Back
2019 Supreme(SC) 877
SUPREME COURT OF INDIA
UDAY UMESH LALIT, VINEET SARAN, JJ.
Kanwaljit Singh – Appellant
Versus
National Insurance Company Ltd – Respondent
Civil Appeal No.6255 of 2019
Decided on : 14-08-2019
For the Appellant(s) :Satish Kumar, Advocate
For the Respondent(s) Mridula Ray Bharadwaj, Advocate
IMPORTANT POINT
Mediclaim Policy – Quantum of reimbursement cannot exceed limits of policy.
Headnote:
Consumer Protection Act, 1986 – Section 23 – Insurance – Mediclaim Policy – Extent of liability of Insurance Company – Part settlement of claim – Scaling down of claim by National Commission on ground of pre-existing ailment – Sum insured under Family Mediclaim Policy, was Rs.5,00,000/- – For any individual claim or illness for any one member of family, limit would be 50% of sum insured – At best the maximum claim which could be payable in present case would be 50% of sum insured under Family Mediclaim Policy for the medical treatment of one member of family – Claim could not have been repudiated by Insurance Company as there was no pre-existing disease when initial individual Mediclaim Policy of Master Jasnoor Singh was taken in year 2007-2008 – Since then policy was regularly renewed up to year 2014-2015 – Question of pre-existing disease in case of claimant was not considered to be material by Insurance Company – Medical expense incurred and claimed by appellant for treatment of Master Jasnoor Singh within effective period of policy was over Rs.8,00,000/- – As such, appellant would be entitled to a sum of Rs.2,50,000/- minus amount already paid by Insurance Company under orders of District Forum – Appellant would also be entitled to amount of Rs.50,000/- towards mental agony and harassment plus Rs.30,000/- towards costs of litigation. (Paras 11 to 14)
Facts of the Case:
Question involved in this appeal is with regard to extent of liability of Insurance Company with regard to individual claim under Mediclaim for Family Policy.
Findings of Court:
Claim could not have been repudiated by the Insurance Company as there was no pre-existing disease when the initial individual Mediclaim Policy of Master Jasnoor Singh was taken in the year 2007-2008. Since then policy was regularly renewed up to the year 2014-2015. Thus in the facts of the present case, the respondent – Insurance Company cannot take the plea of any pre-existing disease of Master Jasnoor Singh. Even otherwise, after having initially repudiated claim of appellant, the Insurance Company had itself allowed the claim to the extent of Rs.27,550/-, which amount was deposited in account of the appellant, meaning thereby that question of pre-existing disease in the case of the claimant was not considered to be material by Insurance Company.
Result : Appeal allowed.
JUDGMENT :
Vineet Saran, J
The question involved in this appeal is with regard to the extent of the liability of the Insurance Company with regard to individual claim under “Parivar - Mediclaim for Family Policy” (for short “Family Mediclaim Policy”).
2. The admitted facts of this case are that since 2007-2008, the appellant had been taking individual Mediclaim Policies for his individual family members. The dispute in the present appeal pertains to the medical claim for the year 2014-15, with regard to son of the appellant, namely Master Jasnoor Singh. The individual Mediclaim Policies of the said Master Jasnoor Singh from 2007-2008 to 2013-2014 was for different sum insured, varying from Rs.50,000 in 2007-2008 to Rs.2,54,000/- in 2013-2014. In the year 2014-2015, the appellant took Family Mediclaim Policy for a sum insured of Rs.5,00,000/- for the period 07.02.2014 to 06.02.2015, which was for the appellant himself and his family members, namely, his wife, son Master Jasnoor Singh and daughter.
3. It was during the validity of the Family Mediclaim Policy 2014-15, that in the year 2014 Master Jasnoor Singh fell sick and had to undergo treatment in Post Graduate Institute (PGI), Chandigarh. He was initially hospitalized from 24.05.2014 to 19.07.2014 for which the medical bill was for an amount of Rs.5,40,741/-. He was again hospitalized from 31.08.2014 to 17.10.2014, for which the medical bill was for Rs.3,14,485/-. The total amount of medical bill thus came to Rs.8,55,226/-. The appellant lodged a claim for the said amount with the respondent-National Insurance Company Ltd (for short “Insurance Company”), which was initially repudiated by the Insurance Company without assigning any reason. However, later considering that the said Master Jasnoor Singh had an individual medical claim policy in the year 2009-2010 for Rs.55,000/-, the respondent - Insurance Company deposited a sum of Rs.27,550/- in the account of the appellant towards final payment of the claim.
4. Since the remaining claim was not paid, the appellant filed a complaint before the District Consumer Disputes Redressal Forum (for short “District Forum”) claiming an amount of Rs.5,00,000/-, which was the sum insured under the Family Mediclaim Policy for the relevant year 2014-2015. Before the District Forum, the respondent - Insurance Company raised various preliminary objections but had mainly claimed that since the said Master Jasnoor Singh was having pre-existing disease, hence the claim was not payable under the terms of the Policy. The District Forum, however, held that since the sum insured under the individual Mediclaim Policy of Master Jasnoor Singh for the year 2010-2011 (four years prior to his hospitalisation) was Rs.1,07,500/-, the amount payable would be 50% of such sum insured for the year 2010-2011, which comes to Rs.53,750/- and not 50% of the sum insured in the year 2009-2010, according to which Insurance Company had paid Rs.27,550/-. Thus, District Forum directed that the balance amount of Rs.26,200/- would be payable to the appellant, along with Rs.5000/- towards harassment and mental agony, plus Rs.2000/- on account of litigation expenses, along with interest @ 9% p.a.
5. Challenging the said order, the appellant herein filed an appeal before the State Consumer Disputes Redressal Commission (for short “State Commission”), which allowed the appeal of the claimant in toto, and directed payment of the entire sum insured i.e. Rs.5,00,000/-, minus the amount already paid by the Insurance Company. Besides this, the Insurance Company was also directed to pay Rs.30,000/- as compensation for mental agony and harassment, plus Rs.10,000/- as litigation cost.
6. Aggrieved by the said order of the State Commission, the respondent-Insurance Company filed a Revision Petition No. 2295 of 2017 before the National Consumer Disputes Redressal Commission (for short “National Commission”). By its order dated 20.07.2017, the National Commission upheld the order of the Distric
