Order Name: Oriental Insurance Co. Ltd. Vs. Kamleshbhai Udani
Case No.: R.P. No. 1658/2019
The National Consumer Disputes Redressal Commission recently held Oriental Insurance responsible for service shortcomings. They highlighted that it is the insurer’s duty to prove if a case fits within an exclusion clause.
Case Background
A man filed a complaint after his wife’s medical reimbursement was denied. She had been treated at Hinduja Hospital for diabetes, hypertension, and obesity, incurring costs of Rs. 4,75,184. The insurance company rejected the claim, arguing the treatment was for weight loss, which their policy didn’t cover. Despite receiving a clarification from Dr. Raman Goel, affirming the treatment was primarily for diabetes and hypertension, the insurer persisted in denying the claim. Dissatisfied with this, the man approached the District Forum, which dismissed his case. He then moved to the State Commission, which ruled in his favor, ordering the insurer to pay the medical costs along with Rs. 10,000 for legal expenses. The insurer challenged this decision at the National Commission.
Insurer’s Argument
The insurance company claimed the treatment was for a condition not covered by their policy, specifically citing a clause that excludes procedures like sleeve gastrectomy related to obesity.
National Commission’s Findings
The National Commission examined whether the man’s wife was entitled to a reimbursement for her Laparoscopic Sleeve Gastrectomy under the policy. The insurer had denied the claim based on an exclusion clause concerning obesity treatments. However, Indian Supreme Court precedents dictate that exclusion clauses should be strictly interpreted against insurers. Additionally, the burden of proof for any exclusion rests with the insurer. The Commission found that the insurer couldn’t convincingly prove that the surgery was solely for obesity. Consequently, they upheld the State Commission’s decision and dismissed the insurer’s revision petition.
Takeaway
This decision underscores the importance of insurers clearly proving their grounds for claim denials, especially when relying on exclusion clauses. Policyholders should be aware of their rights and the insurer’s responsibilities in such cases.
