Pavan Sachdeva v. Office of the Insurance Ombudsman and Anr

NAVIN CHAWLA, J JULY 27, 2020

Page 1 * IN THE HIGH COURT OF DELHI AT NEW DELHI Reserved on: 14.07.2020 Date of decision: July 27, 2020 + PAVAN SACHDEVA ..... Petitioner Through: Petitioner in person. versus OFFICE OF THE INSURANCE OMBUDSMAN AND ANR. ..... Respondents Through: Mr.Sushant Thakur, Adv. CORAM: HON'BLE MR. JUSTICE NAVIN CHAWLA 1. This petition has been filed by the petitioner inter alia challenging the order dated 21.02.2019 passed by the respondent no. 1 whereby the complaint of the petitioner against the rejection of his claim under the "Cigna TTK Health Insurance Family Policy" (hereinafter referred to as the "Policy") taken by him was rejected and the decision of the respondent no. 2 was upheld. 2. It is the case of the petitioner that the petitioner had obtained the abovementioned Policy from the respondent no. 2 on 14.08.2017. On 16.09.2017, while undertaking his morning walk, the petitioner felt mild pain and visited Fortis Escort Hospital. On 23.09.2017, after an Angiography, the petitioner was advised to undergo a bypass surgery, which was duly carried out on the petitioner. The petitioner lodged a claim against the abovementioned Policy with the respondent no. 2, Page 2 however, the respondent no. 2 denied the same with the following remarks:- "Note: The policy since 14/8/2017. The liability cannot be ascertained at this juncture, as the patient has history of Sarcoidosis since 1997; which is preexisting to the policy inception with CignaTTK which is non- disclosure of material facts; hence cashless denied." 3. The petitioner protested against the said rejection and the respondent no. 2 deputed an officer to visit the petitioner to record his statement. In the statement so recorded, the petitioner clarified that the petitioner had Sarcoidosis in 1982 and was advised to take steroids, which he took for a period of three months in 1982 and was perfectly fine thereafter. This fact was also recorded in the Discharge Summary of the petitioner issued by the hospital. 4. The respondent no. 2, however, by an e-mail dated 21.10.2017, again rejected the claim of the petitioner and terminated the Policy alleging "non-disclosure of material fact". 5. The petitioner protested against the same with the Grievance Management Cell of the respondent no. 2, however, by an e-mail dated 22.11.2017, the same was again rejected relying upon Clause VIII.1 of the Policy. 6. The petitioner feeling aggrieved of the said rejection filed a complaint with the respondent no. 1, which has been rejected by way of the Impugned Order observing as under:- Page 3 "4. I heard both the sides the complainant as well as the Insurance Company. During the hearing, the complainant reiterated that he had been hospitalized in Fortis Escorts Hospital from 23.09.2017 to 01.10.2017 for treatment of coronary angiography and bypass surgery was done. He submitted claim documents for Rs.600309/- only, and his claim was rejected and policy was terminated by the company due to non disclosure of Sarcoidosis disease at the inception of insurance policy. The Insurance Company reiterated that the insured complainant did not disclose the previous history of Sarcoidosis of the patient at the inception of the Insurance Policy, hence they terminated the said policy and rejected the claim. The Discharge Summary dated 01.10.2017 confirms that the insured patient had Sarcoidosis since 1982. During the Pre-Medical Examination, the insured did not reveal his previous medical history of Sarcoidosis at the inception of the said insurance policy, hence the said claim is not payable as per the terms and conditions of the policy. It is a clear case of non- disclosure. As per the Supreme Court judgment in the case of Satwant Kaur Sandhu vs. New India Assurance (2009) 8 SCC 316, the Hon'ble Supreme Court emphasised that insurance is a contract of utmost good faith on the part of the insured, when an information on a specific aspect is asked for in the proposal form. An insured is under solemn obligation to m