The Insurance Ombudsman acted within jurisdiction, and the Insurance Company must comply with the award, emphasizing accountability for delays and suppression of documents.

JUDGMENT :

(M.S. Sonak J.)

1. Heard learned counsel for the parties. Rule in both these Petitions. The Rule is made returnable immediately at the request of and with the consent of the learned counsel for the parties.

2. Interim Application No.424 of 2022 seeking leave to amend Writ Petition No.706 of 2024 is allowed. Amendment to be carried out immediately. Reverification is dispensed with.

3. Learned counsel for the parties agree that a common order can dispose of both these Petitions. In any event, Writ Petition No.2903 of 2021 seeks to implement the Insurance Ombudsman’s award dated 03 May 2021 and Writ Petition No.706 of 2024 questions the same award dated 03 May 2021.

4. The learned counsel for the parties submitted that Writ Petition No.706 of 2024 be considered first because the fate of Writ Petition No.2903 of 2021 would depend upon the decision in Writ Petition No.706 of 2024. This is correct, and the suggestion of the learned counsel for the parties is accepted.

5. In Writ Petition No.706 of 2024, the Oriental Insurance Company Limited (“Insurance Company”) challenges the Insurance Ombudsman’s award dated 03 May 2021, directing the Insurance Company to pay to Bharat Dedhia (the second Respondent and the Petitioner in Writ Petition No.2903 of 2021) an amount of Rs.27,13,582/- against the health insurance policy taken by Bharat Dedhia (“Bharat”) from the Insurance Company.

6. Ms Dwivedi, the learned counsel for the Insurance Company, submitted that the Ombudsman exceeded the scope of its jurisdiction in making the impugned award. Therefore, she submitted that the award is illegal, arbitrary, unconstitutional, and without jurisdiction.

7. Ms Dwivedi submitted that Bharat had submitted a proposal form (self-declaration form) based upon which the health insurance policies or at least the additional health insurance policies were issued to Bharat. She submitted that in this proposal form, Bharat had referred to the ischemic heart disease contacted by him on 14 May 2016 and the fact that he was suffering from diabetes mellitus. She submitted that given these proposals/self- declaration forms and the information contained therein, there was no question of offering any health insurance to Bharat.

8. Ms Dwivedi submitted that though, factually, premia were accepted by the Insurance Company and even health insurance policies were issued, the acceptance of such proposal by the Insurance Companies was void. The health insurance policies based upon such acceptance were also void. She submitted that the Ombudsmen should have rejected Bharat’s claim at the threshold since the health insurance policies were void.

9. Without prejudice, Ms Dwivedi submitted that in terms of the Insurance Regulatory and Development Authority’s (“IRDA”) Notification dated 25 April 2017, the Insurance Ombudsman’s functions and duties relate to receiving and considering complaints or disputes relating to partial or total repudiation of the claims by the Life Insurer, General Insurer or Health Insurer.

10. Ms Dwivedi submitted that there was no repudiation of the claim in this case, and the Insurance Company offered to pay Rs.5,00,000/- towards the full and final settlement of Bharat’s claim. Accordingly, she submitted that the Insurance Ombudsman had no jurisdiction to consider Bharat’s complaint or dispute. She submitted that such consideration by the Ombudsman was beyond the jurisdiction conferred upon the Ombudsman under Clause 13 of the IRDA’s Notification dated 25 April 2017. She maintained that the impugned award should, therefore, be set aside as exceeding the jurisdiction vested in the Ombudsman.

11. Ms Dwivedi submitted that Bharat claims to have paid Rs.21,87,500/- as surgeon’s charges to Dr Sudhanshu Bhattacharyya at Breach Candy Hospital. However, the Insurance Company had produced material on record to suggest that three other patients who were operated on for similar ailments, i.e. coronary artery diseases (“CAD”) in Breach Candy Hospital itself, were c