In a significant legal battle, the Supreme Court of India has delivered a crucial judgement in a Mediclaim dispute. The case involves a dispute between the insured party and the insurance company regarding the payment of medical expenses for Master Jasnoor Singh. Stay updated with the latest developments in this case by reading our detailed summary.
Facts
- Appellant took Family Mediclaim Policy for a sum insured of Rs.5,00,000/- for the period 07.02.2014 to 06.02.2015.
- Son Master Jasnoor Singh fell sick during the validity of the policy and incurred medical expenses.
- State Commission allowed the claim in full, directing payment of the entire sum insured minus amount already paid by the Insurance Company.
- National Commission upheld the State Commission’s decision.
- Appellant entitled to 50% of the sum insured under individual Mediclaim Policy for the year 2010-2011 for Son Jasnoor Singh.
- Insurance Company directed to pay balance amount, compensation for mental agony and harassment, litigation costs, and interest.
- Insurance Company repudiated claim initially but later paid based on individual medical claim policy of Son Jasnoor Singh in 2009-2010.
- Appellant filed complaint seeking the remaining amount of the sum insured under the Family Mediclaim Policy for the year 2014-2015.
- District Forum held that 50% of sum insured for 2010-2011 was payable, not 2009-2010 sum insured paid by Insurance Company.
Arguments
- Individual Mediclaim Policy of Master Jasnoor Singh was continuously held from 2007-2008 till 2014-2015.
- No evidence that Jasnoor Singh had any pre-existing disease at the time of taking the initial policy in 2007.
- The repudiation or scaling down of the claim was deemed unjustified by the appellant’s counsel.
- Learned counsel for the respondent Insurance Company justified the National Commission’s decision to award compensation of 50% of the sum insured for 2010-2011.
- The respondent’s counsel argued for the dismissal of the appeal and maintained the District Forum’s decision in awarding the compensation.
- The respondent’s counsel emphasized the need to restore the entire amount awarded by the State Commission and requested the appeal to be allowed.
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Analysis
- The claim could not have been repudiated as there was no pre-existing disease when Master Jasnoor Singh’s initial individual Mediclaim Policy was taken in 2007-2008.
- Total medical claim for the family during the policy period was Rs.5,00,000/- with a limit of 50% of the sum insured for individual claims.
- Insurance Company cannot claim pre-existing disease for Master Jasnoor Singh.
- The Family Mediclaim Policy had a total sum insured amount of Rs.5,00,000/- and was regularly renewed up to 2014-2015.
- Master Jasnoor Singh had continuously taken Mediclaim Policies for varying sum insured since 2007-2008.
- Insurance Company allowed a partial claim of Rs.27,550/- indicating no concern for pre-existing disease.
- The maximum claim payable under the Family Mediclaim Policy would be 50% of the sum insured for one member’s medical treatment.
- Company’s liability arises if the treatment is during the policy period.
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Decision
- The appellant is entitled to Rs.50,000/- for mental agony and harassment.
- Additionally, Rs.30,000/- is awarded towards costs of litigation.
- The medical claim for Master Jasnoor Singh under the policy is limited to Rs.2,50,000/-.
- The medical expenses claimed exceeded Rs.8,00,000/- within the policy period.
- The appellant is entitled to Rs.2,50,000/- minus the amount already paid by the Insurance Company.
- The Insurance Company is ordered to pay the appellant Rs.2,50,000/- minus the amount already paid as final settlement of the medical insurance claim.
- The sum insured for the family under the Family Mediclaim Policy was Rs.5,00,000/-.
Case Title: KANWALJIT SINGH Vs. NATIONAL INSURANCE COMPANY LTD.
Case Number: C.A. No.-006255-006255 / 2019
