned Counsel for the Petitioner, that suppression by policy holder must be fraudulent, and mere inaccuracy or
falsity cannot be a ground to deny the benefit under the policy. It is thus contended that the impugned order cannot be sustained.
The learned Counsel for the Petitioner placed reliance on the judgment of the Hon''ble Supreme Court in Biman Krishna Bose Vs. United India
Insurance Co. Ltd., wherein the action of the Insurance Company, refusing to renew the policy was held to be bad in law.
It is the contention of the learned Counsel for the Petitioner, that the Insurance Company is State, within the meaning of Article 12 of the
Constitution of India, thus amenable to Writ jurisdiction.
This writ petition is opposed by the learned Counsel for the Respondents, by contending that disputed question of facts have been raised
regarding the suppression of material facts while taking out the policy.
It is also the contention of the learned Counsel for the Respondents, that contrary stand has been taken by the Petitioner, as one side it is
stated that the Petitioner came to know about the factum of suffering from ""Diabetic Mellitus"" only after hospitalization, whereas now the stand is
that the factum was not suppressed.
On consideration, I find that the writ petition is not competent before this Court. It cannot be disputed that the Insurance Company is ""STATE
within the meaning of Article 12 of the Constitution of India, therefore, amenable to writ jurisdiction, but at the same time, the disputed question of
facts cannot be gone into in the writ petition, as the remedy with the Petitioner is to take out appropriate proceedings before the Consumer Court,
regarding the deficiency in service or appropriate Civil remedy, in accordance with law, where disputed question of facts can be gone into.
This Court, in exercise of writ jurisdiction cannot adjudicate the disputed question of facts.
Consequently, this writ petition is dismissed as not maintainable. The liberty is granted to the Petitioner to avail his alternative legal remedy, in
accordance with law.
The Petitioner has been prosecuting his remedy before this Court bonafide since 2008. In case, the Petitioner chooses to avail alternative
remedy, he shall be entitled to the benefit of Section 14 of the Limitation Act, in those proceedings.
No costs. Consequently, the connected M.P.(MD) No. 1 of 2008 is closed.