HONOURABLE MR JUSTICE D.BHARATHA CHAKRAVARTHY W. P(MD)No.35832 of 2025and W.M.P(MD)Nos.28463 and 28461 of 2025 1. S.Samythasan 2. S.Kasthuri … Petitioners Vs. 1. The Director, Insurance Regulatory and Development Authority of India, Sy. No.115/1, Financial District, Nanakramguda, Gachibowli, Hyderabad – 500032. 2. The Managing Director, Star Health and Allied

BEFORE THE MADURAI BENCH OF MADRAS HIGH COURT
Dated: 26.03.2026
CORAM
THE HONOURABLE MR JUSTICE D.BHARATHA CHAKRAVARTHY
W. P(MD)No.35832 of 2025and
W.M.P(MD)Nos.28463 and 28461 of 2025
1. S.Samythasan
2. S.Kasthuri … Petitioners
Vs.
1. The Director,
Insurance Regulatory and Development Authority of India,
Sy. No.115/1, Financial District, Nanakramguda,
Gachibowli,
Hyderabad – 500032.
2. The Managing Director,
Star Health and Allied Insurance Company Limited,
Registered and Corporate Office,
No.1, New Tank Street,
Valluvar Kottam High Road,
Nungambakkam,
Chennai 600 034.
3. The Regional Manager,
Star Health and Allied Insurance Company Limited,
Corporate office – Claims Department,
Balaji Complex,
No.15, Whites Lane, Whites Road, Royapettah, Chennai 600 014.
4. The Branch Manager,
Star Health and Allied Insurance Company Limited,
No.10B/1K, First Floor,
Trivandrum Road, Opp. to RMKV Silks,
Vannarapettai, Tirunelveli – 627 002. …Respondents
Prayer: Writ Petition filed under Article 226 of the Constitution of India, praying this Court to issue a Writ of Certiorarified Mandamus, calling for the records relating to the impugned communication dated 29.05.2025 issued by the 3rd Respondent rejecting the Petitioners mediclaim request with Claim Intimation No.
CIG/2026/121400/0308660 and quash the same as illegal and and consequently direct Respondents 2 to 4 to process, sanction, and settle the Petitioners mediclaim in full for the treatment undergone by the 2nd Petitioner at Vadamalayan Hospitals (P) Ltd., Madurai, in accordance with the STAR GROUP HEALTH INSURANCE POLICY, by disbursing the medical expenditure of Rs.1,53,129/- (Rupees One Lakh Fifty Three Thousand One Hundred and Twenty Nine Only), corresponding to Vadamalayan Hospitals (P) Ltd., Receipt No.32345 dated 29.05.2025 for Rs.25,000/-, Receipt No.32333 dated 29.05.2025 for Rs.50,000/-,
Receipt No.32468 dated 30.05.2025 for Rs.25,000/-, and Receipt No.42057 dated 31.05.2025 for Rs.53, 129/-, together with interest at the rate of 12 percentage per annum from the date of claim till the date of realization and pass such other further orders that this Honble Court may deem fit and proper in the circumstances of the case and thus render justice.
For Petitioner :Mr.C.Masilamani
For R1 :Mr.S.Anwar Sameem
For R2 to R4 :Mr.K.Ravi Kumar
ORDER
The writ petition is filed calling for the records relating to the communication dated 29.05.2025 issued by the 3rd respondent, rejecting the petitioners’ mediclaim request, and to quash the same, and consequently to direct respondents 2 to 4 to process, sanction and settle the petitioners’ mediclaim in full for the treatment undergone by the 2nd petitioner.
2. The case of the petitioners is that the 1st petitioner, Mr. S.
Samythasan, is an employee of a public sector bank, the Tamil Nadu Grama Bank, which is said to be a subsidiary of Indian Bank. Pursuant to the Bank’s policy to outsource medical reimbursement through group insurance, a mediclaim policy was introduced on behalf of the employer, and insurance policies have been obtained from various insurance companies periodically. It is stated that, for some previous years, the policy was obtained from United India Insurance Company. For the year in question, that is 2023, the policy was issued by the 2nd respondent / Star Health and Allied Insurance Company Limited. A policy was issued covering the first petitioner, the employee, and the second petitioner, his spouse. The Star Group Health Insurance Policy was issued by the second respondent on 03.04.2025.
3. In 2015, the second petitioner was diagnosed with Sick Sinus Syndrome (hereinafter referred to as ‘SSS’), a disorder in which the heart’s natural pacemaker (sinoatrial node) fails to maintain the normal rhythm, causing dizziness, fainting, fatigue, palpitations, etc. As a result, a permanent pacemaker was implanted in 2015 for the wife of the 1st petitioner, namely Kasturi, the 2nd petitioner herein. In May 2025, the 2nd petitioner became unwell, and upon admission, it was found that the permanent pacemaker’s battery needed to be replaced.
4. When the second petitioner was admitted to the hospital for the “pulse generator change,” a cashless treatment request was made on
28.05.2025. The second petitioner underwent the treatment and paid a sum of Rs. 1,53,000/- to the hospital, where the pulse generator was replaced. When the claim was made, the 2nd respondent denied the claim by stating that the insured patient had ‘SSS’ in 2015, prior to the inception of the first medical insurance policy. Since the pre-existing disease was not disclosed at the time the insurance cover was proposed, it was considered void ab initio. Aggrieved by this, the present writ
petition is filed.
5. The learned counsel for the petitioner submits that although the policy categorically governs the claims that are to be made for the 2nd petitioner, it was repudiated for flimsy reasons. The learned counsel for the petitioner contends that the term “pre-existing disease” is defined in the documents annexed to the Insurance Policy. The same is extracted hereunder:
“Pre-Existing Disease: Pre-existing Disease means any condition, ailment, injury or disease:
(a)That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement or
(b)For which medical advice or treatment was recommended
by, or received from, a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement. “
(Emphasis supplied)
6. Therefore, the learned counsel for the petitioner would submit that since the diagnosis of the disease was made in 2015, i.e., prior to 48 months from the effective date of the policy, and the medical advice for replacement was given subsequent to the issue of the policy, the impugned order is not sustainable.
7. The learned counsel for the petitioner would further submit that the stand taken in the counter affidavit, claiming that the writ petition is not maintainable, should not be considered by this Court, as the writ petition has already been entertained and the parties have filed their submissions on merits. According to the learned counsel, the term “medical condition” would mean illness, and illness is defined in the policy document’s terms and conditions, which include both acute and chronic conditions. The relevant portion is extracted hereunder:-
“Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function and requires medical treatment.
a.Acute condition – Acute condition is a disease, illness or injury that is likely to respond quickly to treatment which aims to return the person to his or her state of health immediately before suffering the disease/ illness/ injury which leads to full recovery.
b.Chronic condition – A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics:-
1.It needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /or tests
2.It needs ongoing or long-term control or relief of symptoms
3.It requires rehabilitation for the patient or for the patient to be specially trained to cope with it
4.It continues indefinitely
5.It recurs or is likely to recur”
8. Besides, the learned counsel for the petitioner also relied upon the judgment of this Court in K. Krishna and another vs. The
Managing Director, M/s. Star Health and Allied Insurance Company Ltd. (W.P(MD) No. 18130 of 2021, etc.), wherein this Court entertained the writ petition and granted relief with respect to Ayush treatment under the same Insurance Company.
9. Per contra, the learned counsel appearing on behalf of the Insurance Company, relying on the counter-affidavit and the documents filed, submitted that the contract of insurance is based on the principle of ‘uberrima fides’. When the petitioner filled out the application, there was a tabular column. Row No. 8 of the tabular column required the proposer to disclose details of pre-existing diseases. Row No. 9 required the proposer to disclose any other medical conditions, disabilities, physical deformities, diagnostic tests, routine health check-ups, investigations, or prior history of accidents. The petitioners willfully stated “nil” in these columns. Therefore, since false particulars were provided in the proposal form, the Insurance Company has rightly cancelled the policy in accordance with Clause 7 of the terms and conditions. Consequently, the petitioner is not entitled to reimbursement for any amount.
10. The learned counsel would rely upon the judgment of the
Hon’ble Supreme Court of India in Reliance Life Insurance Company Limited vs. Rekhaben Nareshbhai Rathod (2019) 6 SCC 175, wherein the Court emphasised the importance of the proposal form and held in paragraph 29 that contracts of insurance are governed by the principles of utmost good faith. Therefore, if the relevant particulars are not filled in the proposal form, the Insurance Company will not be liable to reimburse the claim amount.
11. Therefore, if not within the category of ‘pre-existing disease’, at least within the category of ‘medical condition’, the petitioner’s chronic condition (i.e., her diagnosis of ‘SSS’ and the permanent pacemaker implant requiring regular check-ups) should have been disclosed in the proposal form. Had it been disclosed, the Insurance Company would have had the opportunity to refer the patient for further medical check-ups. Depending on the outcome, an additional premium could have been collected under the policy, potentially covering the issue. In the absence of such disclosure and specific coverage for the condition, the policy has rightly been cancelled due to the petitioner’s failure to disclose relevant information in the proposal form. In any event, any claim should be made before the appropriate consumer forum. If there is a grave dispute on facts, the party must approach the competent Civil Court.
12. The learned counsel for the 1st respondent submitted that the
1st respondent, the Insurance Regulatory and Development Authority of India (IRDAI), has no role in individual insurance claims or repudiations. Under the scheme, the Insurance Ombudsman has been established to provide the petitioner with a remedy for any wrongful repudiation.
13. I have considered the rival submissions made on either sideand perused the material records of the case. The following questions arise for consideration:
A)Whether the writ petition is maintainable?
B)Whether the impugned order passed by the 2nd respondent,
cancelling the policy ab initio from the date of issue of the policy, is in order?
C)Whether the claim of the petitioner is liable to be repudiated on account of the ‘nil’ endorsement made by them in the proposal form ?
Question (A):
14. With reference to the maintainability of the writ petition, the matter is no longer res integra. Under Article 226, a writ can be issued against any authority, provided that: (a) the authority is a state or any local or other authority under the state; (b) the order is in violation of any statutory exercise of power or public duty. In this regard, it can be seen that by the impugned order, the policy was issued, the 2nd petitioner was admitted and underwent treatment, and when a cashless request was made, there was no positive response. She underwent treatment, reimbursement was sought, and the policy was cancelled ab initio. In this context, it is essential to refer to Section 46 of the Insurance Act, 1938:
“46. Application of the law in force in India to policies issued in India.—The holder of a policy of insurance issued by an insurer in respect of insurance business transacted in India after the commencement of this Act shall have the right, notwithstanding anything to the contrary contained in the policy or in any agreement relating thereto, to receive payment in India, of any sum secured thereby and to sue for any relief in respect of the policy in any Court of competent jurisdiction in India; and if the suit is brought in India; any question of law arising in connection with any such policy shall be determined according to the law in force in India:
Provided that nothing in this section shall apply to a policy of marine insurance.”
(Emphasis
supplied)
15. Thus, even though the provision is predominantly with reference to the territorial jurisdiction, it incidentally creates a substantive right for the policyholder to receive payment under the policy. I am of the view that this case squarely falls for examination as to whether the impugned exercise of power is in violation of Section 46. Since this matter falls within the statutory regime, I am of the opinion that the writ petition is maintainable. Accordingly, the question is answered.
Question (B):
16. When the petitioner underwent treatment, the impugned ordercancelled the policy ab initio. The operative portion of the impugned order is contained only in paragraph number one, which is extracted hereunder:-
“1. It is observed from the submitted records that the insured patient had the sick sinus syndrome 2015 disease prior to inception of the first medical insurance policy. Since the preexisting disease was not disclosed at the time of proposing the insurance, the cover for the insured patient is deleted ab initio.”
17. Firstly, when the policy has been issued and thereafter, when the patient undergoes the treatment and a claim is made, it is one thing to repudiate the claim on the basis of uberrima fides, but what has been done here is that the policy itself is deleted ab initio. This directly contravenes Section 46 of the Insurance Act, 1938. When a substantial right has been granted to the policyholder to realise the claim due under the policy, merely relying on any clause in the policy cannot justify the ab initio deletion of the policy after a claim has been made. Therefore, the impugned action of the respondent insurance company is illegal and violative of Section 46 of the Insurance Act. Accordingly, the question is answered.
Question (C) :
18. With respect to question no. 3, the picture of the proposal form submitted by the petitioner at the time of availing the policy is extracted hereunder:-
19. Row No. 8, which is complained of in the impugned order as a pre-existing disease, shows that the petitioner entered “nil.” In this context, the 2nd respondent company drafts the clauses. According to their own definition, the diagnosis or treatment recommendation should have occurred ‘within 48 months’ prior to the issue of the policy. Therefore, any diagnosis made before this period does not fall within the said definition. Thus, when the petitioner stated “nil” with reference to the pre-existing disease, no exception can be made. As a matter of fact, the impugned order repudiates the claim solely on the grounds that the petitioner stated “nil” with respect to the pre-existing disease. Therefore, the claim could not have been denied on this ground.
20. Alternatively, before this Court, the learned counsel pleads that even with respect to Row No. 9, which pertains to medical conditions, the word “nil” is mentioned. Firstly, this reason was not stated in the impugned order. Nevertheless, since insurance is a contract of uberrima fides, it is incumbent upon this Court to consider the issue in light of the judgment of the Honourable Supreme Court of India in Reliance Insurance (cited supra). The learned counsel contends that the term “medical condition” would encompass both acute and chronic
conditions. The term “medical condition” is not defined in the insurance policy. However, in normal parlance, it could mean illness, which includes both acute and chronic conditions.
21. The petitioners argue that the disease was SSS (Sick Sinus Syndrome). When the sinoatrial node (the heart’s natural pacemaker) fails to maintain a normal rhythm, a permanent pacemaker is implanted.
Once implanted, the pacemaker maintains the heart’s normal rhythm. After this, the petitioner did not consider it an illness. Therefore, considering the above, the 2nd respondent, being in a dominant position to draft the policy terms and conditions, must bear the consequences in cases of any doubt or ambiguity in the policy clauses. This is due to the contra proferentem rule, which favours the interpretation most beneficial to the insured party. Since the term “medical condition” is not clearly defined in the policy, and there may be doubt as to whether the requirement of periodical change in battery to the pacemaker should be mentioned or not and whether it would come within the definition of ‘chronic illness’ contained the policy, which is extracted in paragraph 7 supra. Useful reference in this regard can be made to the paragraph 6 Judgment of the Hon’ble Supreme Court of India in United India
Insurance Company Ltd -Vs- Pushpalaya Printers(2004 3 SCC 694). Accordingly, I answer that the petitioners’ claim cannot be repudiated.
22. Above all, the most important factor to consider is that this is not an individual policy negotiated between the parties, column by column, with the insurance company’s representative present. In this case, the employer is duty-bound, under the service conditions, to reimburse medical expenses under applicable service rules. The employers have found a new mechanism by involving the insurance company and taking out a group insurance policy for all employees. This effectively transfers their liability to the insurance company. But for such group insurance policies, the petitioner would have normally received reimbursement for medical benefits directly from the employer or the operational scheme. Thus, the above findings relating to the Uberrima fides and contra proferentem rules are made in light of the peculiar context of medical reimbursement arising out of service in the particular organisation.
23. Accordingly, this writ petition is allowed on the following terms”-
i.The impugned order dated 29.05.2025 shall stand set aside.
ii.The 2nd and 3rd respondents are directed to process the claim of the petitioner and release a sum of Rs.1,53,000/- claimed by the petitioner for the expenses within a period of eight weeks from the date of receipt of the web copy of the order without waiting for the certified copy of the order.
iii.It is made clear that before the policy commences next week year, the petitioners shall appear before the 2nd respondent or the insurance company and the fresh proposal form shall be obtained and depending on the same, the renewal of the policy shall be made in accordance with the rules.
iv.No costs. Consequently, connected miscellaneous petitions are closed.
26.03.2026
NCC:Yes/No rgm
D.BHARATHA CHAKRAVARTHY, J.
rgm
To
1. The Director,
Insurance Regulatory and Development Authority of India,
Sy. No.115/1, Financial District, Nanakramguda,
Gachibowli,
Hyderabad – 500032.
2. The Managing Director,
Star Health and Allied Insurance Company Limited,
Registered and Corporate Office,
No.1, New Tank Street,
Valluvar Kottam High Road,
Nungambakkam,
Chennai 600 034.
3. The Regional Manager,
Star Health and Allied Insurance Company Limited,
Corporate office – Claims Department,
Balaji Complex,
No.15, Whites Lane, Whites Road, Royapettah, Chennai 600 014.
4. The Branch Manager,
Star Health and Allied Insurance Company Limited,
No.10B/1K, First Floor,
Trivandrum Road, Opp. to RMKV Silks,
Vannarapettai, Tirunelveli – 627 002.
W.P(MD)No.35832 of 2025 and
W.M.P(MD)Nos.28463 and 28461 of 2025