The Kerala High Court allowed the insurance company’s writ appeal, set aside the single judge’s order directing policy payout, and dismissed the policyholder’s writ petition.
The respondent- policyholder had medical events and investigations (ultrasound, scan, and preliminary diagnosis) shortly before the 180-day mark from policy purchase date, but the formal specialist’s biopsy confirmation was received after the 180-day mark.
The policy claim was rejected by the appellant-insurer and ombudsman due to the “waiting period” clause, but the Single Judge directed payment of the cancer coverage benefits under the policy, holding that the critical date was final biopsy confirmation.
The insurer appealed against the order, arguing that earlier medical reports amounted to first diagnosis within the period, excluding coverage under Clause 8(G) of the policy.
The Bench comprising Justice Anil K. Narendran and Justice Muralee Krishna S. parsed policy language and contemporaneous medical evidence, concluding that multiple medical records, including ultrasound and histopathology noted endometrial malignancy, which the policyholder’s expert later confirmed.
The Court found that the policy’s “waiting period” must be strictly construed, and “date of diagnosis” means the first competent medical professional’s noted finding, even if full confirmation comes later.
In result, the insurer’s writ was allowed, the Single Judge’s directive was set aside, and the original writ petition (policyholder’s claim) was dismissed.
Appearances:
For the Appellant: Adv. Sri Harish Gopinath
For the Respondent: Adv. Shri K. Balachandran
