Kerala High Court
M/S. Care Health Insurance Ltd ... vs Mereeta Jesudas on 27 October, 2023
W.A.No.1600 of 2023 1
IN THE HIGH COURT OF KERALA AT ERNAKULAM
PRESENT
THE HONOURABLE THE CHIEF JUSTICE MR. A.J.DESAI
&
THE HONOURABLE MR.JUSTICE V.G.ARUN
FRIDAY, THE 27TH DAY OF OCTOBER 2023 / 5TH KARTHIKA, 1945
WA NO. 1600 OF 2023
AGAINST THE ORDER/JUDGMENT WP(C) 7208/2021 OF HIGH COURT OF KERALA
APPELLANT/1St RESPONDENT IN W.P.(c):
M/S. CARE HEALTH INSURANCE LTD FORMERLY KNOWN AS
RELEGHARE HEALTH INSURANCE COMPANY LTD.
VIPUL TECH SQUARE, TOWER C, 1 ST FLOOR SECTOR-43, GOLF
COURSE ROAD, GURGAON REPRESENTED BY IT'S AUTHORISED
SIGNATORY, PIN - 122009
BY ADVS.
AKHIL K.MADHAV
P.S.RAMU
RESPONDENT/S:
1 MEREETA JESUDAS
AGED 37 YEARS,
D/O JESUDAS DINESH N BANGERA, BANGERA BHAVAN, PARAVOOR-
PUNNAPRA, ALAPPUZHA DISTRICT, KERALA STATE ., PIN -
688004
2 JESLY JESUDAS BANGERA,
W/O JESUDAS DINESH N BANGERA, BANGERA BHAVAN, PARAVOOR-
PUNNAPRA, ALAPPUZHA DISTRICT, KERALA STATE ., PIN -
688004
BY ADVS.
JOSEPH GEORGE
P.A.REJIMON(K/700/2017)
THIS WRIT APPEAL HAVING COME UP FOR ADMISSION ON
27.10.2023, THE COURT ON THE SAME DAY DELIVERED THE
FOLLOWING:
W.A.No.1600 of 2023 2
A. J. Desai, C.J.
&
V.G. Arun, J.
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W.A.No.1600 of 2023
---------------------------------------------
Dated this the 27th day of October 2023
JUDGMENT
A.J. Desai, C.J.
By way of the present appeal filed under Section 5 of the High
Court Act, the original respondent - Insurance Company has
challenged the judgment dated 03/03/2023, by which the learned
Single Judge allowed the writ petition filed by the original petitioner
challenging Ext.P10 award of the Insurance Ombudsman,
dismissing the complaint filed by the original petitioner claiming an
amount of Rs.10,48,499/- towards the expense incurred for
providing medical treatment to the father of the original petitioner,
under the policy issued by the appellant.
2. The short facts of the case are as under;
One Jesudas Dinesh N.Bangera was admitted in the hospital
viz.Lilavati Hospital, Mumbai on 10/06/2019 and was discharged
on 23/6/2019. Thereafter, he was shifted to another hospital,
wherein he passed away on 10/07/2019. An amount of
Rs.10,48,499/- was spent for the treatment of late Jesudas during
the period of hospitalisation. The original petitioner sought
reimbursement of the said amount from the appellant company.
The claim was rejected by the Insurance Company and therefore,
the original petitioner-beneficiary filed a complaint under Rule 13
(1)(b) read with Rule 14 of the Insurance Ombudsman Rules, 2017,
as complaint No.KOC-H-037-2021-0414. As the complaint came to
be dismissed by the Authority, the decision of the Authority was
challenged in the captioned writ petition. The first respondent in
the writ petition, the Insurance Company, has filed counter affidavit
opposing the granting of relief.
The learned Single Judge, after considering the materials
placed before him, allowed the writ petition and directed the
Insurance Company to pay the amount spent for the medical
treatment of the deceased. Hence, this appeal.
3. Learned Counsel appearing for the Insurance Company
would submit that the learned Single Judge has committed error in
allowing the petition. Counsel would further submit that, the
deceased was suffering from hypertension which fact was not
disclosed at the time of applying for insurance policy. Learned
Counsel would also submit that if this aspect was disclosed, the
Insurance Company might have either rejected the application or
asked for additional amount of premium and, therefore, the
Ombudsman had rightly rejected the claim put forth by the original
petitioner on the ground that his illness was suppressed by the
deceased. He would therefore submit that the appeal ought to be
allowed and the order passed by the learned Single Judge, set
aside.
4. Learned Counsel appearing for the original petitioner,
opposing the appeal, submitted that the appellant company failed
to produce any document, either before the Insurance Ombudsman
or before the learned Single Judge, to establish that the deceased
had suppressed the ailment of hypertension while applying for the
policy. Learned Counsel would further submit that Insurance
Company as well as the Authority placed undue reliance on the
prescription in the certificate issued by the Lilavati Hospital while
discharging the deceased from the hospital, wherein there is an
observation regarding illness of the deceased including the ailment
of hypertension. However, except the above document, no other
material is placed by the Insurance Company to establish the
allegation regarding suppression of the ailment of hypertension by
the deceased. Therefore, the Counsel would submit that the
learned Single Judge has committed no error in allowing the writ
petition particularly, in the absence of the fact that the deceased
had never undergone any treatment for hypertension as alleged by
the Insurance Company.
5. We heard the learned Counsel appearing for the respective
parties and perused the order of the the Insurance Ombudsman as
well as the judgment delivered by the learned Single Judge. We
have also gone through the documents which have been relied on
by the learned Single Judge and dealt with in paragraph Nos. 15 to
22 of the impugned judgment. We find that, even though the
Insurance Ombudsman has referred to an investigation conducted
by the insurer, absolutely no material was produced to substantiate
the findings in the investigation report.
6. After considering the available documents, the learned
Single Judge arrived at the conclusions in paragraph Nos. 22 to 28
of the impugned judgment. We are in complete agreement with the
observations made by the learned Single Judge and do not find any
reason to interfere with the judgment impugned in this appeal.
Hence, the appeal is dismissed.
Sd/-
A. J. Desai
Chief Justice
Sd/-
V.G. Arun
Judge
dpk
