KANWALJIT SINGH versus NATIONAL INSURANCE COMPANY LTD

Citation: [2019] 10 S.C.R. 230 · Decided: 14-08-2019 · Supreme Court of India · Bench: UDAY UMESH LALIT · Disposal: Appeal(s) allowed

Judgment (excerpt)

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SUPREME COURT REPORTS
[2019] 10 S.C.R.
KANWALJIT SINGH
v.
NATIONAL INSURANCE COMPANY LTD
(Civil Appeal No. 6255 of 2019)
AUGUST 14, 2019
[UDAY UMESH LALIT AND VINEET SARAN, JJ.]
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 pre-
existing 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
   [2019] 10 S.C.R. 230
230
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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
KANWALJIT SINGH v. NATIONAL INSURANCE CO

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