LIC's Cancer Cover Valid Only If 'First Diagnosis' Occurs After Waiting Period, Not Expert Confirmation: Kerala High Court

The Kerala High Court allowed Life Insurance Corporation's appeal against direction to pay insurance coverage claim of a cancer patient, holding that LIC's coverage for cancer care would apply only if the first diagnosis–which does not include confirmation by expert, occurred after waiting period of 180 days. The claimant, an LIC policy holder, had renewed her cancer cover on 16.03.2021. As per the terms of the policy, there was a waiting period of 180 days and if any diagnosis made during the said period, the policy would not apply. During the waiting period, claimant was hospitalised due to bleeding and on the same day, impression of endometria malignancy was found in the ultra sound. The Histopathology and MRI reports during the waiting period suggested that she had the cancer she was finally diagnosed with. Later, within the waiting period, she got admitted to another hospital and underwent surgery. The pathology report of samples taken during surgery confirmed Endometrial Carcinoma on 28.09.2021, i.e., after the waiting period got over. She claimed coverage of policy for her cancer, which according to her was diagnosed when confirmed as per biopsy report.On rejection of claim by insurer, claimant approached the Ombudsman, who also rejected her claim and subsequently, she moved before the single judge of the high court. The Single Judge allowed her writ petition holding that the confirmation of cancer by expert would be considered as diagnosis for the purpose of insurance coverage.; against this LIC moved the division bench. Justice Anil K. Narendran and Justice Muralee Krishna S. relied on Taber's Cyclopedic Medical Dictionary's definition of 'diagnosis' as per which:“Diagnosis means;"1. The term denoting the disease or syndrome a person has or is believed to have.2. The use of scientific or clinical methods to establish the cause and nature of a person's illness or injury and the subsequent functional impairment caused by the pathology. The diagnosis forms the basis of patient care."”Going by the definition, the bench opined that the diagnosis on 28.09.2021 was not the first date of cancer diagnosis and only a confirmation of earlier reports. Therefore, it held that the first diagnosis was within the waiting period and the 1st respondent is not entitled to policy coverage.The bench said that the claimant was admitted in the hospital due to illness "for the first time" on 25.08.2021. It noted that Ultrasound Scan Report dated 25.08.2021, showed "Endometrial Malignancy". Thereafter a histopathology Report dated 31.08.2021, recorded that there were Fragments of moderately differentiated endometrioid carcinoma. Thereafter an MRI Report dated 01.09.2021 gave findings suggestive of "Ca endomentrium - Stage 1 a". Subsequently, the claimant was admitted in Lake Shore Hospital on 09.09.2021 and discharged on 16.09.2021, and in the meanwhile, she was subjected to a surgery. Thereafter samples were collected during surgery, and the pathology report dated 28.09.2021 confirmed "Endometrial Carcinoma".The court said that this showed that the "final opinion arrived at by the pathology report dated 28.09.2021" is the confirmation of the diagnosis made in the earlier reports (Ultrasound, histopathology Report, MRI Report)."This diagnosis, done on 28.09.2021, is the confirmation by an expert, and it is not the first date on which cancer has been diagnosed. In such circumstances, it can only be said that the diagnosis of cancer was within the waiting period of 180 days. Therefore, the 1st respondent is not entitled for the policy coverage as rightly contended by the appellant and found by the learned Ombudsman," the bench ruled. The insurer had also taken a contention that the claimant had suppressed the material fact that her mother had cancer. However, the Court found that the 1st respondent had to disclose it only if there was family history in which someone suffered from or died due to cancer before the age of 60 years. There was no evidence pointing to the age of the mother in her discharge summary and the 1st respondent contended that she was 74 years at the time. The Court held that contention of suppression would not stand since there was no material to contradict the respondent's submission regarding age of mother. It thus agreed the Single Judge's finding in this regard.The Court allowed LIC's appeal and dismissed the writ petition, holding that the claimant is not entitled to cancer coverage.Case No: WA 1670 of 2024Case Title: Life Insurance Corporation of India v. Haripreetha T. and Anr.Citation: 2025 LiveLaw (Ker) 628Counsel for the appellant: Harish GopinathCounsel for the respondents: K. Balachandran (PN)Click to Read/Download Judgment

LIC's Cancer Cover Valid Only If 'First Diagnosis' Occurs After Waiting Period, Not Expert Confirmation: Kerala High Court

K. Salma Jennath

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LIC's Cancer Cover Valid Only If 'First Diagnosis' Occurs After Waiting Period, Not Expert Confirmation: Kerala High Court

K. Salma Jennath

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