Insurer's Panel Doctor Opinion Can't Override Aviation Authority's Medical Certification for Loss of License Claim: Telangana State Consumer Commission - 2025-08-23

Insurer's Panel Doctor Opinion Can't Override Official Aviation Medical Report in Loss of License Claim, Rules Telangana Consumer Commission

HYDERABAD – The Telangana State Consumer Disputes Redressal Commission has delivered a significant ruling in favour of a senior airline pilot, holding that an insurance company cannot repudiate a "Loss of License" claim by relying on its own medical expert's opinion over the official certification of the Director General of Civil Aviation (DGCA).

The bench, comprising Presiding Officer Sri K. Ranga Rao and Member Smt. R. S. Rajeshree, directed The Oriental Insurance Company Ltd. to pay over ₹1.72 crore to Captain Jangam Raghunath Gowd, a former Senior Commander with Jet Airways, for unfairly denying his insurance claims after his pilot's license was permanently cancelled on medical grounds. The Commission found the insurer's actions amounted to a deficiency in service and an unfair trade practice.

Background of the Case

Captain Jangam Raghunath Gowd, a pilot with approximately 20,000 hours of flying experience, was covered under two "Aviation Loss of License" (LOL) group policies obtained by his employer, Jet Airways, from Oriental Insurance. These included a primary 'Base Policy' and an additional 'Top-Up Policy', each with a sum insured of ₹1.15 crore.

In January 2016, following a mandatory medical examination, Captain Gowd was declared temporarily unfit. After subsequent evaluations, the DGCA and the Air Force Central Medical Establishment (AFCME) declared him permanently unfit for flying on September 5, 2017, due to "Diabetes Mellitus Type II," leading to the cancellation of his Airline Transport Pilot's Licence (ALTP).

Captain Gowd filed a claim for a total of ₹2.30 crore under both policies. However, the insurance company paid only ₹57.50 lakh (50% of the sum insured) under the Base Policy and completely repudiated the ₹1.15 crore claim under the Top-Up Policy.

Arguments of the Parties

The Insurer's Stance: Oriental Insurance argued that Captain Gowd had a pre-existing condition (diabetes) before the Top-Up policy commenced in December 2015. Their repudiation was based on a policy exclusion clause for pre-existing illnesses. The company relied on the opinion of its medical consultant, Dr. C.H. Asrani, who concluded that the pilot was a "known case of Diabetes prior to 24th July 2015." The insurer pointed to a DGCA medical assessment from that date which recommended tests like HbA1C and a "cured certificate by Endocrinologist" as evidence of a pre-existing condition.

The Pilot's Contention: Captain Gowd countered that the DGCA and AFCME—the paramount authorities for aviation medical fitness—had declared him fit to fly on July 24, 2015, renewing his license without any operational restrictions. He emphasized that he flew an international flight from Brussels to Mumbai as late as January 21, 2016. He argued that if he were medically unfit, neither the DGCA nor Jet Airways would have risked the lives of 300 passengers and an aircraft worth crores. He submitted pathology reports from July and December 2015 showing his blood sugar levels were within normal limits. He asserted that the insurer's reliance on its panel doctor, who is not an aviation medicine specialist, to override the findings of the AFCME was arbitrary and unjust.

Commission's Analysis and Key Findings

The Commission critically examined the evidence and sided with the pilot, establishing that the onus was on the insurance company to justify its repudiation with cogent proof.

In its detailed order, the Commission highlighted several key points:

• Primacy of Official Medical Authority: The Commission gave credence to the reports and certifications of the AFCME and DGCA over the retrospective opinion of the insurer's panel doctor. It observed, "...his opinion cannot be equated with the Expert/specialist Doctors of Air Force Central Medical Establishment (AFCME)..." The Commission suggested that obtaining the opinion was a self-serving act to deny a legitimate claim.

• Lack of Concrete Evidence for Repudiation: The pathology reports (Ex. A10 and A11) submitted by the pilot showed normal blood sugar levels in July and December 2015. The Commission noted that the insurer failed to appreciate these reports and instead based its decision on speculation.

• Inconsistency in Insurer's Actions: The insurer had renewed the Base Policy annually since 2009 based on the same DGCA medical certifications it later chose to question. Furthermore, the Commission found it unjustified for the insurer to pay only 50% of the Base Policy amount when the policy terms stipulated 100% payment upon loss of license.

The Commission's order stated:

"Had it been that the Complainant was not medically fit on 24.07.2015, why would the DGCA allow the Pilot to fly the Plane and why would Jet Airways risk the Aircraft worth crores of rupees and lives of about 300 passengers by allowing an unfit Pilot to fly the Plane. The Insurance Company has repudiated the rightful claim without any concrete proof."

The Final Verdict

The Telangana State Consumer Disputes Redressal Commission found a clear deficiency in service on the part of The Oriental Insurance Company Ltd. It allowed the complaint in part and issued the following directives:

• Pay the full Top-Up Policy amount of ₹1,15,00,000.
• Pay the remaining balance of ₹57,50,000 under the Base Policy.
• Both amounts are to be paid with interest at 9% per annum from the date of license cancellation (September 5, 2017) until realization.
• Pay ₹25,000 towards legal costs.

The Commission stipulated a compliance period of 30 days, failing which the interest rate on the principal amounts would increase to 12% per annum.