Health Insurance & Marine Cargo Insurance

Mr. Ravindra Prabhakar Kumbhar was covered under a health insurance policy by United India Insurance Co. Ltd.

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Case Study : Health Insurance

Supreme Court Judgment - Ravindra Prabhakar Kumbhar vs Divisional Manager, United India Insurance Co. Ltd. (2020)

Background

He had been regularly renewing his mediclaim policy for several years without any reported health complications.

However, when he filed for a reimbursement claim after undergoing heart surgery, the insurer rejected the claim citing alleged nondisclosure of a preexisting condition— hypertension.

The Dispute

The insurer contended that the insured failed to disclose his hypertension condition during the policy inception, which, they claimed, contributed to his cardiac ailment. Mr. Kumbhar argued that:

• He had no major ailment prior to the heart issue.

• He had disclosed all known medical facts to the best of his knowledge.

• The insurer had not asked for detailed health checkups or medical declarations in earlier policy renewals.

Additionally, it was pointed out that the policy had been renewed several times without any red flags being raised regarding the supposed condition.

Key Legal Issues

• Whether a mild case of hypertension amounts to a material nondisclosure.

• Whether the insurer had performed appropriate due diligence at the time of policy renewal.

• Whether rejection of a claim based on ambiguous or unverified assumptions is justified.

Court Observations

The Supreme Court made the following critical observations: