Pinnacle Court says Insurer Can not Refuse Claims After regarding Mediclaim policy

The Top Court was hearing an appeal filed by Manmohan Nanda against an order of the National Consumer Disputes Redressal Commission (NCDRC), rejecting his plea seeking a claim for medical expenses incurred in the United States. No insurance company can a refuse a mediclaim citing that the policyholder only disclosed certain medical conditions while signing up, the Supreme Court has ruled, PTI reported 

A proposer is under a duty to disclose to the insurer all material facts within his knowledge, mentioned by the bench of justices comprising D Y Chandrachud and B V Nagarathna, according to news agency PTI report. The proposer is presumed to know all the facts and circumstances concerning the proposed insurance, it added. While the proposer can only disclose what is known to him, the proposer's duty of disclosure is not confined to his actual knowledge, it also extends to those material facts which, in the ordinary course of business, he ought to know, the court said.

"Once the policy has been issued after assessing the medical condition of the insured, the insurer cannot repudiate the claim by citing an existing medical condition, which was disclosed by the insured in the proposal form and which condition has led to a particular risk in respect of which the claim has been made by the insured," the bench said in a recent judgment.

Nanda had bought an Overseas Mediclaim Business and Holiday Policy as he intended to travel to the US. On reaching the San Francisco airport, he suffered a heart attack and was admitted to a hospital, where angioplasty was performed on him and three stents were inserted to remove the blockage from the heart vessels.

Subsequently, the appellant claimed the treatment expenses from the insurer, which was repudiated by the latter stating that the appellant had a history of hyperlipidaemia and diabetes, which was not disclosed while buying the insurance policy.