Road Accident Treatment Claim Rejection Ruled Deficiency in Service

The Ernakulam district consumer disputes redressal commission has held that denying reimbursement for treatment taken after a road accident on the grounds of non-emergency constitutes unfair trade practice and deficiency in service. The ruling followed a complaint by K M Muhiyudheen of Pallari Mangalam, Ernakulam, against Oriental Insurance Company and Medisep.

The complainant was seriously injured in a road accident involving a jeep in January 2023 and was rushed to Kolenchery Medical College for immediate treatment. As the hospital was not part of the approved network, he sought reimbursement of Rs 94,276 from Oriental Insurance Company.

The insurer rejected the request, stating that treatment at non-empanelled hospitals is reimbursable only if classified as an emergency. It further claimed that the treatment provided did not qualify as an emergency and that the complainant had failed to use the Medisep grievance redressal system.

The commission relied on the memorandum of understanding signed on June 27, 2022, between the state finance department and the insurer, under which road accidents are clearly defined as emergency cases eligible for reimbursement even at non-empanelled hospitals.

The commission also referred to a Supreme Court judgment which states that ambiguities in insurance policy conditions must be resolved in favour of the policyholder. It rejected the insurer’s argument regarding non-exhaustion of internal remedies, holding that consumer courts retain jurisdiction irrespective of such mechanisms.

Oriental Insurance Company and Medisep were ordered to refund Rs 94,276 with 9 percent interest and pay Rs 20,000 as compensation for mental agony and Rs 5,000 as litigation costs within 45 days.

Glive24/SS