Madras HC orders disbursal of Insurance Claim, says Suppression of Medical Leave and Treatment Not Grounds for Denial

A bench led by G.k.Ilanthiraiyan was hearing a petition challenging the repudiation of the petitioner's insurance claim. The petitioner's husband, who was the Principal in charge at Government Arts and Science College, Manimedu, Mayiladuthurai District, had subscribed to the policy, which assured a sum of Rs 10 lakhs. The petitioner, the wife of the insured is a nominee.

The insured individual passed away on January 9, 2020, due to sudden cardiac arrest. He had chest pain and immediately, he was taken to hospital, unfortunately, he died without taking any treatment.

After his demise, the petitioner made a claim under the policy, it was denied on the grounds of suppression of material facts that the petitioner was taking treatment for chest pain from the year 2016 onwards and he was admitted to the hospital on several occasions. He also obtained medical leave on many occasions. The claim of the petitioner was rejected and repudiated the amount, which was subscribed to the policy to the tune of Rs. 53,713.

The advocate for the respondent i.e. the insurance company informed the court that the petitioner, at the time of taking the policy, claimed that during the last five years, he did not consult a Medical Practitioner for any Ailment requirement for more than a week. He also said that he never remained absent from his place of work on grounds of health during the last 5 years.

However, on verification of records from the deceased employer as well as from the hospital it was found that the deceased availed leave on medical grounds on various occasions for a period of more than a week from his employer before taking the policy. He was also admitted to the Meenakshi Mission Hospital for his cardiac Artillery Disease from 12.12.2016 to 13.12.2016 as an In-patient, that too, in the ICU. “These facts were suppressed by the insured who obtained the policy. If at all the deceased revealed the said facts, the respondent would not accept the proposal for Rs.10 lakhs under the Policy,” the respondent submitted.

After considering the submissions, the court found that though he was undergoing treatment in the Meenakshi Mission Hospital from 12.12.2016 to 13.12.2016 for his chest pain, he was admitted as an inpatient and discharged from the hospital within one day without any surgery. After 2016, there was no medical leave by the insured and he did not even undergo any surgery or treatment.

The court stated, “The petitioner suffered from fever and Typhoid, those are incidental to any one life, there is no evidence to show that the petitioner had chronic heart ailments. In fact, on 09.01.2020 he suffered sudden cardiac arrest and died, even before taking any treatment. Therefore, mere suppression of facts that the petitioner had taking treatment during the last 5 years and he obtained medical leave on the health ground are not the reason for rejection of claim.”

The court also pointed out that normally, the application for the insurance policy is filled up by the Agent without getting any instructions from the insured. Moreover, the petitioner did not approach the respondent directly to take the insurance policy. “He was canvased by the agent and the proposal form was also filled up by him without even consulting the insured and obtained the signature. Therefore, it cannot be said that the insured suppressed the fact that he went on medical leave and also admitted in the hospital,” the court added.

To view the order, click the link below: