Earliest Medical Certification Fixes the “Date of Diagnosis” Under Cancer Cover Waiting Periods: LIC of India v. Haripreetha T

Court: High Court of Kerala, Division Bench (Ernakulam)

Citation: 2025 KER 72989

Date of Decision: 06 October 2025

Coram: Anil K. Narendran, J. and Muralee Krishna S., J.

Case No.: W.A. No. 1670 of 2024 (arising out of W.P.(C) No. 38249 of 2023)

Introduction

This Division Bench decision addresses a recurring and practically significant question in critical illness insurance: when does the “date of diagnosis” occur for the purposes of a waiting period in a cancer cover policy? The policyholder, Haripreetha T, had taken a LIC Cancer Cover policy commencing on 16.03.2021. She experienced medical issues in late August 2021, underwent a series of investigations, and ultimately received a histopathology report confirming endometrial carcinoma on 28.09.2021. LIC repudiated the claim on the ground that the first diagnosis occurred within the 180-day waiting period.

Before the learned Single Judge, the policyholder succeeded on the reasoning that the definitive diagnosis by a specialist was only on 28.09.2021, after the 180-day window. On appeal, LIC contended that earlier medical records already constituted a diagnosis within the waiting period and also alleged suppression of material fact relating to family history of cancer. The Division Bench reversed the Single Judge on the waiting period issue, while rejecting the suppression argument for want of proof.

The decision crystallizes a clear rule: where the policy defines “date of diagnosis” as the day a registered medical practitioner first examines and certifies the diagnosis of a specified cancer, the earliest medical certification evidencing such diagnosis—whether via radiological impressions suggestive of malignancy corroborated by histopathology or other clinical documentation—constitutes the operative “date of diagnosis,” notwithstanding later confirmatory reports or specialist endorsements.

Background and Key Facts

Policy: LIC Cancer Cover Policy (Policy No. 319261424), commenced on 16.03.2021; 180-day waiting period as per Clause 8(G) of Part C; “date of diagnosis” defined in Clause 13 of Part B as the date a medical practitioner first examines and certifies the diagnosis of specified cancer; “medical practitioner” broadly defined in Clause 25.
Medical events and documents:
- 25.08.2021: Hospitalization at Life Line Hospital, Adoor; Ultrasound Scan Report records final impression as “Endometrial Malignancy” (Ext. R1(b)).
- 31.08.2021: Histopathology Report records “Fragments of moderately differentiated endometrioid carcinoma [FIGO Grade II]” (Ext. R1(c)).
- 01.09.2021: MRI Report: “Imaging findings are suggestive of Ca endometrium - Stage 1a” (Ext. R1(d)).
- 09–16.09.2021: Admission and surgery at Lake Shore Hospital; samples sent for pathology.
- 28.09.2021: Pathology report confirms endometrial carcinoma (Ext. R1(f)).
Claim and repudiation: Claim submitted; LIC called for details; finally rejected on 06.01.2023 on the ground that the first diagnosis occurred during the 180-day waiting period (policy commenced 16.03.2021; 25.08.2021 being the 162nd day).
Ombudsman: Complaint rejected; LIC’s repudiation upheld (Award dated 29.09.2023).
Single Judge: Allowed the writ petition (29.08.2024), holding that the diagnosis was only on 28.09.2021 upon receipt of biopsy/histopathology; no suppression proved.
Appeal: LIC filed W.A. No. 1670 of 2024; the Division Bench reversed on the waiting period issue and dismissed the writ petition.

Summary of the Judgment

Holding on “date of diagnosis” and waiting period: The Division Bench held that the diagnosis of cancer occurred within the 180-day waiting period. The pathology report dated 28.09.2021 was a confirmation of earlier diagnostic findings. The earliest medical certifications (Ultrasound “Endometrial Malignancy” on 25.08.2021, Histopathology diagnosing endometrioid carcinoma on 31.08.2021, and MRI suggestive of cancer on 01.09.2021) fixed the diagnosis within the waiting period. Consequently, the policy’s benefits were not applicable and the claim was not payable.
Suppression of material facts: LIC’s allegation that the insured suppressed family history of cancer (mother’s carcinoma breast) failed for lack of proof that the familial cancer occurred before age 60, as required by the proposal form question. The Court concurred with the Single Judge that there was no suppression.
Outcome: Writ appeal allowed; judgment of the Single Judge set aside; writ petition dismissed; Ombudsman’s award stands effectively restored.

Analysis

Precedents Cited

The judgment does not rely on reported judicial precedents. Instead, it meticulously applies:

The contractual definitions within the LIC policy itself, particularly Clause 13 (date of diagnosis), Clause 25 (medical practitioner), and Clause 8(G) (waiting period for “any stage” cancer).
A standard medical dictionary definition of “diagnosis” from Taber’s Cyclopedic Medical Dictionary, emphasizing diagnosis both as the designation of disease and the process of establishing the cause and nature of an illness.

This approach underscores a textual-contractual method: construe the policy by its terms and incorporate ordinary medical meanings where the policy references medical concepts.

The Court’s Legal Reasoning

1) Contractual Text as the Starting Point

Three policy provisions govern the issue:

Clause 13 (Part B) – “Date of diagnosis”: The date on which a medical practitioner first examines the life assured and certifies the diagnosis of a specified early or major stage cancer.
Clause 25 (Part B) – “Medical practitioner”: Broadly encompasses any registered medical practitioner under relevant councils, not limited to specialists like oncologists; excludes only certain connected persons (insured, agents, etc.).
Clause 8(G) (Part C) – Waiting period: A 180-day waiting period applies to the first diagnosis of “any stage” cancer from issuance/revival; benefits are inapplicable and the policy stands terminated if any stage of cancer occurs/is diagnosed within that window.

Read together, these clauses make two points pivotal: the earliest “certification” of diagnosis by any registered medical practitioner triggers the date of diagnosis; the waiting period applies to any stage and is indifferent to whether the cancer is early or major stage.

2) Medical Evidence Sequencing and Its Legal Effect

The Bench carefully sequenced the medical evidence to identify the earliest point when a diagnosis was certified:

25.08.2021: Ultrasound with final impression “Endometrial Malignancy” (not a mere suspicion, but an impression consistent with malignancy).
31.08.2021: Histopathology reporting “moderately differentiated endometrioid carcinoma (FIGO Grade II).” Histopathology is a core diagnostic tool; the report itself is a certification by qualified medical professionals.
01.09.2021: MRI “suggestive of Ca endometrium - Stage 1a.”
28.09.2021: Post-surgical pathology confirms carcinoma.

The Court reasoned that the 28.09.2021 report is not the first diagnosis; it is a confirmation. By policy definition, the first date a medical practitioner certifies the diagnosis controls. On these facts, that occurred well within 180 days from 16.03.2021 (notably, the Court identified 25.08.2021 as the 162nd day). Thus, the claim fell squarely within the waiting period exclusion.

3) “Diagnosis” Versus “Confirmation”

To eliminate ambiguity, the Court leaned on Taber’s definition of “diagnosis” and the policy’s own language. A diagnosis does not require the latest or most definitive confirmation by a super-specialist; it requires a medical practitioner’s certification that a specified cancer exists. The presence of an earlier histopathology report diagnosing carcinoma was decisive. In short, once a qualifying diagnostic certification exists, later confirmatory findings do not reset or shift the date of diagnosis.

4) The Specialist-Only Argument Rejected

The insured’s argument that only a specialist’s post-operative biopsy report can fix the diagnosis date was at odds with the policy’s definition of “medical practitioner.” The clause was unqualified and did not limit “certification” to oncologists or to post-surgical biopsies. The Division Bench’s construction holds the parties to the words of their contract.

5) Suppression of Material Facts – Materiality and Proof

LIC alleged non-disclosure of family history (mother’s carcinoma breast) as per the proposal form. The Court emphasized the precise framing of the proposal question: whether a parent or sibling suffered from or died due to cancer before age 60. The record did not establish the mother’s age at diagnosis; the insured asserted the mother was 74 and the cancer had occurred approximately 30 years earlier. With no contrary evidence, the non-disclosure was not material within the meaning of the question. The Bench therefore agreed with the Single Judge that suppression was not proved.

Impact and Significance

A. Clarifying the Trigger for Waiting Periods in Cancer Cover

This ruling sets a clear benchmark for similar policies: the operative “date of diagnosis” is the earliest date on which any registered medical practitioner certifies the presence of a specified cancer, as documented in medical records. Radiology impressions that directly identify malignancy, histopathology reports diagnosing carcinoma, and other clinical certifications will trigger the date, even if later reports offer more granular staging or confirmatory detail.

B. Reduced Scope for “Confirmation-Date” Arguments

Policyholders can no longer successfully argue that the waiting period ends by relying on the date of the most definitive or specialist confirmation (e.g., post-surgical biopsy) if earlier records already constitute a certification of diagnosis. This closes a line of litigation premised on sequencing diagnostic steps to fall outside the waiting period.

C. Precision in Proposal Form Disclosures

The judgment also underscores that allegations of suppression must align with how the proposal questions are framed. If a proposal asks about cancer in a parent or sibling “before age 60,” the insurer bears the burden to prove that age condition. Vague references in discharge summaries are insufficient absent proof of age at diagnosis. This injects rigour and fairness into underwriting disputes.

D. Administrative Guidance for Ombudsmen and Insurers

For Insurance Ombudsmen and insurers, the decision offers a practical roadmap for evaluating claims:

Identify the earliest medical document that constitutes a certification of cancer by a registered practitioner.
Apply the waiting period to that date, not to subsequent confirmatory or specialist reports.
When alleging non-disclosure, match the allegation precisely to the wording of the proposal question and marshal concrete proof.

Complex Concepts Simplified

Waiting period: A contractually defined time after policy commencement during which specified claims are not payable. Here, 180 days for “any stage” of cancer. If diagnosis occurs within this period, benefits are not available and the policy may terminate vis-à-vis the covered event.
Date of diagnosis: Under this policy, it is the date a registered medical practitioner first certifies the diagnosis. It is not necessarily the date of the most definitive or final confirmation; the earliest qualifying certification counts.
Any stage cancer: The waiting period applies to early and major stages alike. The phrase ensures the waiting period cannot be circumvented by characterizing the cancer as “early stage” or awaiting staging refinement.
Diagnosis versus confirmation: Diagnosis is the medical act of identifying disease; confirmation may be a later test corroborating the initial diagnosis. For policy timing, diagnosis starts the clock even if later tests confirm it.
Ultrasound/MRI “impression”: Radiology reports commonly include “impressions.” When an impression explicitly identifies malignancy (e.g., “Endometrial Malignancy”), it may qualify as a certification of diagnosis, especially when supported by histopathology.
Histopathology: Microscopic examination of tissue samples; a cornerstone of cancer diagnosis. An early histopathology report stating carcinoma typically constitutes a diagnosis.
Suppression of material fact: Non-disclosure of information that would influence the insurer’s decision to accept risk or terms. Materiality is tested against the specific proposal question and requires proof.

Key Clauses and Their Practical Import

Clause 13 (Date of Diagnosis): Broad—any registered medical practitioner can fix the date. Practical import: do not assume only oncologist-confirmed, post-operative biopsy dates matter.
Clause 25 (Medical Practitioner): Broad inclusion of registered practitioners. Practical import: earlier diagnostic certifications by pathologists, radiologists, or treating physicians may trigger the date of diagnosis.
Clause 8(G) (Waiting Period): Applies to the first diagnosis of “any stage” cancer within 180 days. Practical import: if the earliest qualifying certification falls within 180 days of issuance/revival, claim is not payable and the policy may terminate for that event.

Practical Timelines and Application

Policy commencement: 16.03.2021
Earliest documented diagnostic certification: 25.08.2021 (Ultrasound impression “Endometrial Malignancy”), followed by 31.08.2021 histopathology diagnosing carcinoma
Waiting period: 180 days from 16.03.2021
Court’s computation: 25.08.2021 was the 162nd day; thus within the waiting period
Result: Policy benefits inapplicable; claim rightly repudiated on waiting period grounds

Practice Pointers

For policyholders:
- Understand that any earliest diagnostic certification (even pre-surgical) can start the diagnosis clock for waiting periods.
- Maintain a chronology of all tests and reports; do not assume the final biopsy date controls.
- Answer proposal questions precisely; if age thresholds are specified, consider retaining proof that a relative’s illness falls outside the specified age band.
For insurers:
- Anchor repudiations to the earliest medical document constituting a diagnosis by a registered practitioner; explain how the policy definitions apply.
- When alleging non-disclosure, ensure documentary proof maps exactly to the proposal questions (e.g., age at diagnosis for relatives).
- Maintain clear records and consistent communication, as Ombudsmen and courts will scrutinize the precise grounds of repudiation.
For adjudicators (Ombudsmen/courts):
- Start with policy definitions; if unambiguous, apply them as written.
- Sequence medical evidence carefully; distinguish between “diagnostic certification” and “confirmatory” testing.
- Assess suppression claims within the four corners of the proposal form’s wording and evidentiary rigor.

Conclusion

The Kerala High Court’s decision in LIC of India v. Haripreetha T establishes a clear, contract-faithful rule for cancer cover waiting periods: the “date of diagnosis” is fixed by the earliest medical certification of cancer by any registered medical practitioner, not by a later confirmatory or specialist report. This aligns with the policy’s definitions and the ordinary medical meaning of diagnosis, curbs attempts to re-sequence diagnostic steps to outlast waiting periods, and brings much-needed certainty to claim adjudication.

Equally, the judgment tempers insurers’ repudiation strategies by demanding precision in suppression allegations: unless the insurer proves the elements embedded in the proposal question (here, the age-at-diagnosis threshold), non-disclosure claims will fail. The dual holdings—strict adherence to waiting period triggers and strict scrutiny of suppression claims—promote contractual clarity, fairness in underwriting disputes, and predictability for stakeholders across the insurance ecosystem.

Key takeaways are straightforward: read and apply the policy text as written; treat the earliest diagnostic certification as decisive for waiting periods; and prove suppression with specificity and evidence. Future disputes in the critical illness domain, especially those involving sequencing of diagnostic events and family history disclosures, are likely to be guided by this robust, text-centric approach.