Back
2017 Supreme(Online)(KER) 46624
HIGH COURT OF KERALA
K VINOD CHANDRAN, J
M SUBAIR – Appellant
Versus
THE CHAIRMAN UNITED INDIA INSURANCE COMPANY LTD REGISTERED – Respondent
WRIT PETITION (CIVIL) 38738/2015
Insurance claims cannot be denied on vague grounds if the surgery is deemed necessary and covered under the policy.
Headnote:
Insurance - Claim Handling - RPG Rules - Policy Exclusions - Ombudsman Decision
Fact of the Case:
The petitioner challenged the award regarding a health policy claim for his daughter's surgery, which was initially repudiated due to a genetic disorder exclusion. The Ombudsman found the surgery covered under the policy terms, but the award lacked specified amounts.
Finding of the Court:
The court upheld the Ombudsman's decision that the surgery was covered and directed the insurer to specify the amount due, while allowing interest on the claim from the application date.
Issues: Whether the surgery for mandibular prognathism is covered under the health policy and the obligation of the insurer to specify the payable amount.
Ratio Decidendi: The court affirmed the Ombudsman's ruling that the surgery was covered by the health policy despite the insurer's initial repudiation based on genetic disorder exclusion.
Final Decision: Insurer must pay the claim along with interest within two months.
JUDGMENT
The petitioner has challenged the award dated 10.6.2015 produced at Ext.P8. The petitioner and his family were covered under an individual health policy, of the respondent, for ten years. The first claim raised by the petitioner was for a surgery undertaken by the daughter of the petitioner termed as the Mandibular Prognathism. A claim was raised for Rs.1,09,313/- along with bills. It was repudiated by the insurer on the ground that the surgery is to correct a genetic disorder, which is excluded under the terms of the policy.
2. The petitioner approached the Ombudsman who relied on the opinion of the Doctor who treated the patient and found that it could be caused for other reasons also. The surgery was found to be covered under the Scheme. It was directed that on W.P.(C) No.38738/2015 furnishing a letter of acceptance as per Rule 16 (2) of the RPG rules, the claim would be settled. The grievance against Ext.P8 is that there is no amounts specified.
3. This Court does not find any reason to sent back the same to the Ombudsman for specifying the amount. The claim raised is of Rs.1,09,313/. The claim has to be necessarily accepted by the insurer subject only to disallowance of any amount as revealed from the bills which are not covered under the policy. The surgical intervention as held by the Ombudsman is covered under the policy. The insurer also has not challenged the order. The same shall be done within a period of two months from the date of receipt of a copy of this judgment and the petitioner shall be entitled to interest at the rate of 7% from one month, from the date of application to the date of payment of the amounts allowed under the claim by the insurer. No order as to costs.
