Remanded

Star Health & Allied Insurance Co.Ltd v. Sebastian Joseph

Kerala HC17 Sept 2014WP(C)/15846/2013

Case brief

AI extract

What is this about?

Insurance company challenged the Ombudsman's award allowing an insured's claim in a travel insurance dispute. The court remanded the matter for an inquiry into pre-existing ailments mentioned in records that the Ombudsman failed to address.

What did the court decide?

Ordered the Insurance Ombudsman to conduct an enquiry into the pre-existing ailments of the insured within six weeks and hear both parties.

Star Health & Allied Insurance Co.Ltd Vs Sebastian Joseph — Consumer Protection | Kerala HC (2014)

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IN THE HIGH COURT OF KERALA AT ERNAKULAM

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PRESENT:

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THE HONOURABLE MR. JUSTICE A.MUHAMED MUSTAQUE

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WEDNESDAY, THE 17TH DAY OF SEPTEMBER 2014/26TH BHADRA, 1936

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WP(C).No. 15846 of 2013 (E)

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PETITIONER/INSURER:

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STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED, REP. BY ITS ZONAL MANAGER, ZONAL OFFICE, FIRST FLOOR, VIJAYA PLAZA, S.S. KOVIL ROAD, THAMPANOOR, TRIVANDRUM- 695 001.

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BY ADVS.SRI.T.J.LAKSHMANAN IYER, SRI.K.N.ABHILASH.

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RESPONDENT/INSURED:

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SEBASTIAN JOSEPH, MANNATHUKKARAN GARDENS, YMCA ROAD, MOOVATTUPUZHA- 686 661.

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BY ADVS. SRI.BIJU K. VAVA, SRI.V.GIRISHKUMAR, SRI.JAME M.JOHN.

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THIS WRIT PETITION (CIVIL) HAVING COME UP FOR ADMISSION ON 17-09-2014, THE COURT ON THE SAME DAY DELIVERED THE FOLLOWING:

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rs.

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WP(C).No. 15846 of 2013 (E)

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APPENDIX

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PETITIONER'S EXHIBITS:-

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EXT.P1 -	TRUE COPY OF PROPOSAL FORM DATED 10-05-2011.
EXT.P2-	TRUE COPY OF INSURANCE POLICY NO. P/181211/03/2012/000008.
EXT.P3-	TRUE COPY OF SPECIMEN OF POLICY CONDITIONS.
EXT.P4-	TRUE COPY OF HEALTH INSURANCE CLAIM FORM DATED 25-07-2011.
EXT.P5-	TRUE COPY OF HISTORY AND PHYSICAL DETAILS OF THE RESPONDENT/INSURED DATED 06-09-2011.
EXT.P6-	TRUE COPY OF REPUDIATION LETTER DATED 14-11-2011.
EXT.P7-	TRUE COPY OF THE COMPLAINT DATED 12-12-2011 FILED BEFORE THE INSURANCE OMBUDSMAN.
EXT.P8-	TRUE COPY OF THE SELF CONTAINED NOTE DATED 22-12-2011 FILED BEFORE THE INSURANCE OMBUDSMAN.
EXT.P9-	TRUE COPY OF THE ORDER DATED 18-03-2013 PASSED BY THE INSURANCE OMBUDSMAN IN COMPLAINT NO.IO/KCH/GI/11-017- 727/2011-12.

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RESPONDENT'S EXHIBITS:- NIL.

//TRUE COPY//

P.A. TO JUDGE

rs.

A.MUHAMED MUSTAQUE, J.

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= = = = = = = = = = = = = WP(C).No.15846 of 2013-E.

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= = = = = = = = = = = = =

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Dated this the 17^th day of September, 2014.

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J U D G M E N T

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The petitioner is an insurance company. This writ petition is filed challenging Ext.P9 order passed by the Insurance Ombudsman. The matter related to travel insurance. The claim made by the respondent under the policy was objected by the petitioner. This was repudiated as per Ext.P6. Thereafter the respondent insured has approached the Insurance Ombudsman as per Ext.P7. The Insurance Ombudsman after adverting to the rival claim has passed a detailed order allowing the claim of the insured as per Ext.P9. It is challenging the award of the Insurance Ombudsman, this writ petition is filed.

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This Court while exercising power under Article 226 of the Constitution is not expected to unsettle a decision based on merit. The scope of judicial review is limited to the extent of challenge regarding decision making

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WP(C).No.15846/2013-E.

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process of the authority passed the impugned order. The main contention made by the insurance company before this Court in Exts.P4 and P5 would prove that the insured is having treated ailment before the commencement of the policy coverage.

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The case of the petitioner is that even though Exts.P4 and P5 would form part of the records of the proceedings before the Ombudsman, the Ombudsman never adverted to Exts.P4 and P5 with respect to the contentions raised by the insurance company before the Ombudsman. Whether the treatment of ailment referred to in Exts.P4 and P5 have been there prior to the commencement of the policy coverage, is a question of fact can be decided only based on an enquiry. It is apparent from the impugned order itself Ombudsman had not adverted to Exts.P4 and P5. I am not entering into decision based on other facts made in Ext.P9 with respect to the other issues referred in Ext.P9. An enquiry shall be conducted by the Ombudsman whether Exts.P4 and P5 would justify the repudiation made

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WP(C).No.15846/2013-E.

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by the Insurance Company. An enquiry shall be conducted by the Ombudsman after hearing the petitioner as well as the insured/complainant. Needful shall be done within six weeks from the date of receipt of a copy of this judgment. The findings so far made will depend upon the enquiry to be conducted, based on Exts.P4 and P5.

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The petitioner insurance company has deposited Rs.2.5 lakhs before the Ombudsman as per the direction of this Court. The above amount is directed to be disbursed

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based on the decision to be made by the Ombudsman.

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Writ petition is disposed of as above.

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Sd/-

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A.MUHAMED MUSTAQUE, (Judge)

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Kvs/-

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// true copy //

Star Health & Allied Insurance Co.Ltd v. Sebastian Joseph

Case brief

What is this about?

What did the court decide?

Star Health & Allied Insurance Co.Ltd v. Sebastian Joseph

Case brief

What is this about?

What did the court decide?

What the court decided

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Issues for consideration

Statutes considered

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