High Court refrains from interfering with Lok Adalat's factual findings on insurance policy interpretation absent perversity; diagnosis integral to treatment.

JUDGMENT

The petitioner is a company engaged in the general insurance business. This writ petition is submitted by the petitioner challenging the order passed by the Permanent Lok Adalat (for Public Utility Services), Kozhikode, allowing an Original Petition submitted by the respondent herein. Facts that led to the filing of the original petition are as follows:

2. The respondent herein availed an Individual Health Insurance Policy for a sum of Rs.3,00,000/- from the petitioner Insurance Company, which was having coverage for the period from 19.09.2023 to 18.09.2024. During the period of policy, the respondent/complainant was admitted to Christian Medical College, Vellore on 23.04.2024, as he was diagnosed with mild cognitive impairment with small vessel disease and coronary artery disease. He was discharged on 25.01.2024, as evidenced by Ext.P2 discharge summary. Seeking reimbursement of the amount spent by the respondent, a claim was raised before the petitioner, which was repudiated on the ground that, as per the terms and conditions of Ext.P1 policy, the Company shall not be liable to make any payment under the policy, in respect of any expenses related to any admission primarily for diagnostics and evaluation purposes.

3. As the claim of the respondent was repudiated, the respondent approached the Permanent Lok Adalat (for Public Utility Services), Kozhikode by filing O.P.No.54 of 2024. The petitioner, upon receipt of notice, appeared before the Permanent Lok Adalat and filed a written statement, disputing the contention raised by the respondent herein and also reiterating the stand taken by them while repudiating the claim raised by the petitioner. It was asserted that, the medical documents produced by the respondent would only show the diagnostics, which is excluded from the coverage of the policy as per the terms and conditions. However, rejecting the aforesaid contention, the Original Petition was allowed by the Permanent Lok Adalat, by directing the petitioner Company to pay an amount of Rs.76,848/- as reimbursement of the treatment expenses together with 9% interest per annum from 22.06.2024 onwards. The Insurance Company was also directed to pay an amount of Rs.10,000/- as cost of the said application. This writ petition is submitted by the petitioner challenging the same. 4. I have heard the learned counsel for the petitioner, who argued at length, highlighting certain aspects which according to the petitioner, are the discrepancies in the order passed by the Permanant Lok Adalat (for public utility services). However, on going through the directions of the order and the reasons which prompted the Permanent Lok Adalat to reject the contentions of the petitioner, I do not find any scope for interference. This is particularly because, it is evident from the records that the Permanent Lok Adalat arrived at a specific conclusion in favour of the respondent, after interpreting the terms and conditions of the policy, and found that there is nothing to indicate that the in-patient treatment availed by the petitioner in the hospital in question was only for the purpose of diagnosis.

5. I have no reason to take a different view in the matter.

On careful perusal of the records also, it is evident that there were symptoms of certain diseases which prompted the petitioner to avail in-patient treatment in the hospital, and merely because of the reason that initial expenses incurred by the petitioner were for the purpose of diagnosis, it cannot be concluded that the sole purpose of the in-patient treatment was for diagnosis. Even going by the medical records, there were certain symptoms of the deceases claimed by the respondent. Moreover, diagnosis is an important part of the treatment, and without the same, a proper treatment cannot be ensured. This aspect was specifically taken note of by the Permanent Lok Adal