Mediclaim Insurance: The insurance company cannot repudiate the claim on the basis of pre-existing disease - suffered during the tenure of previous policy; SC.

Supreme Court of India

Justice Vineet Saran and Justice U U Lalit

The SC { KANWALJIT SINGH v. NATIONAL INSURANCE COMPANY LTD } holds that the insurance company cannot repudiate the Mediclaim on the basis of pre-existing disease, when the insured suffered from the disease first time, during the tenure of earlier insurance policy by the same company. It was held that 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 Master Jasnoor Singh was taken in the year 2007-2008. Since then the policy was regularly renewed up to the year 2014-2015. It was held thus in the facts of the present case, the respondent – Insurance Company cannot take the plea of any pre-existing disease of Master Jasnoor Singh. It was futher held, that 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.

It was further held that as per the policy, 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 present case, as the sum insured for the family under the Family Mediclaim Policy was Rs.5,00,000/-. Thus, the SC held that the amount payable against the medical claim of Master Jasnoor Singh, under the policy, would be limited to the extent of Rs.2,50,000/-.

In the said case, since 2007-2008, the appellant had been taking individual Mediclaim Policies for his individual family members. The dispute in the present case pertains to the medical claim for the year 2014-15, in the year 2014 Master Jasnoor Singh fell sick and had to undergo treatment in Post Graduate Institute (PGI), Chandigarh. The individual Mediclaim Policies of the said Master Jasnoor Singh from 2007-2008 to 2013-2014 was for different sum insured, varying from Rs.50,000 in 2007-2008 to Rs.2,54,000/- in 2013-2014. In the year 2014-2015, the appellant took Family Mediclaim Policy for a sum insured of Rs.5,00,000/- for the period 07.02.2014 to 06.02.2015, which was for the appellant himself and his family members, namely, his wife, son Master Jasnoor Singh and daughter. In the said case, at the time of taking initial individual Mediclaim Policy in the year 2007, the said Master Jasnoor Singh did not have any such disease - inspite of that the insurance company repudiated claim for the year 2014 on the basis of pre-existing disease - which was held to be illegal by the SC.