Insurance: Extent of liability of Insurance Company with regard to individual claim under “Parivar-Mediclaim for Family Policy” – In the instant case, appellant was taking individual mediclaim policies since 2007-2008 for his individual family members and in the year 2014-15, he took family mediclaim policy for Rs.5 lacs – During validity of the family mediclaim policy, appellant’s son fell sick and was hospitalized for which medical bill was raised – Appellant filed claim – Insurance company initially repudiated the claim without assigning any reason – However, later considering that the appellant’s son had an individual mediclaim policy in the year 2009-2010 for Rs. 55000, deposited Rs. 27,550/- towards final payment of the claim – Complaint before District Forum – Plea of insurance company was that since appellant’s son was having preexisting disease, his claim was not payable under the terms of the policy – District Forum, however, held that since the sum insured under the individual Mediclaim Policy of appellant’s son 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, and not 50% of the sum insured in the year 2009-2010, according to which Insurance Company had paid Rs.27,550/- – On appeal, State Commission allowed the claim of appellant in toto – Appeal before National Commission – National Commission while observing that the appellant’s son had pre-existing disease which was symptomatic in the year 2009, held that the appellant would be entitled to 50% of the sum insured under the individual Mediclaim Policy of appellant’s son for the year 20102011 – Challenge against – Held: The claim could not have been repudiated by the Insurance Company as there was no pre-existing disease when the initial individual Mediclaim Policy of appellant’s son was taken in the year 2007-2008 – Since then the policy was regularly renewed upto year 2014-2015 – The total medical expense or claim for any one illness for any individual member of the family would be limited to 50% of the sum insured for the family – The sum insured for the family under the Family Mediclaim Policy was Rs.5 lacs – Thus, the amount payable against the medical claim of appellant’s son under the policy, would be limited to the extent of Rs.2,50,000/-.
Allowing the appeal, the Court
HELD : 1. The fact that Mediclaim Policy of son of the appellant was continuously taken by the appellant for varying sum insured since 2007-2008 till 2014-2015 is admitted by the insurance company. It is also not disputed that at the time of taking the initial Mediclaim Policy for the year 2007-2008, the son of the appellant did not have any pre–existing disease. In fact, it is admitted that prior to the year 2014-2015, the appellant had been taking individual Mediclaim Policies for his family members and it was only in the year 2014-2015, at the time of renewal of the individual Mediclaim Policies, that the appellant had taken the Family Mediclaim Policy, which was effective from 07.02.2014 to 06.02.2015. The sum insured under the Family Mediclaim Policy, was Rs.5,00,000/–. The total medical claim for all the four members of the family during the period of commencement of the Insurance Policy (i.e. 07.02.2014 to 06.02.2015) would be Rs.5,00,000/- and for any individual claim or illness for any one member of the family, the limit would be 50% of the sum insured, which in the instant case would come to Rs.2,50,000/-. Thus, at best the maximum claim which could be payable in this case would be 50% of the sum insured under the Family Mediclaim Policy for the medical treatment of one member of the family, which was appellant’s son. [Paras 10, 11] [235-B-H]
2. The claim could not have been repudiated by the Insurance Company as there was no pre-existing disease when the initial individual Mediclaim Policy of appellant’s son was taken in the year 2007-2008. Since then the policy was regularly renewed up to the year 2014-2015. Even otherwise, after having initially repudiated the claim of the appellant, the Insurance Company had itself allowed the claim to the extent of Rs.27,550/-, which amount was deposited in the account of the appellant, meaning thereby that the question of pre–existing disease in the case of the claimant was not considered to be material by the Insurance Company. [Para 12] [236-A-C]
3. The total medical expense or claim for any one illness for any individual member of the family would be limited to 50% of the sum insured for the family. In the instant case, the sum insured for the family under the Family Mediclaim Policy was Rs.5,00,000/-. Thus, the amount payable against the medical claim of appellant’s son under the policy, would be limited to the extent of Rs.2,50,000/-. Undisputedly, the medical expense incurred and claimed by the appellant for the treatment of his son within the effective period of the policy was over Rs.8,00,000/-. As such the appellant would be entitled to a sum of Rs.2,50,000/- minus the amount already paid by the Insurance Company under the orders of the District Forum. The respondent-Insurance Company shall pay to the appellant a sum of Rs.2,50,000/- minus the amount already paid, towards final settlement of the medical insurance claim of the appellant. The appellant would also be entitled to an amount of Rs.50,000/- towards mental agony and harassment, plus Rs.30,000/- towards costs of litigation. [Paras 13, 14] [236-D-G]
As published in the Supreme Court Reports, Supreme Court of India. Text from the Indian Supreme Court Judgments open data set (Dattam Labs), CC BY 4.0.
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