Kerala High Court
Flosy Sunny vs The Insurance Ombudsman on 5 November, 2025
WP(C) NO. 15960 OF 2025
1
2025:KER:84052
IN THE HIGH COURT OF KERALA AT ERNAKULAM
PRESENT
THE HONOURABLE MR.JUSTICE BASANT BALAJI
WEDNESDAY, THE 5TH DAY OF NOVEMBER 2025 / 14TH KARTHIKA, 1947
WP(C) NO. 15960 OF 2025
PETITIONER:
FLOSY SUNNY
AGED 55 YEARS
W/O.SUNNY, MANJALY HOUSE, ANNANAD, KALLUR VADAKKUMMURI
THRISSUR, PIN - 680309
BY ADVS.
SRI.LINDONS C.DAVIS
SMT.E.U.DHANYA
SMT.N.S.SHAMILA
SMT.CHINJU P. JOYIES
SHRI.VINAYAK MANOHARAN P.
RESPONDENTS:
1 THE INSURANCE OMBUDSMAN
KOCHI OFFICE OF THE INSURANCE OMBUDSMAN, 10TH FLOOR, LIC
BUILDING, JEEVAN PRAKASH, M.G. ROAD, ERNAKULAM, KOCHI,
PIN - 682011
2 NIVA BUPA HEALTH INSURANCE CO. LTD,
REPRESENTED BY ITS AUTHORIZED SIGNATORY, 3RD FLOOR,
ALAPPAT HERITAGE BUILDING, MG ROAD ERNAKULAM, COCHIN,
PIN - 682035
3 THE FEDERAL BANK LTD,
ERNAKULAM MARINE DRIVE BRANCH, REPRESENTED BY ITS BRANCH
MANAGER, RETAIL BUSINESS DEPARTMENT, FEDERAL TOWERS,
MARINE DRIVE, ERNAKULAM, KERALA, PIN - 682031
BY ADVS.
SRI.JITHIN SAJI ISAAC
SMT.DEEPA GEORGE
SHRI.K.J.SAJI ISAAC
DR.ELIZABETH VARKEY
SHRI.ABHISHEK S. KUMAR
SHRI.JOSHUA SEBASTIAN
THIS WRIT PETITION (CIVIL) HAVING COME UP FOR ADMISSION ON
05.11.2025, THE COURT ON THE SAME DAY DELIVERED THE FOLLOWING:
WP(C) NO. 15960 OF 2025
2
2025:KER:84052
JUDGMENT
(Dated this the 05th day of November, 2025) The petitioner had availed two health insurance policies from the 2 nd respondent company for a sum assured to the tune of Rs.10,00,000/-. Subsequently, the petitioner took another policy on 29.07.2022, namely, the Niva Bupa GCC Plan-Health Plus Policy, for a sum assured of Rs.25,00,000/-. The said policy comes under the category of group health insurance, known as a Group Master Policy, offering cashless treatment and coverage for various medical expenses. The petitioner had availed an overdraft facility of Rs.25,00,000/- from the 3rd respondent Bank, and as part of the said loan, she was enrolled under the Group Master Policy.
2. While the said policy was in force, the petitioner was admitted to Aster Medicity, Kochi on 01.12.2022, for coronary angiogram, which showed CAD with Triple Vessel Disease, and PTCA was done on 03.12.2022. She was discharged on 05.12.2022. The petitioner thereafter raised a claim under the Niva Bupa GCC Plan-Health Plus Policy, which was rejected as per Ext.P4 on the following grounds:
"Non-disclosure-1.1. As per submitted documents, patient has a history of Hypertension from 1 year and basilar aneurysm - treated with stent-assisted coiling on 24.05.22 which is prior to policy start date. This was not disclosed to us at policy issuance stage. We regret the claim is not payable under non disclosure, WP(C) NO. 15960 OF 2025 3 2025:KER:84052 policy clause 2(XIV)."
3. Aggrieved by the repudiation of the claim, the petitioner approached the 1st respondent, Insurance Ombudsman, and a complaint was registered as KOC-H-031-2425-0206. The Ombudsman conducted a hearing and thereafter passed Ext.P8 award, directing the refund of the premium amount of Rs.1,83,254/- to the complainant. Challenging the said award, the petitioner has filed this writ petition.
4. A counter affidavit has been filed by the 2 nd respondent contending that the petitioner had submitted an enrollment form for the issuance of Niva Bupa GCC Plan-Health Plus Policy based on the disclosures made therein. The policy was valid from 29.07.2022 to 28.07.2027 for a base sum insured of Rs.25,00,000/-. It was a Group Policy, with the 3 rd respondent as the master policyholder. Ext.R2(a) is the enrollment form signed by the petitioner on 29.07.2022. In Ext.R2(a), sub-clause 3 deals with medical history. For all the questions where the petitioner was required to mark either 'Yes' or 'No', she had marked 'No' in all the columns, except one marked as 'N', indicating that she was in good health.
5. As mentioned earlier, the petitioner, however, was a patient of systemic hypertension and had an intracranial aneurysm and she had undergone stent-assisted coiling of the basilar aneurysm on 24.05.2022. WP(C) NO. 15960 OF 2025 4 2025:KER:84052 Though Ext.R2(a) was signed on 29.07.2022, the said material fact was suppressed. It is contended that, had the petitioner disclosed the true details, the company would not have issued the policy. Thus, the policy was obtained by suppression of material facts and also non-disclosure of pre- existing illness. Under the contract of insurance, the parties are bound to observe the principle of uberrima fidei (utmost good faith), which the petitioner failed to uphold.
6. As per Clause 5.14 of the policy conditions, it is specifically stated that the policy shall be void and all premiums paid thereon shall be forfeited to the company in the event of any misdescription or non-disclosure of material facts by the policyholder. Since there was non-disclosure of pre- existing disease, the rejection of the claim is valid. The Ombudsman has rightly held that the petitioner is not entitled to any claim amount. Therefore, prayed that the writ petition be dismissed.
7. A counter affidavit was also filed by the 3rd respondent, wherein it is averred that the petitioner had availed overdraft facility from the 3 rd respondent Bank and was enrolled in the Group Master Policy. In the proposal form, the petitioner had not disclosed her previous illness. The averment in paragraph 17 of the writ petition that the petitioner had revealed her medical history regarding hypertension and basilar aneurysm to the agent of the 3rd respondent was denied. In the proposal form, under sub- WP(C) NO. 15960 OF 2025 5 2025:KER:84052 clause 10, the petitioner had declared that all statements and answers given were true and correct, and had signed the same.
8. The petitioner with open eyes has entered the details in the proposal form and has signed it, accepting all the statements as true and correct, while at the same time, the petitioner suppressed the fact of systemic hypertension and procedure undergone for aneurysm. In such case, Clause 5.14 is rightly attracted.
9. It is true that there was an earlier policy and the claim made by the petitioner was paid by them. Each policy starts with a fresh proposal and acceptance. In the proposal at hand, the earlier disease was suppressed, so the petitioner cannot contend that the company was aware of the pre- existing disease and therefore there is no suppression. The company is under no obligation to search their database and found out the previous history of the patient. The petitioner is bound to disclose all the previous illness when a new proposal form is given. In such circumstances, I am of the considered opinion that the Ombudsman has rightly dismissed the complaint.
Resultantly, this writ petition stands dismissed.
Sd/-
BASANT BALAJI JUDGE GBG WP(C) NO. 15960 OF 2025 6 2025:KER:84052 APPENDIX OF WP(C) 15960/2025 PETITIONER EXHIBITS Exhibit P1 A COPY OF THE POLICY STATEMENT DATED 26.07.2022 Exhibit P2 A COPY OF THE POLICY STATEMENT DATED 29.12.2022 Exhibit P3 A COPY OF THE DISCHARGE SUMMARY OF THE PETITIONER FROM ASTER MEDCITYDATED 05.12.2022 Exhibit P4 A COPY OF THE CLAIM REPUDIATION LETTER DATED 14.04.2023 Exhibit P5 A COPY OF THE DISCHARGE SUMMARYOF THE PETITIONER FROM ASTER MEDCITY DATED 26.05.2022 Exhibit P6 A COPY OF THE CLAIM SETTLEMENT VOUCHER DATED 05.07.2022 Exhibit P7 THECOPY OF THE COMPLAINT DATED 27.11.2023 BEFORE THE INSURANCE OMBUDSMAN IS ATTACHED Exhibit P8 THE COPY OF AWARD DATED 01.10.2024 Exhibit P9 A COPY OF THE LETTER DATED 16.10.2024 SUBMITTED BY THE PETITIONER TO THE 1ST RESPONDENT Exhibit P10 A COPY OF THE LETTER DATED 28.11.2024 ISSUED BY THE 1ST RESPONDENT TO THE PETITIONER Exhibit P11 A COPY OF THE REPLY DATED 19.12.2024SUBMITTED BY THE PETITIONER TO THE 1ST RESPONDENT Exhibit P12 A COPY OF THE LETTER ISSUED BY THE 2ND RESPONDENT TO THE PETITIONER DATED 29.11.2024 Exhibit P13 A COPY OF THE REPLY SUBMITTED BY THE PETITIONER TO THE 1ST RESPONDENT DATED 19.12.2024 RESPONDENT EXHIBITS Exhibit R2(a) True copy of the enrolment form submitted by the petitioner to the 2nd respondent Exhibit R2(b) True copy of the relevant pages of policy number 50081700202000 issued by the 2nd respondent to the petitioner Exhibit R3 (a) Copy of proposal form/member enrolment form dated 29/07/2022 submitted by the petitioner for getting enrolled in the Group Master Policy is produced herewith as Exhibit R3(a)