On Monday, in a ruling clarifying the operative meaning of “first diagnosis” under a cancer insurance policy, the Kerala High Court held that coverage under the Life Insurance Corporation of India’s (LIC) Cancer Cover policy applies only when the first detection of cancer, and not its later expert confirmation, occurs after the mandatory waiting period.
The Division Bench of Justice Anil K. Narendran and Justice Muralee Krishna S. allowed LIC’s appeal and set aside the Single Judge’s direction requiring the insurer to honour a claim made by policyholder Haripreetha T, observing that her initial medical reports indicating malignancy were within the 180-day exclusion period.
The case arose when Haripreetha T, a 44-year-old policyholder, challenged the rejection of her claim under LIC’s Cancer Cover policy. She had obtained the policy in March 2021, which stipulated a waiting period of 180 days during which no benefits would be payable if cancer was diagnosed.
During the waiting period, she was first hospitalised in August 2021 due to profuse bleeding. An Ultrasound Scan conducted that day recorded “Endometrial Malignancy”, followed by a Histopathology Report dated August 31, 2021, indicating “Fragments of moderately differentiated endometrioid carcinoma (FIGO Grade II)”. An MRI Scan on September 1, 2021, further suggested “Ca endometrium – Stage 1A.”
Subsequently, she underwent surgery, and the Pathology Report confirmed Endometrial Carcinoma. Based on this confirmation, she submitted a claim asserting that the “first diagnosis” occurred only when the biopsy report established the malignancy, after the expiry of the 180-day waiting period.
The insurer, however, rejected her claim, holding that the first diagnosis fell within the waiting period. The Insurance Ombudsman upheld this decision. Aggrieved, Haripreetha approached the High Court by way of a writ petition, where the Single Judge accepted her plea that the confirmation by a specialist post-surgery amounted to the first diagnosis and directed LIC to release the insurance benefit.
The Bench, after examining the policy terms and medical evidence, took a contrary view. Referring to the case Taber’s Cyclopedic Medical Dictionary, the Court observed that the term “diagnosis” refers to “1. The term denoting the disease or syndrome a person has or is believed to have; 2. The use of scientific or clinical methods to establish the cause and nature of a person’s illness… The diagnosis forms the basis of patient care.”
Relying on this definition, the Bench held that the reports collectively established that cancer was already diagnosed before the expiry of the waiting period. The subsequent biopsy report, merely confirmed the earlier diagnosis and could not be treated as its first occurrence. “This diagnosis, done on 28.09.2021, is the confirmation by an expert, and it is not the first date on which cancer has been diagnosed. In such circumstances, it can only be said that the diagnosis of cancer was within the waiting period of 180 days,” the Court observed.
Accordingly, it concluded that the respondent was not entitled to policy coverage, as the first detection of malignancy fell squarely within the exclusionary period prescribed in Clause 8(G) of Part C of the policy.
On LIC’s alternative contention that the policyholder had suppressed her mother’s medical history of breast cancer, the Court upheld the Single Judge’s finding rejecting the allegation. It noted that the age of the mother was not recorded in the discharge summary relied upon by LIC, while the claimant had asserted that her mother was 74 years old and had suffered cancer nearly three decades ago. “In the absence of any material to contradict this pleading, we concur with the finding of the learned Single Judge that there is no suppression of material fact,” the Bench held.
Setting aside the Single Judge’s order, the Bench allowed the appeal and dismissed the writ petition, thereby affirming LIC’s stand.
Case Title: Life Insurance Corporation of India Vs. Haripreetha T And Anr.
Case No: WA NO. 1670 OF 2024
Coram: Justice Anil K. Narendran, Justice Muralee Krishna S.
Advocate for Appellant: Adv. Harish Gopinath
Advocate for Respondent: Adv. K.Balachandran
Picture Source : https://commons.wikimedia.org/wiki/File:Kerala_New_High_Court.jpg
