Oriental Insurance Held Liable For Unjustified Claim Repudiation; Orders Reimbursement And Compensation

The Thrissur Consumer Disputes Redressal Commission bench comprising C.T Sabu, President, Sreeja S, Member and Ram Mohan R, Member has held Oriental Insurance Co. Ltd. liable for repudiating the claim of the complainant on unfounded grounds. It was held that the denial of claim was based on a misinterpretation of the exclusion clause of the policy. Brief facts: The complainant availed a healthy policy from Oriental Insurance Co. Ltd. ('insurer'). Subsequently, he underwent a treatment for Intervertebral Disc Prolapse L1/L2 and L2/L3 ('IVDP') at M/s Jubilee Mission Medical College and Research Institute, Thrissur. The complainant was admitted on 15.12.2018 and discharged on 16.12.2018. It was stated that the insurance claim of the complainant seeking reimbursement of pertinent medical expenses was repudiated by the insurer on unfounded grounds. As per the complaint, no response was received from the insurer despite service of legal notice. Hence, a complaint was filed by the complainant praying for reimbursement of medical expenses of Rs. 8,530/- and appropriate reliefs. Submissions of the insurer: The issuance of the policy and the claim made by the complainant was admitted by the insurer. It was argued that the claim of Rs. 8,530/- was exaggerated since the actual hospital expenses came to Rs. 3,530/-. It was submitted that the complainant's confinement at the hospital was not justifiable as he needed examination and evaluation only. As per the insurer, the complainant underwent conservative management- post evaluation and hence the claim was repudiated under the exclusion clause of the policy which excluded expenses for evaluation purposes. Observations of the commission: The bench, at the outset, carefully examined all the documents on record produced by the complainant. It examined the discharge summary as per which the complainant with low back ache was medically diagnosed with IVDP L1/L2 and L2/L3 and was conservatively treated. It was observed that the doctor is the one who is competent to decide whether the patient is to be treated as In-patient or Out-patient. The bench also examined the repudiation letter which stated that the complainant's confinement to the hospital was not justifiable as evaluation was a normal procedure. It was observed that the insurer is not a medical expert to answer the point. It was concluded that the complainant was admitted for proper treatment which renders the exclusion clause of the policy inapplicable. Thus, the repudiation of the claim was held to be unfounded and bad in law. With respect to the amount of insurance claim, the bench examined the bill which summed up to Rs. 3,530/-. Since the amount was not rebutted by the complainant, a claim of Rs. 3,530/- was granted instead of Rs. 8,530/-. Hence, the complaint was partly allowed with the following reliefs: A sum of Rs. 3,530/- as reimbursement of medical expenses Rs. 10,000 as compensation for mental agony, hardship and financial loss Rs. 10,000 as litigation costs Case Title: Sunil Kumar vs Manager, Oriental Insurance Co. Ltd. Case Number: CC/137/2019 Date of decision: 27.10.2025 Click Here To Read/Download The Order

Oriental Insurance Held Liable For Unjustified Claim Repudiation; Orders Reimbursement And Compensation

Aakanksha Bajoria

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