STAR HEALTH AND ALLIED INSURANCE Vs. ANANTHAN K

JUDGEMENT

(1.) These two writ petitions are filed by Insurance Companies engaged in the business of Health/Allied Insurance seeking to challenge orders issued by the Insurance Ombudsman, Kochi, in favour of the party respondents in these writ petitions.

(2.) The petitioner in W.P(C) No.15775 of 2019 had extended an insurance coverage to the 1st respondent therein pursuant to Ext.P1 policy dtd. 11/8/2017. The validity of the afore insurance was till 10/8/2018. The 1st respondent obtained treatments at Najath Hospital, Aluva and Sunrise Hospital, Kakkanad, from 12/9/2017 and was discharged on 30/9/2017. He submitted two separate claims for hospitalization at Najath Hospital and Sunrise Hospital. The petitioner relied on the discharge card/summary from the respective hospitals and referred to the terms of the insurance proposal submitted by the 1st respondent and by Exts.P6 and P7 communications, repudiated the claims since, according to it, the treatment was for "pre-existing " disease. The 1st respondent, in such circumstances, submitted a complaint before the Insurance Ombudsman and the Ombudsman by Ext.P11 dtd. 29/3/2019 decided the matter in favour of the 1st respondent holding that the petitioner has only relied on a "passing remark in the discharge summary " for repudiating the claim which according to the Ombudsman was not supported by any medical evidence. In the light of the afore, the petitioner was directed to pay Rs.1,77,000.00 to the 1st respondent herein.

(3.) In W.P(C)No.33986 of 2019, the 2nd respondent's wife, availed a Travel Care Policy for the period from 18/7/2016 to 20/11/2016. On the basis of the afore, the insured went abroad. While she was in London, she was admitted to a hospital on 23/10/2016 for treatment and she passed away on 29/10/2016, as evidenced by Ext.P2 Death Certificate and Ext.P3 post-mortem report. The husband - 2nd respondent - raised a claim before the petitioner on the basis of the Travel Care Policy obtained by the wife. The petitioner, by Ext.P5, repudiated the claim, placing reliance on the past medical history of the deceased. In such circumstances, the 2nd respondent presented a complaint before the Insurance Ombudsman and by Ext.P8, the Ombudsman decided the issue in favour of the 2nd respondent holding that the "insured died due to an accidental injury by a fall ".