Mumbai: Bombay high court has upheld the insurance ombudsman’s order to an insurer to pay an ex gratia of 50% of the balance Rs 7.2 lakh claim of a deceased cancer patient who was hospitalised even during the successive policy period.“No perversity is found in the impugned order,” said Justice Milind Sathaye on Sept 21. He dismissed National Insurance Company Limited’s petition challenging the ombudsman’s Aug 2010 order.The first policy of the patient, Manish Munni, was in effect from Nov 2007 to Nov 2008 for Rs 5 lakh with cumulative benefits, and the second from Nov 2008 till Nov 2009. Manish was admitted to a hospital for treatment of leukaemia from Oct 24, 2008, till his death on Dec 14, 2008. While the claim was over Rs 13.7 lakh, the insurer settled Rs 5.4 lakh. Manish’s brother, Pankaj, then approached the ombudsman, who awarded an ex gratia payment.Despite HC’s notice to Pankaj, none represented him.The insurer’s advocates, Shasvat Vidyarthi and Asim Vidyarthi, citing policy condition 3.13, argued that as Manish’s hospitalisation commenced during the first policy, the claim could not be extended to the second policy.But Justice Sathaye noted that the same condition was there in the second policy. The word ‘hospitalisation’ in the condition was not qualified by any specific period and had to be interpreted as a general term, he said. Manish’s first part of hospitalisation was when the first policy was in force and the second during the second policy’s period.The judge said a patient is charged daily for room, doctors and other charges. The period of hospitalisation falling under the second policy “was certainly charged by the hospital under various heads”. “Therefore, I see no reason why such hospitalisation during the second policy period should not be covered by term ‘hospitalisation’ under condition 3.13 of the second policy,” he added.Justice Sathaye said Redressal of Public Grievances Rules permit an ombudsman to grant compensation including ex gratia and other expenses. Shasvat said for granting ex gratia payment, the ombudsman could not have taken the balance amount as the basis and directed 50% of it to be paid. But the judge said it is settled law that to arrive at a figure for monetary liability, the deciding authority has to have a basis. Considering that the ombudsman chose the balance as the basis and permitted only 50% of the admissible charges, he was “well within his limit” under the Rules, said Justice Sathaye.
