Allowed

Anil N.Menon v. the Insurance Ombudsman

Kerala HC5 Nov 2021WP(C)/3695/2021

Case brief

AI extract

What is this about?

This writ petition challenged an Insurance Ombudsman's award granting 50% of a rejected insurance claim for medical treatment. The court set aside the award for failing to mention the specific policy clause and remanded for reconsideration.

What did the court decide?

Ext.P8 order set aside; the 1st respondent directed to reconsider the claim afresh within two months after giving an opportunity of hearing to both parties.

Anil N.Menon Vs the Insurance Ombudsman — Insurance | Kerala HC (2021)

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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 P.V.KUNHIKRISHNAN

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FRIDAY, THE 5^TH DAY OF NOVEMBER 2021 / 14TH KARTHIKA, 1943

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W.P.(C) NO.3695 OF 2021

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PETITIONER:

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ANIL N.MENON,

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AGED 50 YEARS, S/O. NARAYANANKUTTY MENON, MANGATTIL HOUSE, MANGATTIL ROAD, THIRUVANKULAM, IRUPANAM P.O., CHITRAPUZHA, ERNAKULAM-682 309.

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BY ADVS. ANIL GEORGE SRI.JOBY JACOB PULICKEKUDY SHRI.DAJISH JOHN SHRI.HARIKRISHNAN P.

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RESPONDENTS:

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1 THE INSURANCE OMBUDSMAN, KOCHI, PULINAT BUILDINGS, 2ND FLOOR, M.G.ROAD, KOCHI-682 015.

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2 THE ORIENTAL INSURANCE COMPANY LIMITED, REGIONAL OFFICE, METRO PALACE, OPP. NORTH RAILWAY STATION, ERNAKULAM-682 011 REPRESENTED BY ITS REGIONAL MANAGER

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BY ADVS. SRI.GEORGE A.CHERIAN SRI.ALEXY AUGUSTINE

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R1 SMT.K.S.SANTHI, STANDING COUNSEL

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THIS WRIT PETITION (CIVIL) HAVING COME UP FOR ADMISSION ON 05.11.2021, THE COURT ON THE SAME DAY DELIVERED THE FOLLOWING:

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W.P.(C) NO.3695 OF 2021

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P.V.KUNHIKRISHNAN, J.

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W.P.(C) No.3695 of 2021

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Dated this the 5^th day of November, 2021

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JUDGMENT

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The petitioner is an autorickshaw driver. The petitioner availed an insurance policy from the 2^nd respondent, as evident by Ext.P1. The petitioner was admitted at Medical Trust Hospital for the treatment of liver disease from 12.11.2019 to 18.11.2019. Thereafter, the petitioner claimed for the expenses of Rs.68,733/incurred for treatment with claim No.KOC-1119-CL-0005153 to the 2^nd respondent. It is the case of the petitioner that he availed the policy for more than 10 years and was paying the premium annually without default for renewal each year. According to the petitioner, this was the first time the petitioner made a claim before the 2^nd respondent and the claim has been rejected arbitrarily by the 2^nd respondent alleging that the ailment was caused due to consumption of alcohol. The true copy of the rejection letter sent by the Branch Manager of the Insurance Company is Ext.P2. It is stated in Ext.P2 that “from the given

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W.P.(C) NO.3695 OF 2021

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particulars of treatment and course of treatment adopted as per medical records, it is found that the hospitalisation is due to an ailment caused due to consumption of alcohol. Ailment/injury attributed to alcoholism is not payable, as per clause 4.8 of the policy.” According to the petitioner, the above finding is unsustainable. The hospitalisation of the petitioner was not due to alcoholic liver disease. It is the case of the petitioner that the medical practitioner who consulted the petitioner in the said hospital has given a medical certificate as evident by Ext.P3, in which it is stated that the amount of alcohol consumed as testified by the patient, seems to be inadequate to produce chronic liver disease. The particulars of the treatment and the course of treatment adopted as per the medical records shows that the hospitalisation was true. It is the case of the petitioner that the hospitalisation was not due to any alcoholic related disease as alleged by the 2^nd respondent in Ext.P2. Exts.P4 and P5 are the discharge summary and the inpatient bill. The petitioner sent lawyer notice as evident by Ext.P6. Even then, there is no response and hence the petitioner submitted a complaint before the 1^st respondent. Ext.P7 is the complaint. The petitioner

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W.P.(C) NO.3695 OF 2021

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produced documents to substantiate his case. The 1^st respondent considered the complaint and granted 50% of the admissible amount on non-standard basis. Aggrieved by the same, this writ petition is filed.

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Heard the counsel for the petitioner and the Standing Counsel for the 1^st respondent.

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The counsel for the petitioner reiterated his contention. The counsel submitted that after finding that the petitioner was treated not for disease related to alcoholism, the 1^st respondent erred in rejecting the entire claim of the petitioner. It is also the case of the petitioner that the claim of the petitioner was for Rs.68,733/- and in Ext.P8, it is stated that 50% of the admissible amount is Rs.46,261/-. The counsel submitted that the petitioner is aggrieved by the same.

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On the other hand, the Standing Counsel who appeared for the 1^st respondent submitted that there is nothing to interfere with Ext.P8 order. The Standing Counsel submitted that the 1^st respondent already allowed 50% of the admissible amount of Rs.46,261/-. The counsel submitted that a perusal of the documents will show that the petitioner is alcoholic. In such

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situation, the counsel submitted that there is nothing to interfere with Ext.P8 order.

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I considered the contention of the petitioner and the 1^st respondent and also perused Ext.P8 order. It will be better to extract the relevant portion of Ext.P8 order:

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“3. I heard the Complainant and the Respondent Insurer. The Complainant submitted that he was admitted in Medical Trust Hospital for treatment and he submitted bills to the Ins. Co. but they did not settle his claim. The complainant stated that he is an auto driver and working since early morning till night. His illness is due to untimely food and DM. The Respondent Insurer submitted that the TPA sought etiology of CLD and the Doctor stated that the complainant is an occasional alcoholic and so the claim was repudiated as per clause 4.8 of the policy.

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I have heard both the sides and perused the documents. The complainant was provisionally diagnosed for upper GI bleed and ultrasound of abdomen showed features of Chronic Liver Disease. On enquiry of etiology of CLD by the respondent insurer, the Doctor issued a Certificate stating that the complainant is a k/c/o DM, admitted with CLD, that he is an occasional alcoholic and that amount of alcohol consumed as testified by the patient seems to be

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inadequate to produce DLC. The words occasional and alcoholic do not go together. It is observed that the Discharge Summary has no mention of alcoholism/ alcohol consumption. I am of the opinion that the claim can be settled on non-standard basis at 50% of the admissible amount of Rs.46,261/-.

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In the result, an award is passed, directing the Respondent Insurer to pay an amount of Rs.23,130/-, within the period mentioned hereunder. No cost.

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As prescribed in Rule 17(6) of Insurance Ombudsman Rules, 2017, the Insurer shall comply with the award within 30 days of receipt of the award and intimate compliance of the same to the Ombudsman.”

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It is clear from Ext.P8 that the 1^st respondent already found that

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the petitioner is an occasional alcoholic and the amount of alcohol consumed as testified by the patient seems to be inadequate to produce CLD. According to the Ombudsman, the words occasional and alcoholic do not go together. It is also observed by the learned Ombudsman, that the discharge summary has no mention of alcoholism/alcohol consumption. Thereafter, the learned Ombudsman observed that “I am of the opinion that the claim can be settled on non-standard basis at 50% of the admissible amount of Rs.46,261/-.” I specifically asked the Standing Counsel

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for the 1^st respondent whether there is any such Clause in the insurance policy. But the counsel submitted that there is no such Clause in the insurance policy. I also asked the counsel for the petitioner and the Standing Counsel to verify whether there is such power to the Ombudsman to disburse the amount on non-standard basis. Both sides submitted that there is no such power in the Ombudsman Rules but the Standing Counsel for the 1^st respondent submitted that the Ombudsman has done justice to both parties and passed this order. I think the stand of the Ombudsman cannot be accepted. Once it is found that the discharge summary has no mention of alcoholism/alcohol consumption and it is also found that the words occasional and alcoholic do not go together, the Ombudsman erred in denying the entire claim of the petitioner. The petitioner has got a case that the admissible amount fixed by the Ombudsman is Rs.46,261/- instead of Rs.68,733/-. I think this is a matter to be looked into by the Ombudsman and the matter can be remanded back to the 1^st respondent for fresh consideration, in the light of the observations in this judgment. Therefore, this writ petition is allowed in the following manner:

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i) Ext.P8 order is set aside.

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ii) The 1^st respondent is directed to reconsider the claim No. KOC-1119-CL-0005153 afresh and pass appropriate orders, after giving an opportunity of hearing to the petitioner and the 2^nd respondent, as expeditiously as possible, at any rate, within a period of two months from the date of receipt of a copy of this judgment.

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Sd/- P.V.KUNHIKRISHNAN

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JUDGE

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bpr

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W.P.(C) NO.3695 OF 2021

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APPENDIX

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PETITIONER'S EXHIBITS

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EXHIBIT P1 THE TRUE PHOTOCOPY OF THE MEDICLAIM INSURANCE POLICY SCHEDULE. EXHIBIT P2 CLAIM REJECTION LETTER DATED 30.02.2019. EXHIBIT P3 THE TRUE PHOTOCOPY OF THE MEDICAL CERTIFICATE DATED 04.01.2020. EXHIBIT P4 TRUE COPY OF DISCHARGE SUMMARY. EXHIBIT P5 TRUE COPY OF INPATIENT BILL DATED 21.11.2019. EXHIBIT P6 OFFICE OF LAWYER NOTICE SENT TO THE 2ND RESPONDENT DATED 25.02.2020. EXHIBIT P7 THE TRUE PHOTOCOPY OF COMPLAINT SENT BY THE PETITIONER VIA EMAIL TO THE 1ST RESPONDENT ON 07.06.2020. EXHIBIT P8 THE TRUE PHOTOCOPY OF AWARD DATED 25.01.2021 PASSED BY THE 1ST RESPONDENT.

Anil N.Menon v. the Insurance Ombudsman

Case brief

What is this about?

What did the court decide?

Anil N.Menon v. the Insurance Ombudsman

Case brief

What is this about?

What did the court decide?

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