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Insurance Ombudsman Rules 2017 – Quasi Judicial Authority – Duties and Functions

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On 15.12.2022, the Insured had taken Overseas Travel Insurance Policy of the petitioner through Online Platform based on his declaration.  It was for the period from 17.1.2023 to 16.5.2023 for travel to Europe by the Insured with his wife.   During the overseas travel, the insured experienced the symptoms of vertigo and sought medical consultation on 8.5.2023.  However, he aborted the journey due to persistent symptoms and returned to India on 10.5.2023.  He was admitted in the Reliance Hospital from 15th to 22nd May 2023, for some other disease.

On 10.6.2023 the insured filed the claim for expenses on treatment in Reliance Hospital.   It was denied by the email dated 20.6.2023.

On 4.3.2024, the Insurance Ombudsman directed the Insurer to process the entire claim in 30 days without deciding the dispute and has not determined the amount.

HELD that Rule 13 of the Ombudsman Rules, 2017, provide for the duties and function of the Insurance Ombudsman.   Rule 17 is in respect of Award for compensation granted to the insured.  Thus, the object of the Ombudsman Rules is for dispute resolution against rejection of claims.  The Ombudsman performs duties of quasi-judicial nature while adjudicating the issue. While passing the impugned order the Ombudsman did not pass award in term of Rule 17 and also did not take into account the terms of policy.  The matter was, therefore, remanded back to the Ombudsman.

Judgment dated 14.8.2024 of the Bombay High Court in W.P.No.6625 of 2024 of Tata AIG General Insurance Co. Ltd  Vs. Insurance Ombudsman for Mumbai and another

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