Once proceedings before the Insurance Ombudsman move beyond mediation to the adjudicatory stage under Rule 17, the process assumes a quasi-judicial character, and denial of legal representation to a party would be contrary to the principles of natural justice and the right to practice under Section 30 of the Advocates Act.

THIS WRIT PETITION IS FILED UNDER ARTICLES 226 AND 227 OF THE CONSTITUTION OF INDIA PRAYING TO QUASH AND SET ASIDE THE INTIMATION DATED 10/09/2024 ISSUED BY THE RESPONDENT (ANN-A) AND ETC.

THIS PETITION, COMING ON FOR PRELIMINARY HEARING, THIS DAY, ORDER WAS MADE THEREIN AS UNDER:

CORAM: HON'BLE MR. JUSTICE SACHIN SHANKAR MAGADUM

ORAL ORDER

The petitioner, who had subscribed to a ‘Family Health Optima Insurance Plan’ on 31.01.2019, is stated to have undergone surgery for the ailment of umbilical hernia. It is averred that prior to the said procedure, the petitioner had been admitted to Ratkal’s Rescue Urology Center, Chikkellur Hospital, where he underwent surgery for ‘calculous cholecystitis’ and was subsequently discharged. The petitioner thereafter submitted a claim before the Insurer seeking reimbursement of medical expenses incurred towards the said surgery for ‘calculous cholecystitis’. The Insurer, however, repudiated the claim. Aggrieved by such repudiation, the petitioner asserts to have addressed an email requesting reconsideration of the claim, bearing No. CIR/2022/141124/2977028. Upon failure of the Insurer to accede to the said request, the petitioner approached the respondent – Insurance Ombudsman by filing a complaint challenging the repudiation of his claim.

2. The records further disclose that the petitioner was initially aggrieved by the award passed by the respondent – Insurance Ombudsman, which, according to him, suffered from gross violation of the principles of natural justice. In that background, the petitioner had approached this Court in W.P. No.3160/2023. This Court, upon consideration, allowed the writ petition and set aside the award passed by the Ombudsman, remitting the matter back for fresh consideration with a direction to afford an opportunity of hearing to the petitioner. Pursuant to the remand, the petitioner filed an application invoking Rule 15 of the Insurance Ombudsman Rules, 2017 read with Order III Rule 1 and Section 151 of the Code of Civil Procedure, 1908, seeking permission to engage the services of an advocate to represent and conduct the proceedings before the Ombudsman.

3. The respondent – Insurance Ombudsman, by placing reliance on Rule 17 of the Insurance Ombudsman Rules, 2017, has rejected the said application. The rejection is premised on the reasoning that the proceedings before the Ombudsman are intended to be informal and non-adversarial in nature; that neither the Ombudsman nor the representatives of the Insurance Company are legally trained; and therefore, permitting legal practitioners would disturb the parity between the parties. On these grounds, the request made by the petitioner seeking legal representation came to be rejected. The said order is assailed in the present writ petition.

4. Heard the learned counsel appearing for the petitioner and the learned counsel appearing for the respondent – Insurance Ombudsman.

5. Upon perusal of the impugned order and the material placed on record, the following point arises for consideration:

i) Whether the impugned order of respondent - Insurance Ombudsman declining the legal assistance to the petitioner on the premises that the respondent - Insurance Ombudsman is not legally qualified and therefore, assistance of an Advocate is not required runs contrary to Rule 17 of the Insurance Ombudsman Rules, 2017 warrants interference?

ii) What order?

Findings on Point No.(i)

6. Before this Court adverts to the case on hand, this Court deems it fit to extract Rules 15 to 17 of the Insur