Dismissed

M/S. Care Health Insurance Ltd. Formerly Known as Releghare Health Insurance Company Ltd. v. Mereeta Jesudas

Kerala HC27 Oct 2023WA/1600/2023

Case brief

AI extract

What is this about?

A writ appeal filed by an Insurance Company challenging the Single Judge's order directing the company to reimburse medical expenses incurred for the treatment of the original petitioner's father. The High Court upheld the lower court's decision after finding the insurer failed to substantiate its claim that the deceased suppressed his medical history.

What the court decided

AI extract

M/S. Care Health Insurance Ltd. Formerly Known as Releghare Health… — Insurance | Kerala HC (2023)

¶1

W.A.No.1600 of 2023

¶2

¶3

IN THE HIGH COURT OF KERALA AT ERNAKULAM

¶4

PRESENT

¶5

THE HONOURABLE THE CHIEF JUSTICE MR. A.J.DESAI

¶6

¶7

THE HONOURABLE MR.JUSTICE V.G.ARUN

¶8

FRIDAY, THE 27^TH DAY OF OCTOBER 2023 / 5TH KARTHIKA, 1945

¶9

WA NO. 1600 OF 2023

¶10

AGAINST THE ORDER/JUDGMENT WP(C) 7208/2021 OF HIGH COURT OF KERALA APPELLANT/1St RESPONDENT IN W.P.(c):

¶11

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

¶12

BY ADVS. AKHIL K.MADHAV P.S.RAMU

¶13

RESPONDENT/S:

¶14

1 MEREETA JESUDAS AGED 37 YEARS, D/O JESUDAS DINESH N BANGERA, BANGERA BHAVAN, PARAVOORPUNNAPRA, ALAPPUZHA DISTRICT, KERALA STATE ., PIN - 688004 2 JESLY JESUDAS BANGERA, W/O JESUDAS DINESH N BANGERA, BANGERA BHAVAN, PARAVOORPUNNAPRA, ALAPPUZHA DISTRICT, KERALA STATE ., PIN - 688004 BY ADVS. JOSEPH GEORGE P.A.REJIMON(K/700/2017)

¶15

THIS WRIT APPEAL HAVING COME UP FOR ADMISSION ON 27.10.2023, THE COURT ON THE SAME DAY DELIVERED THE FOLLOWING:

¶16

W.A.No.1600 of 2023

¶17

¶18

A. J. Desai, C.J. &

¶19

V.G. Arun, J.

¶20

=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=

¶21

W.A.No.1600 of 2023

¶22

Dated this the 27^th day of October 2023

¶23

JUDGMENT

¶24

A.J. Desai, C.J.

¶25

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.

¶26

The short facts of the case are as under;

¶27

One Jesudas Dinesh N.Bangera was admitted in the hospital viz.Lilavati Hospital, Mumbai on 10/06/2019 and was discharged

¶28

on 23/6/2019. Thereafter, he was shifted to another hospital,

¶29

wherein he passed away on 10/07/2019. An amount of

¶30

W.A.No.1600 of 2023

¶31

¶32

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

¶33

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.

¶34

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.

¶35

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

¶36

W.A.No.1600 of 2023

¶37

¶38

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.

¶39

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

¶40

W.A.No.1600 of 2023

¶41

¶42

had never undergone any treatment for hypertension as alleged by the Insurance Company.

¶43

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.

¶44

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

¶45

reason to interfere with the judgment impugned in this appeal.

¶46

Hence, the appeal is dismissed.

¶47

Sd/-

¶48

A. J. Desai Chief Justice Sd/-

¶49

V.G. Arun Judge

¶50

dpk

M/S. Care Health Insurance Ltd. Formerly Known as Releghare Health Insurance Company Ltd. v. Mereeta Jesudas

Case brief

What is this about?

What the court decided

M/S. Care Health Insurance Ltd. Formerly Known as Releghare Health Insurance Company Ltd. v. Mereeta Jesudas

Case brief

What is this about?

What the court decided

A compact analysis

Issues for consideration

Statutes considered

Parties & counsel

Coram

Case details

Similar cases

Jose K.Francis, Vs the Authorised Officer, Yes Bank Ltd.

N.M.Vijayan, Vs the Kerala State Election Commission

Apj Abdul Kalam Technological University Vs Joel Sunny Varghese

P.K.Shanavaz Vs the Micro and Small Enterprises Facilitation Council

Mr. Thomas Joseph Alias Joseph Vs the Authorised Officer

Mr. Thomas Joseph Alias Joseph Vs the South Indian Bank Ltd.