Summary
The Supreme Court held that death from encephalitis malaria contracted through a mosquito bite in malaria-prone Mozambique was not accidental death under the personal-accident policy in issue. An element of chance in contracting illness did not itself transform disease transmitted in the ordinary course into an insured accident. The contrary consumer-forum interpretation was set aside. However, because the insurer had already paid the claim, the Court directed under Article 142 that no recovery be made.
Issues
- Whether the insured’s death from malaria constituted death due to accident under the policy.
- Whether the already-paid claim should be recovered.
Held
- The policy insured death due to accident. Its scope turned on the insurance terms, requiring an unforeseen or unexpected occurrence rather than treating every illness involving an element of chance as accidental. (¶¶ 9–14, 18–20)
- Disease transmitted in the natural course ordinarily differs from an accident, although an affliction may in particular circumstances have an unexpected or unforeseen cause or transmission. Malaria contracted through a mosquito bite in the endemic setting established here did not fall within this policy’s accidental-death cover. (¶ 18–20)
- The National Commission’s interpretation was unsustainable. Since the claim had already been paid, Article 142 was exercised to protect that payment against recovery. (¶ 21–23)
Result
Appeal allowed and contrary insurance-coverage ruling set aside, but no recovery of the already-paid claim permitted under Article 142. No costs.