Ernakulam Commission Calls Claim Denial Unfair

The Ernakulam district consumer disputes redressal commission has ruled that rejecting a consumer’s claim for medical treatment following a road accident on the grounds that it was not an emergency amounts to unfair trade practice and deficiency in service. The order came in response to a complaint filed by K M Muhiyudheen of Pallari Mangalam, Ernakulam, against Oriental Insurance Company and Medisep.

In January 2023, the complainant suffered serious injuries to his left leg in a collision with a jeep and was admitted to the nearby Kolenchery Medical College for emergency treatment. As the hospital was not empanelled, he later applied to Oriental Insurance Company for reimbursement of treatment expenses amounting to Rs 94,276.

The insurer rejected the claim, stating that reimbursement for treatment at non-empanelled hospitals was allowed only in emergency cases. Oriental Insurance also argued that the treatment did not fall under an emergency category and that the complainant had not approached Medisep’s grievance redressal mechanism.

The commission referred to the memorandum of understanding signed on June 27, 2022, between the state finance department and the insurer, which clearly categorises road accidents as emergencies eligible for reimbursement at non-empanelled hospitals.

Citing a Supreme Court ruling, the commission observed that any ambiguity in insurance policy terms must be interpreted in favour of the consumer. It further clarified that consumer protection remedies are additional to other legal remedies and do not restrict the jurisdiction of consumer courts.

The commission directed Oriental Insurance Company and Medisep to refund Rs 94,276 with 9 percent interest, pay Rs 20,000 as compensation for mental agony and Rs 5,000 towards court expenses within 45 days.

Khaborwala/SS