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2003 Supreme(Del) 556
High Court Of Delhi
ASHOK KUMAR DHINGRA - Appellant
Versus
THE ORIENTAL INSURANCE COMPANY LIMITED - Respondent
CIV.WRIT 876 of 2002
Decided On : 07/07/2003
AJAY VIR SINGH, ASHOK SHARMA, RAM N.SHARMA, Vipin Kumar
Headnote:Insurance - Mediclaim policy — Expeditious disposal of disputes — Dispute regarding non-payment of claims under Mediclaim policy — Complaint before Insurance Ombudsman — Delay in adjudication — No Explanationn offered as to why the dispute not resolved within 3 months — Direction for expeditious disposal — Redressal of Public Grievance Rules, 1998, Rules. 14(1), 18(8), 15.
Held:
The complaint in prescribed proforma ws admittedly received by respondent No. 6 on 20.9.2001. Thus, the respondent No. 6, in terms of the said Rules, ought to have passed an award within three months thereof i.e., by 20.12.2001. It is the respondents contention that before he could do so the present petition was already drafted and prepared as would be clear from the date appearing at page 16 of the petition and, thereforee, there was nothing left for respondent No. 6 to do. This is not a proper stand to take. The petition was, in point of fact filed on 1.2.2002. Even if it is assumed that the petition was prepared on 11.12.2001, this still does not enable us to detract from the fact that the affidavit in support of the petition was sworn on 31.1.2002 and the petition itself was filed on 1.2.2002. The mere fact that the petition was dated 11.12.2001 does not entitle the respondent No. 6 to take refuge behind it for his lapse in not passing the award within three months. There was nothing which prevented the respondent No. 6 from passing the award within three months of the date of the receipt of the complaint. The mere fact that the date on the petition filed in this Court only on 1.2.2002 is shown as 11.12.2001 cannot be a ground for the respondent No. 6 to explain away the delay on his part to pass the award. To this extent, the grievance of the petitioners has to be upheld. The institution of the Insurance Ombudsman is for the very purpose of speedy settlement of disputes and claims. The Rides framed also require the disputes to be resolved/adjudicated upon within a strict time frame. The awards have to be passed within three months of the receipt of the complaint. Adequate Explanationn has not been furnished by the Respondents to explain the delay in disposing of the complaint filed by the petitioner No. 1. To this extent, the petitioners are entitled to the issuance of directions requiring the respondent No. 6 who is a quasi-judicial functionary, to promptly take up the complaint of the petitioners with respect to the pending claims and to dispose of the same as expeditiously as possible and not later than three months of this judgment. I have not embarked upon the exercise of deciding the disputed claims mainly for two reasons. First of all, the institution of the Insurance Ombudsman is the forum where the petitioners chose to go for redressal of their grievances in the first instance. That remedy is adequate and efficacious. It is also akin to an arbitration and is governed by the Arbitration & Conciliation Act, 1996 under which a full-fledged machinery is provided and courts are not to interfere except where expressly provided by the Act. Secondly, the settlement of the claims involves examination of disputed questions of fact which may require oral and/or documentary evidence. Thus, it would not be proper for me to adjudicate the same in exercise of jurisdiction under Article 226 of the Constitution of India. These questions are best left to be determined by the Insurance Ombudsman as indicated above. It is made clear that insofar as the so-called pending claims of the petitioners are concerned, this Court has not expressed any opinion on the merits thereof. The respondent No. 6 shall take an independent decision on the same.
Mediclaim policy - Renewal — Break of 2 years in renewal of policy — Respondent ready to renew the policy on being paid 200/-premium and on loss of first clause to extent of Rs. 20,000/ — Imposition of conditions basing on past claims history, not unreasonable — Insurance Act, 1938, Section 64VA(IA).
Coming to the facts of this case, I find that, first of all, the respondent No. 1 has not refused to renew the petitioners mediclaim policy. It was, in fact, ready to renew the mediclaim policy subject to the premium being loaded by 200% and the imposition of the first loss clause, to the extent of Rs. 20,000/-. Secondly, the imposition of these conditions is based on the past claims history and the adverse loss ratio which the respondent No. 1 has been facing in respect of the petitioners in the past few years. As indicated above, the insurance company is also required to maintain a. solvency margin inter alias based on the concept of net incurred claims which, in view of the provisions of Section 64VA(1A)(ii) Explanationn (ii), refers to the average of the net incurred claims during the specified period not exceeding three preceding financial years. It is imperative for the insurer to see that it does not run the risk of not meeting the solvency margin prescribed under the Act. It is, thereforee, clear that in this context the decision of the Respondent No. 1 in imposing the condition of loading the premium by 200% and introducing the first loss clause to the extent of Rs. 20,000/- was neither unreasonable nor arbitrary looking to the extremely adverse loss ratio in respect of the mediclaim policies qua the petitioners as indicated above.
( 1 ). In this writ petition the petitioners have sought issuance of directions , to the Respondent No. 1 (i) to disburse the payments in respect of claims made by the petitioners under their Mediclaim Policies along with interest thereon and, (ii) to renew the Mediclaim Policy of the petitioners on the original terms and conditions including the premium payable as per the previous year s policy.
( 2 ). The facts, which are not in dispute, are that the petitioner No. 1 (Shri ashok Kumar Dhingra) had taken the following Mediclaim Policies as indicated in the table below:-
( 3 ). All the other petitioners being the family members of Petitioner No. 1 were also covered under the above Mediclaim Policies which were provided by the Respondent No. 1. It is clear that after the first policy there was a break of about two years before the next policy (shown at S. No. 2) was taken by the petitioners. There is no dispute that subsequently, i. e. from policy shown at s. No. 3 onwar. ds, the policies had been renewed from year to year by the respondent No. 1. The last renewed policy being the Mediclaim policy shown at S. No. 5 which covered the period 12. 1. 2001 to 11. 1. 2002.
( 4 ). The petitioners have been submitting claims particularly with respect to the illness of the petitioner No. 4 (i. e. , petitioner No. 1 s son) who has been suffering from Pancrititis for approximately three years prior to the filing of the present writ petition. Most of these claims have been paid by the respondent no. 1. At the time of the filing of the writ petition only two claims, being claim Nos. 49/01 and 50/01 in respect of the Mediclaim Policy No. 48/2001/405 for a total amount of Rs. 45,285/-, were stated to be pending. The question of settlement of these claims was the subject matter of a complaint made by the petitioners to the Insurance Ombudsman. This aspect will be considered in greater detail hereinbelow. At this stage, it is sufficient to note that these pending claims have also been cleared by the Respondent No. 1 to the following extent:- (1) Rs. 10,555/- in respect of claim No. 49/2001. (2) Rs. 10,297/- in respect of Claim No. 51 /2001. These payments were made on or about 26. 2. 2002 as indicated in paragraph 9 of the additional affidavit filed on behalf of the Respondent No. 1. Thus, according to Respondent No. 1, all claims have been settled and nothing is owing or due from it to the petitioners under the said Mediclaim policies. On the other hand, the petitioners contend that the claims submitted by them, particularly the afore-mentioned two claims, have not been paid in full and, accordingly, they are entitled to the balance amount along with interest on the delayed payments.
( 5 ). In this connection, it may be pointed out that the petitioners had filed a complaint/petition before the Insurance Ombudsman (Respondent No. 6) in respect of, inter alia, the aforesaid two claims vide its petition dated 24. 7. 2001 which was received by the respondent No. 6 by registered post on 2. 8. 2001 as indicated in the counter affidavit filed on behalf of respondent No. 6. The Insurance ombudsman responded to the said complaint dated 24. 7. 2001 by sending a letter to the petitioners dated 9. 8. 2001 informing the petitioner No. 1 that his complaint has been received on 2. 8. 2001 and the same has been registered as Complaint No. GI/0139/oic/01 and that inquiries were being made from the insured (respondent No. 1) about the facts of the complaint. The insurance Ombudsman (respondent No. 6) also requested the petitioner no. 1 to give, inter alia, detailed particulars of his complaint in the enclosed proforma, Xerox copies (photocopies) of documents in support of the claim, and the petitioner No. 1 s consent and letter of agreement in case the petitioner No. 1 was agreeable for the Insurance Ombudsman to act as a conciliator/arbitrator and authorising him to give his recommendations/award for the resolution of the complaint. Altho
