Content Provider | Supreme Court of India |
---|---|
e-ISSN | 30484839 |
Language | English |
Access Restriction | NDLI |
Subject Keyword | individual claim under “Parivar-Mediclaim for Family Policy” preexisting disease Insurance |
Content Type | Text |
Resource Type | Law Judgement |
Jurisdiction | India |
Case Type | Appeal |
Court | Supreme Court of India |
Disposal Nature | Appeal Allowed |
Headnote | 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 2010- 2011 – 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/-. |
Judge | Hon'ble Mr. Justice Vineet Saran |
Neutral Citation | 2019 INSC 907 |
Petitioner | Kanwaljit Singh |
Respondent | National Insurance Company Ltd |
SCR | [2019] 10 S.C.R. 230 |
Judgement Date | 2019-08-14 |
Case Number | 6255 |
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