Existence Of Efficacious Alternative Remedy Amid COVID-19 Lockdown Doubtful : Delhi HC Entertains Writ Petition On Insurance Claim Dispute

In a matter pertaining to denial of claim by the insurance company, the Single Bench of Justice Prateek Jalan while providing relief to the person insured, noted that since the Petitioner shows urgency of medical treatment and there's no major dispute regarding the evidence, the court could entertain the present plea in a writ petition.

"The entire country has been under a national lockdown since 23.03.2020, and all judicial forums (including this Court) have been functioning restrictively. Although the insurance policy in the present case speaks of grievance redressal through an ombudsman (clause 5.19 of the terms and conditions), Mr. Shahi was unable to confirm whether the office of the ombudsman is functionalat this time. The petitioner's illness is such that his treatment cannot be delayed; his right to life is very directly implicated. The existence of an efficacious alternative remedy, particularly at this juncture, is extremely doubtful. It appears to me that the petitioner would be seriously prejudiced if I were to relegate him to other remedies",the Court observed.

Facts

The petitioner took respondent's insurance policy in 2002 for ₹5,00,000. However, in 2017, the said amount was enhanced to ₹8,00,000 and the Petitioner was informed about the same.

The petitioner was diagnosed with metastatic squamous cell carcinoma in cervical lymph nodes in January 2020, and is undergoing treatment at Medanta Hospital, Gurugram, and Apollo Hospital, Delhi. In accordance with the procedure under the policy, the petitioner applied for the "cashless facility". However, the third-party administrator appointed by the respondent rejected the petitioner's request by citing exhaustion of claim amount.

The petitioner protested to the respondent on the same date and drew the respondent's attention to the enhancement of the sum insured in the year 2017. The TPA responded on 01.04.2020, relying upon the exclusion contained in the policy in respect of pre-existing conditions. It took the position that the petitioner was already suffering from the said ailment when the enhanced coverage was taken, and the enhanced sum assured would therefore not be available until the petitioner completed four years of enhanced coverage.

Arguments Advanced by the Petitioner

When the respondent raised the issue of maintainability of the petition, the petitioner argued that there is no absolute bar to the jurisdiction of the writ court even in contractual matters arising between a citizen and an instrumentality of the State, but the exercise of jurisdiction is a matter for the Court's discretion. He further submitted that that the respondent's characterisation of his present ailment (metastatic squamous cell carcinoma in cervical lymph nodes) as a continuation of the earlier ailment is therefore wholly arbitrary and liable to be set aside.

Arguments Advanced by the Respondent

The respondent, on the other hand, argued that the medical documentation of 2017 and 2018 revealed the existence of cancer, and the petitioner's present ailment is the same. He further submitted that the petitioner suppressed his medical history when he sought enhancement of the sum insured under the policy.

Observations of the Court

On the issue of maintainability, the court at the outset clarified that the question is not one of jurisdiction of the court, but of whether the discretionary power under Article 226 of the Constitution ought to be exercised in a particular case.

After relying upon various judgements of both the Supreme Court and the Delhi High Court, the court decided that the present petition cannot be dismissed on the ground of maintainability as the facts of the matter are not in serious dispute.

Moreover, while taking into consideration the ongoing lockdown and restricted functioning of the judicial fora due to COVID19 pandemic, the court highlighted that:

'The petitioner's illness is such that his treatment cannot be delayed; his right to life is very directly implicated. The existence of an efficacious alternative remedy, particularly at this juncture, is extremely doubtful. It appears to me that the petitioner would be seriously prejudiced if I were to relegate him to other remedies.'

Refuting the respondent's claim regarding the present matter falling under the exclusion clause of the policy, the court noted that the petitioner was found to be free of the disease in the interregnum, thus, it also shows that the petitioner's present condition cannot be treated as a pre-existing one.

It was further noted that respondent's analysis falls short of the minimum required standard. The original position taken by the TPA has simply been reasserted by the respondent without even considering the information it had sought from the petitioner.

Therefore, the court held that the disputed communication of the respondent is contrary to law, unreasonable and arbitrary, and liable to be set aside.

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