Delhi District Court
Krishna Kumar Aggarwal vs Care Heath Insurance Limited on 25 July, 2025
IN THE COURT OF Ms. NIRJA BHATIA
DISTRICT JUDGE (COMM-07), DIGITAL
SOUTH-EAST DISTRICT, SAKET COURT, NEW DELHI
CS (COMM) 3704/2024
Krishan Kumar Agarwal
S/o Sh. Raja Ram Agarwal
R/o A-11, First Floor, C. R. Park,
New Delhi.
.........Plaintiff
Versus
Care Health Insurance Limited
Having registered office at:
5th Floor, 19, Chawla House,
Nehru Place, New Delhi.
....... Defendant
Date of Institution: 23.09.2024
Arguments concluded on : 21.07.2025
Date of Judgment: 25.07.2025
JUDGMENT
(1) This judgment shall decide the present suit filed with prayer for grant of relief of mandatory injunction. (2) The facts upon which the plaintiff have premised the suit is arising from rejection of plaintiff's claim of Rs. 6,77,219/- (Rupees Six Lakhs Seventy-Seven Thousand Two Hundred and Nineteen only) towards medical claim alongwith interest at the rate of 12% per annum up from the date of repudiation till 26.08.2024, total amounting to Rs.1,08,084/-; damages for Rs.3,00,000/- (Rupees Three Lakhs only) qua alleged mental agony, harassment, and suffering caused to the plaintiff with Digitally signed by NIRJA NIRJA BHATIA BHATIA Page no. 1/11 Date:
2025.07.25 16:17:37 +0530 pendente lite and future interest at 12% per annum are also asked.
(3) Plaintiff introduced himself as Krishna Kumar Aggarwal S/o Late Shri Raja Ram r/o A-11, First Floor, Chittaranjan Park, New Delhi-110019. He narrated that he is a senior citizen, aged 74 years, and a reputed Chartered Accountant, being a fellow of the Institute of Chartered Accountants of India (hereinafter referred as plaintiff). He is a widower, residing alone in New Delhi, with both his children settled outside Delhi.
(4) The claim is raised against Care Heath Insurance Limited, a health insurance company, having its address at 5th Floor, 19, Chawla House, Nehru Place, New Delhi (hereinafter referred as defendant). Plaintiff alleges that defendant presents itself as specialized health insurer, offering a range of insurance products and services including retail and group health insurance and claims itself to follow a customer-centric approach with emphasis on technology-driven services and prompt grievance redressal of its customers (5) Plaintiff asserts that he held a valid Group Mediclaim Insurance Policy issued by the Defendant under the Punjab National Bank (PNB) - Group Care 360 (Platinum Plan). The policy was effective from 23.03.2023 to 22.03.2024, with a total sum insured of ₹11,50,000/-, for which the Plaintiff paid a premium of ₹33,664/-. The policy was a renewal of an earlier policy, and the Plaintiff had disclosed his pre-existing condition of hypertension beforehand.
(6) Plaintiff submits that he was diagnosed with a 'cyst in his right kidney', which after further investigations was found to be 'cancerous' (malignant neoplasm of the kidney) in April 2023.
Digitally signed by NIRJA Page no. 2/11 NIRJA BHATIA BHATIA Date:
2025.07.25 16:17:42 +0530 Upon medical advice, he was admitted to Apollo Hospital, New Delhi, for urgent robotic surgery. A cashless authorization request of ₹5,23,400/- was submitted to the Defendant by the hospital, but the Defendant without assigning due reasons, rejected the request on 26.04.2023 while sanctioning only ₹25,000/- under a sub-limit allegedly applicable to urinary problems.
(7) Plaintiff though managed to undergo surgery using his son's group mediclaim policy, which covered ₹4,86,169/-. The balance ₹1,91,050/- was paid by the Plaintiff's son, which was later repaid by the Plaintiff from his personal savings. (8) Plaintiff alleges that despite repeated representations including a detailed email on 12.05.2023 explaining that his surgery was cancer-related and not a urinary issue, the Defendant failed to respond with a proper justification or provide reconsideration of the claim.
(9) Plaintiff submits that he subsequently approached the Insurance 'Ombudsman' on 08.08.2023, but the complaint was closed without adequate reasoning. (10) It is stated that in good faith, plaintiff even renewed the policy with the Defendant in March 2024 by paying an increased premium of ₹38,362/-. However, the final rejection of the claim via email dated 01.04.2024 confirmed that the Defendant had no intention of honoring its contractual obligations, therefore, the present suit is filed.
Note of the proceedings (11) The suit is received on 23.09.2024 by the Ld. Predecessor whereupon summons were served on the defendant. As no Digitally signed by Page no. 3/11 NIRJA NIRJA BHATIA BHATIA Date:
2025.07.25 16:17:46 +0530 written statement was filed within the statutory period, the opportunity to file the same was closed and defendant was proceeded exparte on 07.01.2025. The matter was kept for PE. In the meanwhile, the case was transferred to this Court whereupon PW-1 Sh. Krishna Kumar Aggarwal was examined on 19.04.2025. The matter was then listed for exparte final arguments on 11.07.2025., however, on the said date the matter was adjourned on the request of Ld. Counsel. Exparte final arguments were addressed on 21.07.2025.
Plaintiff' Evidence (12) PW-1 Ms. Krishna Kumar Agarwal tendered his evidence by way of an affidavit and exhibited the following documents:-
(1) The print out of above said policy dated 24.02.2023 along with terms and conditions of Care 360 is Ex.PW1/1 (colly).
(2) Affidavit under Section 63 of BSA, 2023 is Ex.PW1/2. (3) The policy dated 24.02.2023 was renewal of existing policy and the copy of some of the old policies is Mark A. (4) The MRI Report dated 26.01.2023 is Ex.PW1/3. (S) Robotic Surgery vide prescription dated 08.02.2023 is Ex.PW1/4.
(6) The printout of cashless Authorisation letter dated 26.04.2023 received on email is Ex.PW1/5.
(7) Printout of repudiation / denial letter dated 26.04.2023 is Ex.PW1/6.
(8) Stress echo report dated 26.04.2023 is Ex.PW1/7. (9) CT PET report dated 27.04.2023 is Ex.PW1/8. (10) Discharge summary is Ex.PW1/9.
Digitally signed by NIRJA NIRJA Page no. 4/11 BHATIA BHATIA Date:
2025.07.25 16:17:51 +0530 (11) Hospital bills / receipt dated 01.05.2023 is Ex.PW1/10. (12) Biopsy report dated 05.05.2023 is Ex.PW1/11. (13) Print out of email dated 12.05.2023 is Ex.PW1/12. (14) Affidavit u/s 63 of BSA, 2023 is Ex.PW1/13. (15) Printout of online complaint along with Annexure VI A submitted to Ombudsman dated 08.08.2023 is Ex.PW1/14 (colly).
(16) Letters dated 10.08.2023, 12.08.2023, 11.09.2023 are Ex.PW1/15, Ex.PW1/16 and Ex.PW1/17 respectively. (17) Printouts of emails dated 10.09.2023, 09.12.2023 are Ex.PW1/18 and Ex.PW1/19 respectively. (18) Letter dated 23.10.2023 closing the said complaint without giving reasons is Ex.PW1/20.
(19) Print out of email dated 30.03.2024 and 01.04.2024 is Ex.PW1/21.
(13) PE was closed vide separate statement. (14) I have heard the arguments and have carefully gone through the record.
Reasons for Findings (15) The Plaintiff (PW-1), in support of his claim, has relied upon a series of documents, including the health insurance policy dated 24.02.2023 (Ex. PW1/1 colly), medical reports (Ex. PW1/3 to Ex. PW1/11), correspondence with the insurer (Ex. PW1/5, Ex. PW1/6, Ex. PW1/12, Ex. PW1/18, Ex. PW1/19), and complaint to the Ombudsman (Ex. PW1/14 colly). While these documents may reflect the medical treatment undergone and the Plaintiff's communication with the Defendant company, none of Digitally signed by NIRJA NIRJA BHATIA BHATIA Date:
2025.07.25 16:17:57 +0530 Page no. 5/11 these disclose or even suggest that the Plaintiff had informed the Defendant about the existence of another contemporaneous insurance policy under which a claim for the same medical treatment had already been made and processed. Further, there is no explanation or justification as to why such material disclosure was omitted either at the time of policy issuance or claim submission. The Plaintiff also did not dispute the terms and conditions of the policy (Ex. PW1/1), which include clear stipulations governing the claim process and duty of disclosure. (16) The suit does not disclose any material for relief of mandatory injunction directing the defendant to pay the amount of Rs. 6,77,219/- (Rupees Six Lakhs Seventy-Seven Thousand Two Hundred and Nineteen only) towards the plaintiff's medical claim; interest at the rate of 12% per annum on the said amount from the date of repudiation till 26.08.2024, amounting to Rs.1,08,084/-; damages of Rs.3,00,000/- (Rupees Three Lakhs only) for the mental agony, harassment, and suffering caused to the plaintiff; pendente lite and future interest at 12% per annum on the decretal amount and damages.
(17) The present case involves certain issues that needs to be taken into consideration:-
Issue No. 1 - Whether the Defendant was in breach of its contractual obligation?
(18) The principle of uberrima fides (utmost good faith) governs insurance contracts, requiring both parties, especially the insured, to make full and honest disclosure of all material facts. The existence of a second insurance policy is a material fact that ought to have been disclosed at the time of the claim submission, Digitally signed by NIRJA NIRJA BHATIA BHATIA Date:
2025.07.25 16:18:01 +0530 Page no. 6/11 as it may affect claim adjudication, liability allocation, and application of contribution clauses under IRDAI regulations. The Plaintiff's failure to disclose the other policy further weakens his claim. Also, as per Section 7(1)(a) of IRDAI (Insurance Regulatory and Development Authority Act) governing general insurance policies, "it is mandatory that the policy shall clearly state the name(s) and address(es) of the insured and of any bank(s) or any other person having financial interest in the subject matter of insurance ". Hon'ble Courts above in numberous case law, such as Satwant Kaur Sandhu Vs. New India Assurance Co. Ltd., (2009) 8 SCC 316, have consistently held that non-disclosure of material facts by the insured is a valid ground for denial of insurance benefits. (19) Permitting the Plaintiff to enforce a claim under the present policy without accounting for the amount already received under the other policy would amount to double recovery, which is impermissible under the law. The core principle of indemnity-based insurance is to compensate actual loss, not to profit. Granting a mandatory injunction under these circumstances would lead to unjust enrichment and distort the very nature of insurance.
No evidence that repudiation was beyond contractual terms agreed by the plaintiff (20) From the documentary evidence led, it is shown that the insurer acted strictly as per the terms and conditions of the insurance policy (Ex. PW1/1). The repudiation letter (Ex. PW1/6) clearly mentions the reason for denial and was communicated promptly, thereby fulfilling all obligations of Digitally Page no. 7/11 signed by NIRJA NIRJA BHATIA BHATIA Date:
2025.07.25 16:18:06 +0530 transparency and due process. Also, it is an undisputed fact that the insurance policy under which the Plaintiff was covered was a Group Insurance Policy issued to Punjab National Bank customers. The terms of such group policies often include specified disease/procedure sub-limits, and the insurer is within its contractual rights to apply them, unless shown to have acted with malice, negligence, or gross misjudgment. The absence of any of the above is then strengthened by the Insurance Ombudsman who closed the complaint (Ex. PW1/20) without granting relief to the plaintiff. This supports that no deficiency or wrongful conduct was found on part of the insurance company even through the assessment of the grievance redressal level. (21) In vide of above, it is observed that the defendant Insurance Company has acted within the framework of the policy terms and has neither violated any contractual obligation nor committed any breach. The repudiation of claim was based on the insured's non-disclosure of material facts and the settled principle against unjust enrichment through double recovery.
Issue-2 Whether the Plaintiff is entitled to compensation on account of mental harassment and interest due to the alleged wrongful repudiation of the insurance claim?
(22) The Plaintiff has not brought any evidence on record to demonstrate that the Defendant acted with malice, arbitrariness, or deliberate intention to harass. Mere denial of a claim by itself, especially when done in accordance with the terms and conditions of the policy, does not constitute harassment or mental agony warranting damages.
Digitally signed by NIRJA NIRJA BHATIA BHATIA Date:
2025.07.25 16:18:18 +0530 Page no. 8/11 (23) Award of interest under Section 34 CPC is discretionary and must follow a wrongful or unjustifiable withholding of amounts lawfully due. Since the Plaintiff was not found entitled to the insurance claim, no interest can be granted on a non- payable amount.
(24) Since the Plaintiff had already claimed the same expenses under a different insurance policy (which he failed to disclose), any award of interest or damages would amount to unjust enrichment and is legally untenable. (25) In view of the discussions above, plaintiff has failed to establish any willful default, negligence, or arbitrary conduct on part of the Defendant that would attract liability for harassment or interest. Mere repudiation of claim in accordance with policy terms does not, in itself, constitute mental agony or deficiency in service so as to warrant compensatory damages or interest.
Issue 3. Whether the Plaintiff is entitled to seek recovery of the claimed amount under the relief of mandatory injunction?
(26) The relief of Mandatory Injunction under Section 39 of the Specific Relief Act, 1963, is an equitable and discretionary remedy granted to compel performance of a specific act. It is not a substitute for a suit for recovery of money, particularly where disputed claims or damages are involved. (27) The plaintiff is seeking payment of a specific monetary amount allegedly due under an insurance contract. Such a claim, if maintainable at all, would lie in a suit for recovery based on breach of contract, after proving liability, quantum, and default. Mandatory injunction cannot be used to enforce payment of a Digitally signed by NIRJA NIRJA BHATIA BHATIA Date:
2025.07.25 Page no. 9/11 16:18:23 +0530 disputed sum, especially when the entitlement is not conclusively established, and policy terms are under contest. (28) In the matter of State of U.P. & Anr V/s Tara Singh Jaiswala, 2012 SCC Online All 1876, the respondent-plaintiff filed suit for mandatory injunction against appellants-defendants directing them to discharge obligation of payment of assessed contract value arising out of contract bond with interest. The trial court decreed the suit. The Hon'ble Allahabad High Court (DB) reversed the order passed by the trial court and observed that:
(a) The appropriate remedy for respondent-
plaintiff was to file suit for recovery of money due to him under the contract.
(b) Section 41 (h) of the SRA completely bars the suit for injunction in cases where recovery of money is sought.
Thus, the appropriate remedy will be suit for recovery of money with appropriate court fees affixed and not suit for Injunction Further, the form of the present suit being one for injunction alone renders the prayer for monetary relief legally unsustainable. The Court cannot bypass the established procedure for recovery suits and grant mandatory injunction in such circumstances.
(29) In light of the foregoing discussion, it is evident that the Plaintiff has not approached the Court with clean hands. The claim now sought, if allowed, would result in double recovery for the same loss, which is contrary to the principle of indemnity and established norms under insurance law. The Plaintiff has further failed to plead or prove compliance with the duty of full disclosure as mandated under the contract of insurance and regulatory framework. Accordingly, this Court finds no merit in Digitally signed by NIRJA Page no. 10/11 NIRJA BHATIA BHATIA Date:
2025.07.25 16:18:27 +0530 any of the reliefs sought. Hence, the the reliefs prayed, including the prayer for mandatory injunction, compensation, and any other ancillary or consequential reliefs, stand rejected in their entirety (30) File be consigned to Record Room after completion of necessary formalities.
Digitally signed by NIRJA NIRJA BHATIA BHATIA Date:
2025.07.25 16:18:31 +0530 Announced in open Court (Nirja Bhatia) today on 25th July, 2025 District Judge (Comm. Court) (Digital-07) South-East, Saket Court, New Delhi Page no. 11/11