Case Note & Summary
The dispute arose from a claim made by the appellant under a Family Mediclaim Policy for his son, Master Jasnoor Singh, who underwent significant medical treatment in 2014. The appellant had previously held individual Mediclaim Policies for his family members since 2007, with varying sums insured. In 2014, he took a Family Mediclaim Policy for Rs.5,00,000, during which his son incurred medical expenses exceeding Rs.8,00,000. The Insurance Company initially repudiated the claim but later paid a partial amount, citing a pre-existing disease. The appellant contested this decision, leading to a series of rulings from the District Forum, State Commission, and National Commission, each addressing the extent of liability and the validity of the claim. The Supreme Court ultimately found that the Insurance Company could not deny the claim based on pre-existing conditions since the initial policy did not indicate such a disease. The court ruled that the appellant was entitled to Rs.2,50,000, along with additional compensation for mental agony and litigation costs, and mandated interest on the outstanding amount.
Headnote
A) Insurance Law - Liability under Mediclaim Policy - Limitation of Liability - Insurance Company liable for 50% of sum insured under Family Mediclaim Policy - The court held that the Insurance Company cannot repudiate the claim based on pre-existing disease when the initial policy did not indicate such a condition. The appellant was entitled to the maximum limit of Rs.2,50,000/- for the medical claim of Master Jasnoor Singh (Paras 12-14).
Issue of Consideration
Extent of the liability of the Insurance Company under the Family Mediclaim Policy.
Final Decision
The Supreme Court allowed the appeal to the extent that the Insurance Company was directed to pay Rs.2,50,000 minus the amount already paid, along with Rs.50,000 for mental agony and Rs.30,000 for litigation costs, with interest at 7.5% p.a.
Law Points
- Insurance liability
- Mediclaim Policy
- pre-existing disease
- claim repudiation
- compensation for mental agony
