Delhi District Court
Brij Mohan vs Future Generali India Insurance Co. Ltd on 3 September, 2025
IN THE COURT OF MS. ANJU BAJAJ CHANDNA
PRINCIPAL DISTRICT & SESSIONS JUDGE
NEW DELHI DISTRICT : PATIALA HOUSE COURTS :
NEW DELHI
CNR No. DLND01-005399-2021
Civil Suit No. 324/2021
Brij Mohan
S/o Shri Ram
R/o Q-32, Budh Vihar, Phase-I
Nithari, Sultanpuri,
C-Block, North West Delhi,
New Delhi-Begumpur, Delhi-110086
(Plaintiff expired on 02.08.2023 and six LRs were impleaded
vide order dated 18.12.2023)
i. Smt. Pushpa w/o BrijMohan
ii. Smt. Manju d/o BrijMohan
iii Smt. Anju d/o BrijMohan
iv. Smt. Anita d/o BrijMohan
v. Sh.Yogesh s/o BrijMohan
vi. Sh.Kunal s/o Brij Mohan ...Plaintiff
Versus
M/s Future Generali India Insurance Co. Ltd.
303-310, 3rd Floor K. G. Marg,
Connaught Place, New Delhi -110001
Through its
General Manager/ Manager ...Defendant
Date of filing : 25.08.2021
Date of Judgment : 03.09.2025
Appearance:
Sh. Digvijay Rana, Ld. Counsel for plaintiff.
Ms. Priyanka, Ld. Counsel for defendant.
CS No. 324/2021
page no. 1 of 16
JUDGMENT:-
1. Plaintiff has filed the present suit for recovery of Rs.5,00,018/- against the defendant on the basis of mediclaim policy issued by the defendant for the period 07.05.2021 to 06.05.2021 (Policy No. PTO-12-20-7000480-00-000) and thereafter from 27.05.2021 to 26.05.2022 (Policy No. PTO-12- 21-7211249-01-000). Plaintiff was hospitalized on chest pain, breathlessness, lung problem, palpitation and heart problem on 12.01.2021 and discharged on 13.01.2021 and thereafter from 26.01.2021 to 30.01.2021 at Cygnus MLS Super Specialty Hospital, Main Kanjhawala Road, New Delhi-110081.
2. Plaintiff has further claimed that he spent Rs.3,29,954/- in relation to first policy and Rs.1,17,064/- in relation to second policy and in this way, total amount spent is Rs.4,47,018/-. Plaintiff lodged the claim with the defendant but no reimbursement has been made as also defendant tried to linger on the matter on one pretext or the other. Plaintiff suffered physically and mentally and ultimately the claim has been rejected as the treatment done by the hospital was of the disease which pertain to the period prior to the policy. Plaintiff has further contended that panel doctors of the defendant checked up before issuing the policies to the plaintiff and therefore, plaintiff is entitled to the claim in relation to the hospitalization and expenses spent thereof. The defendant is intentionally and deliberately avoiding the legitimate claim of the plaintiff. Plaintiff is also claiming Rs.50,000/- for visiting the office of CS No. 324/2021 page no. 2 of 16 defendant several times in order to get his claim. A legal notice dated 14.07.2021 was served upon the defendant but no payment was made and a letter dated 04.08.2021 was issued seeking treatment related documents and medical certificate. According to the plaintiff, defendant has adopted illegal and unwarranted acts and has not reimbursed the claim of the plaintiff.
3. Plaintiff has prayed for decree of sum of Rs.5,00,018/- in his favour along with pendente-lite and future interest @ 18 % per annum.
4. On behalf of defendant, reply has been filed stating therein that suit has been filed to extort money and clearly plaintiff has indulged in the practice of suppression of material facts and plaintiff has no right to maintain the recovery suit. Plaintiff is not entitled to any relief. The objection as to the jurisdiction of the court is raised stating that insurance contract which culminated into the policy forming subject matter of the complaint is invalid, inoperative and unenforceable. The plaintiff has suppressed material facts pertaining to pre-existing medical condition and as such plaintiff has not approached the court with clean hands. The policy has been obtained by the plaintiff fraudulently and dishonestly. The doctrine of utmost good faith required the party seeking insurance to disclose all the relevant personal information. It is admitted by the defendant that insurance is a contract between the insured and the insurer and the terms and conditions of the policy of insurance are binding.
CS No. 324/2021page no. 3 of 16
5. In this case, there is breach of policy conditions done by non - disclosure of the medical history of the plaintiff . According to the defendant, plaintiff (insured) is a known case of COPD (Chronic Obstructive Pulmonary Disease), Type - II, Diabetes Mellitus, Coronary Artery Disease but the same was not disclosed at the time of purchase of policy. It is admitted that insured / plaintiff was hospitalized on 12.01.2021 during the first policy for the treatment of chest pain and palpitation. From the discharge summary, it came to be known that patient (plaintiff ) had a past history of K/C of DMT 2 (i.e. Type II diabetes mellitus and hypertension ). Plaintiff lodged the claim on 22.01.2021 against the Policy No. PTO-12-20-7000480-00-000 for Rs. 1,42,323/- which was rejected by the insurer. The plaintiff got hospitalized with the same complaint in January 2021 and lodged the claim of Rs.57,172/- and the same was also rejected as the previous claim was rejected. The defendant company claims to have been misled due to non-disclosure of material facts and accordingly claim had been repudiated. The clause from the insurance policy terms and conditions has been mentioned as below:-
"Disclosure to information Norm the Policy shall be void and all premium paid hereon shall be forfeited to the insurer, in the event of misrepresentation , mis-description nor non-disclosure of any material fact".CS No. 324/2021
page no. 4 of 16 It is contended by defendant that plaintiff cannot be allowed to take advantage of his own wrongs. Further denying and refuting all the contentions of the plaintiff, it is prayed that suit of the plaintiff be dismissed with exemplary costs.
6. Plaintiff has filed replication reiterating and reaffirming the contents of the suit and denying the allegations of the written statement. According to the plaintiff, question of pre-existing disease does not arise as panel doctors always examine the person before issuance of medical policy.
7. From the pleadings of the parties following issues were framed on 07.04.2022:-
i) Whether the plaintiff is entitled to reimbursement of claim for medical expenses in the sum of Rs.5,00,018/- as prayed ? And if so, at what rate of interest?
ii) Relief.
8. Plaintiff Brijmohan examined himself as PW-1 by way of affidavit Ex.PW1/A and relied upon the following documents:-
1. Copy of Aadhar card Ex.PW1/1
2. Copies of policies for the period from 07.05.2020 to 06.05.2021 and 27.05.2021 to 26.05.2022 Mark A (colly)
3. Copies of medical records Mark B (colly)
4. Copies of medical bills Mark C (colly) CS No. 324/2021 page no. 5 of 16
5. legal notice dated 14.07.2021 Ex.PW1/5
6. Postal receipts along with its tracking report of legal notice are Ex.PW1/6 and Ex.PW1/7.
7. Copy of letter dated 04.08.2021 with respect to the recovery of claim Mark D.
9. During cross examination, plaintiff stated that he has no knowledge if medical certificate is required to be furnished while subscribing to insurance policy in case insured is more than 50 years old. Plaintiff was not suffering from major ailment prior to subscribing to the insurance policy nor he was suffering from blood pressure or diabetes. Plaintiff came to know about his heart condition in January 2021. Plaintiff is not aware if any ailment in the nature of diabetes and with regard to heart condition becomes progressive with age. Discharge summary dated 13.01.2021 is admitted as Ex.PW1/C (colly) and mark C discharge summary of 30.01.2021 contains indication about past history of ailments. Plaintiff is having no knowledge about COPD/CAD/Post PTCA with regard to discharge summary dated 21.06.2021. The plaintiff was not apprised about the terms and conditions of the insurance policy. Plaintiff has denied the suggestion that he lied to the agent and failed to disclose to the insurance company that he is suffering from COPD (Chronic Obstructive Pulmonary Disease). Plaintiff has denied that he failed to disclose true and correct facts to the insurance company before subscribing to the insurance policy or that his claim is not maintainable.CS No. 324/2021
page no. 6 of 16
10. DW-1 Shiv Mohan Singh Chauhan, Zonal Operation Incharge examined himself as DW-1 on behalf of defendant company by way of affidavit Ex.DW1/A and relied upon the following documents:-
1. Policy schedules Mark A and Aa
2. Claim form and discharge summary Mark B and C
3. Claim form Mark D and E
4. Repudiation letter dated 25.09.2021 Mark F and G.
11. During cross examination, DW-1 stated that they got the checkup of insured prior to issuing the policy but they have not got the medical checkup of the insured / plaintiff. It is admitted that they have doctors on the panel. The knowledge of COPD disease of the plaintiff / insured was known when the claim was lodged. The suggestion is denied that it is mandatory to conduct the medical check up before issuing mediclaim policy.
It is admitted that second policy was issued knowing that insured was already suffering from COPD disease. It is admitted that all the documents regarding medical treatment and bills of hospitalization as well as other expenses towards treatment were submitted by the plaintiff with the company. Witness is not knowing that expenses submitted as claim total comes to Rs. 4,47,018/-. It is admitted that defendant has not placed on record the terms and conditions of the policy. The suggestion has been denied that insured has not misled the defendant and it is CS No. 324/2021 page no. 7 of 16 admitted that policy has been issued on the basis of proposal form filled by the insured. The suggestion is denied that plaintiff has not misled the defendant company or that plaintiff has not done any wrong. DW-1 voluntarily stated that plaintiff has provided wrong information at the time of getting policies.
12. Written submissions have been filed by the plaintiff wherein facts of the suits were reiterated. It is further submitted that as and when medical policies were issued, the defendant company is bound to take the medical report from the paneled doctors, moreover if the defendant company came to know about the pre-existing disease then why the defendant company issued the second policy for the period of 27.05.2021 to 26.05.2022 and during this period the plaintiff was also admitted and spent Rs.1,17,064/-.
13. I have given due consideration to the facts and circumstances of the case and to the material available on record.
14. My findings on abovementioned issues are as under:-
Issue No. 1Whether the plaintiff is entitled to reimbursement of claim for medical expenses in the sum of Rs.5,00,018/- as prayed ? And if so, at what rate of interest?CS No. 324/2021
page no. 8 of 16
15. The only issue involved in the present suit is whether the plaintiff is entitled to the recovery of his claim with respect to the mediclaim submitted by plaintiff in regard to his hospitalization expenses. So far as the issuance of policy no. PTO-12-20-7000480-00-000 and Policy No. PTO-12-21- 7211249-01-000 are concerned, same are not disputed. Also, the claim of the plaintiff is not disputed with respect to his hospitalization in the month of January 2021. It is also not disputed that legal notice Ex.PW1/5 was issued by the plaintiff seeking reimbursement of the medical expenses from the defendant. The policy no. PTO-12-20-7000480-00-000 and Policy No. PTO-12-21-7211249-01-000 have been issued in favour of plaintiff on 07.05.2020 and 01.06.2021 respectively Mark A and premium of Rs. 17,542/- each has been paid for both the policies.
16. The policy letter dated 07.05.2020 Mark A is as follows:-
Dear Mr Brij Mohan Welcome to the Future Generali Experience. We thank you for choosing us for your insurance requirements. Your Policy No . is PTO-12-20-7000480-000 Our initiatives will provide you with the highest standards of service, convenience and quality in insurance and it is our endeavour to constantly better your experience by innovating and evolving our basket CS No. 324/2021 page no. 9 of 16 of conveniences.
The policy has been issued on the basis of the proposal form. A copy has been enclosed for your reference. We would request you to peruse the policy and satisfy yourself that it meets your requirements fully.
Please confirm that the proposal form contains the correct information and is signed by you.
As per individual policy schedule, Special Clauses, Conditions and warranties are as follows:-
1. In case of premium payment by cheque, in the event of dishonor of cheque for any reason whatsoever cover provided under this document automatically stands cancelled from the inception irrespective of whether a separate communication is sent or not.
2. The above records the information of pre-existing illness/hospitalization etc. given by the Insured, pursuant to Clause 8(2) of the IRDAI (Protection of Policyholder interest) Regulations, 2017. If the information shown above is found to be either incomplete or incorrect at the time of claim, the same shall be construed as non-
disclosure of material information.
3. This Policy of Insurance is a Contract between the Company and the Insured Person(s). The Insured Person(s) shall not transfer, assign, alienate or in any way pass the benefits and/or liabilities to any other CS No. 324/2021 page no. 10 of 16 person, institution, hospital, company or body corporate without specific approval in writing by a duly authorised officer of the company. However, if the Insured Person(s) is permanently incapacitated or deceased, the legal heirs of the insured may represent him in respect of claim under the policy.
4. Terms/conditions and exclusions as per the Policy clause and Endorsement wordings attached.
5 . In case of change in Goods and Service Tax the premiums will stand revised.
6. Kindly refer to the policy wording for sublimits, Co- pay limits, Voluntary Deductible if any.
17. It is evident from Mark B and C that claim was lodged by the plaintiff to the tune of Rs. 1,42,323/- against policy no. PTO-12-20-7000480-00-000 and Rs.57,172/- against policy no. PTO-12-21-7211249-01-00 and the said claims were responded through claim repudiation letters dated 12.10.2021 and 25.09.2021 Ex. D and Mark F and G respectively. The said letters are as under:-
Letter dated 12.10.2021 Dear Sir, CS No. 324/2021 page no. 11 of 16 We are in receipt of your claim. On scrutiny, we found that, the claim does not fall under the purview of the policy.
We will not pay your claim. Patient is suffering with COPD and T2 DM. There is non disclosure noted in transcript for illness and personal habitual history of the insured . Hence the claim is repudiated.
Letter dated 25.09.2021 Dear Sir, We are in receipt of your claim. On scrutiny, we found that, the claim does not fall under the purview of the policy kindly note that we have sent following reminders for deficiency as dated below:
Reminder-1 Date: 03-09-2021 *) Medical Certificate from the treating doctor mentioning the duration of CAD, TYPE II DIABETES MELLITUS....NOT PROVIDED *) Please provide all the PTCA treatment related documents done in the past.....NOT PROVIDED
18. The policy letter dated 20.04.2021 Mark A is as follows:-CS No. 324/2021
page no. 12 of 16 Dear Mr. BRIJ MOHAN Welcome to the Future Generali Experience. We thank you for choosing us for your insurance requirements. Your Policy No. is PTO-12-20-7000480- 00-000.
Our initiatives will provide you with the highest standards of service, convenience and quality in insurance and it is our endeavour to constantly better your experience by innovating and evolving our basket of conveniences.
The policy has been issued on the basis of the proposal form. A copy has been enclosed for your reference. We would request you to peruse the policy and satisfy yourself that it meets your requirements fully.
Please confirm that the proposal form contains the correct information and is signed by you.
19. Copy of letter dated 20.04.2021 shows that policy was issued on the basis of proposal form. Copy was enclosed and the insured was asked to peruse the policy and satisfy if the same meets his requirements.
20. On analysing the testimony and documentary evidence of both the sides, I am of the opinion that defendant company should have cleared the claim of the plaintiff with respect to his treatment and hospitalization. Two claims amounting to Rs.1,42,323/- and Rs.57,172/- respectively are CS No. 324/2021 page no. 13 of 16 shown to have been submitted by the plaintiff (insured) with the defendant company. It is evident that vide letter dated 20.04.2021 the policy documents were sent to the insured / plaintiff for perusal of the terms and conditions meaning thereby that policy was issued on the basis of proposal itself with effect from May 2020. The claim lodged by the plaintiff pertains to the period January 2021 while the policy document was sent to the plaintiff in April 2021. The plaintiff accordingly was not having any knowledge of the terms and conditions of the policy even at the time of hospitalization in January 2021.
21. It is also an admitted fact that no medical examination of the plaintiff was conducted before issuing of insurance policy in his favour. The defendant company therefore failed in its duty and responsibility to check the health status of the plaintiff. Even after hospitalization in January 2021, the second policy was issued in May 2021. The defendant company was very much in knowledge about the hospitalization of the plaintiff in January 2021 and despite this second policy was issued. Therefore, defendant company cannot be allowed to claim that there is suppression of material facts on behalf of plaintiff.
22. Vide letter dated 25.09.2021 (Mark F and G), the claim has been rejected on the ground that same does not fall under the purview of the policy. The defendant company, however, has failed to prove as to how the said claim has been CS No. 324/2021 page no. 14 of 16 outside the scope of the policy. Letter dated 12.10.2021 rejects the claim of the plaintiff on the ground that he is suffering from COPD and T2DM. The defendant company came to have knowledge of this fact in January 2021 and even then issued the second policy. Therefore, after lodging of the claim, defendant company cannot be allowed to reject the insurance policy on the ground of past illness.
23. In view of nature of peculiar facts and circumstances, I am not inclined to conclude that there has been misrepresentation or non-disclosure of material facts on behalf of plaintiff, rather it becomes clear that defendant company has not been vigilant in issuing insurance policy to the plaintiff and in taking responsibility to pay the plaintiff with regard to his medical expenses. Even otherwise, the disease for which the plaintiff was hospitalized was different as relating to his heart and there has been nothing on record to show that at the time of issuance of insurance policy, plaintiff was suffering from heart disease.
24. Although the plaintiff has issued legal notice seeking claim of Rs.4,47,018/- from the defendant company along with notice charges of Rs.3,000/- but only two claims amounting to Rs.1,42,323/- and Rs.57,172/- have been shown on record. Plaintiff has failed to file on record copies of other claims and therefore, defendant company cannot be directed to pay the amount as lodging of the claim is the first requirement to CS No. 324/2021 page no. 15 of 16 be fulfilled by the plaintiff. As such, plaintiff is entitled to the recovery of his claims of Rs.1,42,323/- and Rs.57,172/- filed on record. Accordingly, it is concluded that plaintiff is entitled to claim lodged before the defendant company total amounting to Rs.1,99,495/-.
25. As such, issue no.1 is decided in favour of the plaintiff and against the defendant.
Relief.
26. In view of the findings on issue no.1, plaintiff is entitled to recovery of Rs.1,42,323/- and Rs.57,172/- total Rs.1,99,495/- along with pendente-lite and future interest @ 8 per cent per annum from due date till the date of realization along with cost of the suit. Suit is decreed in favour of plaintiff.
27. Decree sheet be prepared accordingly.
28. File be consigned to the record room.
Announced in the open court ANJU
Digitally signed
by ANJU BAJAJ
BAJAJ CHANDNA
on 3rd September 2025 CHANDNA Date: 2025.09.03
17:01:16 +0530
(Anju Bajaj Chandna)
Principal District & Sessions Judge
New Delhi District, Patiala House Courts New Delhi/03.09.2025 CS No. 324/2021 page no. 16 of 16