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SUPREME COURT OF INDIA
(From the National Consumers Disputes Redressal Commission, New Delhi)
DHANANJAYA Y. CHANDRACHUD, B.V. NAGARATHNA, JJ.
Manmohan Nanda - Appellant
Versus
United India Assurance Co. Ltd. & Anr - Respondents
Civil Appeal No. 8386 of 2015
Decided on : 06-12-2021
Constitution of India, 1950 – Article 142 – Consumer Protection Act, 1986 – Section 21 (9) – Material fact – Contra proferentem rule – Facts in a nutshell are that appellant had sought an overseas mediclaim policy-B as he intended to travel to United States of America to attend wedding of his sister-in-law’s daughter – Appellant was medically examined at instance of respondent No. 1 insurance company prior to consideration of his request for issuance of a mediclaim policy – On his medical examination, report categorically noted that appellant had diabetes-type II (also known as diabetes mellitus) – No other adverse medical condition was found – Held, Respondents were not right in stating that as per terms and conditions of policy “all complications arising out of preexisting condition is not payable – ” As already noted, acute myocardial infraction can occur in a person who has no history of diabetes mellitus-II – One of risk factors for aforesaid cardiac episode is diabetes mellitus-II – Fact that appellant had diabetes mellitus-II was made known to insurance company – Therefore, it is observed that any complication which would arise from diabetes mellitus-II was also within consideration of insurer – Despite aforesaid facts regarding medical record of insured, insurance company decided to issue policy to appellant – Aforesaid clause has to be read against respondent insurer by applying contra proferentem rule against it – Otherwise, very contract of insurance would become meaningless in instant case – Hence, in our considered view, respondent-insurance company was not right in repudiating policy in question – Object of seeking a mediclaim policy is to seek indemnification in respect of a sudden illness or sickness which is not expected or imminent and which may occur overseas – If insured suffers a sudden sickness or ailment which is not expressly excluded under policy, a duty is cast on insurer to indemnify appellant for expenses incurred thereunder – Hence in instant case, repudiation of policy by respondent insurance company was illegal and not in accordance with law – Consequently, appellant is entitled to be indemnified under policy – In view of aforesaid discussion, Court hold that Commission was not right in dismissing complaint filed by appellant herein – Appeal allowed.
JUDGMENT :
NAGARATHNA J.
1. This appeal assails order dated 22nd May, 2015, passed by the National Consumer Disputes Redressal Commission (hereinafter referred to as “the Commission” for brevity) in Consumer Complaint No. 92/2010 by which the complaint filed by the appellant was dismissed.
2. The facts in a nutshell are that the appellant had sought an overseas mediclaim policy-B (hereinafter referred to as “mediclaim policy”) as he intended to travel to the United States of America (“USA”) to attend the wedding of his sister-in-law’s daughter. The appellant was medically examined at the instance of respondent No. 1 insurance company prior to the consideration of his request for issuance of a mediclaim policy. On his medical examination, the report categorically noted that the appellant had diabetes-type II (also known as diabetes mellitus). No other adverse medical condition was found.
3. In the medical exam report, a specific query was sought as to whether any abnormalities were observed in the electrocardiogram test of the appellant. There was another query regarding any possible illness or disease for which the appellant may require medical treatment in the ensuing trip to the USA. To both these queries, Dr. Jitendra Jain, the doctor who examined the appellant had answered “normal” and “no” respectively. The representative of the respondent insurer on receipt of the medical reports assured the appellant that on verification of the same the policy would be issued.
4. The insurer thereafter accepted the proposal form and issued the Overseas Mediclaim Business and Holiday Policy bearing Policy Number 190100/46/09/ 44/70000008 valid from 19th May, 2009 to 1st June, 2009, to the appellant. Thereafter, the appellant boarded a flight to San Francisco, USA on 19th May, 2009 at around 1:00 a.m. from Delhi airport and reached San Francisco on the same day at around 2:00 p.m. (local time). On exiting the customs section at San Francisco airport, appellant felt weak and started sweating. His wife got him admitted at the SFO Medical Centre at San Francisco airport and after he received initial medical treatment, he was shifted to the Mills Peninsula Medical Centre (hereinafter referred to as “Medical Centre” for the sake of brevity) where angioplasty was performed on the appellant on 19th May, 2009 and 22nd May and three stents were inserted to remove the blockage from the heart vessels.
5. In order to avail the benefit under the mediclaim policy, appellant’s son-in-law contacted M/s Corris International, a foreign collaborator of respondent No. 1 and 2, which was to provide emergency assistance and claims administration services to the insured. M/s Corris International sought certain documents regarding details of treatment given by the Medical Centre as well as details of the mediclaim policy for the purpose of considering the same for indemnifying the appellant. The appellant was discharged on 24th May, 2009.
6. Two and a half months thereafter, appellant started receiving bills from the cardio vascular wing of the Medical Centre and SFO Medical Centre towards the treatment he received at their facility. On 19th August, 2009, the appellant sent a letter annexing all bills in original as well as the discharge summary to the Divisional Manager of respondent No. 1 at their Bhopal office. The same letter was also sent to respondent No. 2.
7. On 22nd August, 2009, appellant received a letter from respondent No. 2 stating that his claim had been repudiated as the appellant had a history of hyperlipidaemia and diabetes and the policy did not cover per-existing conditions and complications arising therefrom. The said repudiation was with regard to Bill No.1 i.e. the bill raised by the Medical Centre for USD 2,29,719. The appellant protested against the repudiation and requested his claim to be settled on a priority basis as the Medical Centre a
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