Indian Kanoon - Search engine for Indian Law

6. Then the petitioner preferred another claim petition for the said amount on 22.09.2016. This was during the pendency of the earlier writ petition as mentioned above. Then the respondents issued a communication dated 28.04.2017, directing the petitioner to produce the following details.

2025:KER:66325 WP(C) Nos.13244 & 40088 of 2017

1. The history, duration and treatment papers of hernia repair done in past, certified by the treating doctor.

7. It is contended by the petitioner that the reason assigned for rejecting the subsequent claim was unusual, since the hernia repair surgery undergone by his wife, in the year 2006, has no connection with the present disease, namely Vesicovaginal fistula repair. Therefore, the reliance on a pre-existing illness as the ground for rejection is completely erroneous. The rejection was issued as per Ext.P14, and a similar communication followed.

2025:KER:66325 WP(C) Nos.13244 & 40088 of 2017 Hence, the petitioner challenges Ext.P8, P14 & P15 by preferring this writ petition.

18. On the second occasion, the claim was denied on the basis of pre-existing disease. In fact, the insured i.e., the wife of the petitioner, had undergone hernia repair in 2006, which is a procedure to correct hernia, a condition where an organ or tissue protrudes through a weak spot in the surrounding muscle or tissue. The present treatment, however, was for vesicovaginal fistula, which, as stated earlier, is a post-operative complication of hysterectomy. Thereby, denial of benefits on the grounds of a hernia repair done, way back in 2006, or on account of hysterectomy which was performed much after subscribing to the policy amounts to a great miscarriage of justice. Moreover, the 2025:KER:66325 WP(C) Nos.13244 & 40088 of 2017 facts involved in this case appear to be bona fide. Hence, at the first instance, it appears that the writ petition is maintainable.

29. In the present case, the ailment for which the insured underwent treatment has no relation to the pre-existing condition said to have been omitted in the proposal form. The insurer, therefore, cannot rely upon such omission to avoid liability, particularly when the insured has paid premiums for this much of period, that is between 2008 and 2016, with a legitimate expectation of the coverage. Courts have consistently held that unless there is fraudulent and wilful suppression of a material fact which has a direct link to the cause of claim, repudiation of the policy cannot be sustained. Here, in this case, there is no nexus between vesicovaginal fistula, the present treatment undergone by the wife of the insured and the Hernia repair, which was done in 2025:KER:66325 WP(C) Nos.13244 & 40088 of 2017 the year 2006, the alleged pre-existing condition. There is no medical nexus between the two, nor can the earlier surgery be said to have any bearing on the present illness. Hence, the omission to disclose the Hernia repair cannot be treated as material suppression, and repudiation of the claim on this ground is wholly unjustified.