KALYANI AVINASH GOKHALE Vs. UNITD INDIAINSURANCE COMPANY LIMITED

JUDGEMENT

(1.) In this batch of petitions, the decision of the First Respondent to decline a renewal of the Health Insurance Cover has been called into question. The first two writ petitions relate to group insurance policies while the third relates to a top up medicare policy.

(2.) On 18 May 2006, an agreement was entered into between the Bank of Maharashtra (the Second Respondent) and United India Insurance Company Limited (the First Respondent) under which a group Mediclaim insurance cover was to be provided under a scheme of the bank called "Mahabank Swasthya Yojna". The scheme was intended to provide medical insurance coverage to persons who hold accounts with the bank through what was described as "a Tailor made Group Mediclaim". Clause 1(b) of the agreement provided that every account-holder between the ages of five and sixty-five was eligible and that renewals could be granted upto the age of eighty. Clause 2 provided for coverage to the account-holder and to members of his or her family; the expression "family" being defined to mean a prime accountholder, spouse and two dependent children. Clause 2(d) provided as follows :

(3.) The Second Petitioner, Avinash Gokhale, is the spouse of the First Petitioner who is an employee of the Bank of Maharashtra. The Second Petitioner had a policy under the Mahabank Swastha Yojna Scheme on a family floater basis from 27 December 2006 with a sum insured of Rupees five lakhs. That policy has been renewed thereafter from time to time until date. In February 2009, the Second Petitioner was detected to be suffering from cancer of the colon. On 18 April 2009, a proposal for insurance was submitted by the First Petitioner under the Swastha Yojna Scheme on a family floater basis with a sum insured of Rupees five lakhs. The proposal contained in item no.15, a query as to whether the person insured had ever suffered from ailments of the nature specified therein. Clause (h) was "any disorder of the stomach, Ulcer, Bowel or gall bladder, Kidney stones etc." To this, as regards the Second Petitioner, the query was in the affirmative with a note annexing a discharge card of the hospital at Mumbai of March 2009. The discharge card specifically referred to the diagnosis of cancer of the colon, the surgery which had been performed ("Hemicolectomy") as well as the histo pathology findings. Clause 15(i) of the proposal form required a disclosure of "any cancer, Malignant growth, Boil, Cyst or wound etc. which does not heal or improve despite treatment". This was answered in the negative. On 20 April 2009, an insurance policy was issued by the First Respondent. As regards special exclusions, there was an endorsement to the effect that it would be in accordance with the standard group mediclaim and as per the MOU between the bank and the insurer. As regards existing diseases / illness / injury, the insurance policy stated that the discharge card from Bhartiya Arogya Nidhi was attached in respect of the treatment undertaken.