STAR HEALTH AND ALLIED INSURANCE CO. LTD. Vs. THE SECRETARY, INSURANCE OMBUDSMAN, STATE OF BIHAR AND JHARKHAND AND ORS.

JUDGEMENT

(1.) Petitioner in the present case is aggrieved by and dissatisfied with the judgment and award dated 24.10.2016 passed by Insurance Ombudsman in Complaint Reference No. PAT-G-044-1617-0095 as contained in Annexure '3' to the writ application by which the petitioner Insurance Company has been directed to settle the claim without further delay and pay compensation of Rs. 50,000/- towards monetary compensation against the arbitrary cancellation of the policy.

(2.) Learned counsel for the petitioner submits that the facts of the case are not in dispute. The Assured had obtained a mediclaim individual policy from the petitioner based on his proposal and declaration dated 27.03.2014 / 28.03.2014 (Annexure 'P/4'), however, lapsed due to non-payment of renewal premium in time. The Assured filled up a declaration form on 28.03.2014 declaring normal condition of his health 'good'. He declared that he was not suffering from any of the diseases mentioned in the proposal form. Based on the declaration of the good health, the Insurance Company agreed to issue the policy, later on the policy lapsed due to non-payment of premium within grace period of 30 days. The respondent, however, got the policy revived after 32 days for the period 02.05.2015 to the midnight of 01.05.2016. The Assured raised a claim for the expenses incurred by him in course of his treatment in Medanta Hospital. In course of processing of his claim seeking reimbursement of hospitalisation expenses for treatment of chronic kidney disease. The Insurance Company found that the USG report dated 15.03.2013 was showing medical renal disease and serum creatinine report dated 14.05.2013 showed 3.75 mg/dl. The Insurance Company therefore repudiated the claim of the Assured vide letter dated 28.01.2016 as contained in Annexure '4' to the counter affidavit.

(3.) Being aggrieved by the repudiation of claim when the Assured moved before the Insurance Ombudsman by filing a complaint, the Insurance Ombudsman allowed the complaint. It is the contention of learned counsel for the petitioner that the Insurance Ombudsman could not appreciate that contract of insurance is unlike other contracts and it is based on principles of uberrimae fidei i.e. utmost good faith. It is submitted that from the materials available on the record it is quite clear that petitioner was fully aware of the material facts relating to his health that he was suffering from renal disease but for purpose the policy he concealed material facts relating to his health and declared that he was in good health. It is submitted that had the true and correct facts been disclosed to the Insurance Company, the Insurance Company could have taken a decision thereon and there were possibilities of refusal to issue/renew or revive the policy.