National Insurance Company Ltd. Vs Sadhu Singh & Another

The petition has been filed inter alia seeking a writ of certiorari quashing the award dated 26.07.2017, Annexure P-9, passed by Permanent Lok Adalat (Public Utility Services), Patiala, whereby reimbursement claim of the first respondent against the overseas travel insurance policy – Trawell Tag Cover More, has been accepted directing the petitioner - insurance company to pay the claimed amount of `13,47,610 along with interest at the rate of twelve per cent per annum.

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As per brief facts apparent on record, the first respondent took the aforementioned policy for the period he had to travel to Australia, with effect from 24.06.2014 to 20.12.2014. While in Australia, he felt pain in stomach, discomfort and fever, etc., and was treated as outdoor patient from 12.08.2014 to 01.09.2014. As the pain increased, he had to be hospitalised in emergency department of Eastern Health Victoria on 02.09.2014, and was diagnosed with Urosepsis and Renal failure, ureteric stone. He was treated there and discharged from the hospital on 02.10.2014; expenses equivalent

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MANINDER 2026.07.23 09:46 I attest to the accuracy and authenticity of this order/judgment

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CWP-24955-2017 2

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to `13,47,610 were incurred on the treatment. He finally returned to India on 07.05.2015. The reimbursement claim submitted by him was repudiated vide letter dated 30.06.2015, Annexure P-6, on the following grounds:

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Our medical panel is of the opinion that you have been treated for Urolithiasis, UTI and Acute Renal Failure. We have also noticed from your medical documents that you have past medical history of Kidney Stone and Diabetes. Please note that policy doesn’t cover any preexisting disease and related complications.

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Hence based on these documents, and the opinion of our medical panel, we shall not consider your claim admissible for the reasons they are related to the direct complications of your past medical history excluded from the scope of policy coverage.

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2.1. Therefore, the first respondent had to approach the Permanent Lok Adalat by filing an application under Section 22-C of the Legal Services Authorities Act, 2002 (for short, ‘the 2002 Act’), wherein the impugned award dated 26.07.2017 was passed accepting the claim. This has been challenged by the petitioner - Insurance Company before this Court.

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Learned counsel for the petitioner submitted that the application has been wrongly allowed by the Permanent Lok Adalat. The claim was not admissible in terms of the Policy as the first respondent was suffering from a pre-existing disease. The fact has been established on the basis of opinion of the medical panel constituted by the insurance company and other medical documents. Further, it terms of condition 10(c) of the Policy also it was not admissible, which reads as under:

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c. Pre-existing condition. The pre-existing condition means any sickness/illness, which existed prior to the effective date of this insurance including whether or not the insured person had knowledge that symptoms were related to the sickness/illness. Complication arising from a pre-existing condition will also be considered part of the pre-existing condition.

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MANINDER 2026.07.23 09:46 I attest to the accuracy and authenticity of this order/judgment

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CWP-24955-2017 3

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Learned counsel for the first respondent, however, submits that the application has been rightly accepted as there is no evidence on record that the first respondent was suffering from a pre-existing disease. He was not aware about the disease at the time of taking the policy, and the claim was wrongly repudiated by the insurance company. He also submits that the amount awarded by the Permanent Lok Adalat has already been released to him by the Executing Court against security.

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Submissions made by learned counsel for the parties have been considered.

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To substantiate the argument regarding the first respondent’s suffering from pre-existing disease, learned counsel for the petitioner has referred to a letter dated 29.06.2015, Annexure P-5, whereby opinion tendered by Dr. P.R. Purandare has been sent to the Claims Manager, Heritage Health Services Pvt. Ltd. (for short, ‘the HHSPL’). There is no averment in the entire petition as to how the HHSPL is related to the petitioner, nor has it been explained as to how the reimbursement claim of the insured is required to be considered by the said company; the terms of its engagement, if any, have also not been referred to. Learned counsel for the insurance company could only submit that the details have been mentioned in para 9 of the petition, which are only to the effect that the claim was not accepted by the HHSPL after going through the entire record, especially the discharge summary, medical opinion and other available documents. This is not sufficient to establish the relevant facts. Further, the HHSPL does not refer to any specific medical record based upon which the opinion has been tendered, which reads as under:

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OPINION:

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Insured has been treated for Urolithiasis, Urinary Tract Infection and Acute Renal Failure. To rule out pre-existing and

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MANINDER 2026.07.23 09:46 I attest to the accuracy and authenticity of this order/judgment

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CWP-24955-2017

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allow the claim, we had earlier asked for certain documents. However insured has not submitted these documents. Based on available document, as per notes in the Annexure 2- Patient Medical History – daily Record – DM and urinary stone disease are pre-existent. Hence the claim can’t be allowed.

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Apparently, the documents asked for by the company to rule out pre-existing disease were not submitted by the insured. It is also not the case that the insured was ever examined by the said doctor before tendering the opinion. The claim has been rejected for the reason – ‘DM and urinary stone disease are pre-existent’. But these are not the ones for which the insured was treated in Australia. The treatment he took was for – Urosepsis and renal failure. Also, it has not been conclusively demonstrated that the later disease was caused by the former. Therefore, the repudiation of claim on the basis of such an opinion cannot be countenanced.

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The petition accordingly stands dismissed.

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(TRIBHUVAN DAHIYA) JUDGE 15.07.2026 Maninder Whether speaking/reasoned : Yes/No Whether reportable : Yes/No

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MANINDER 2026.07.23 09:46 I attest to the accuracy and authenticity of this order/judgment

National Insurance Company Ltd. v. Sadhu Singh & Another

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National Insurance Company Ltd. v. Sadhu Singh & Another

Case brief

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