Overseas Travel Insurance Policy: Does not provide for treament in India
- Ombudsman – Quasi-Judicial Role:
- The Insurance Ombudsman performs duties similar to a quasi-judicial tribunal when adjudicating complaints under the Insurance Ombudsman Rules 2017. This role involves resolving disputes raised by insured parties against insurers (Rule 13).
- Insurance Ombudsman Rules 2017, Rule 17 – Award Requirements:
- Rule 17 mandates that any award in favor of the complainant must clearly state the amount of compensation after deductions. The objective is to provide a clear dispute resolution mechanism for insured parties. However, in this case, the Ombudsman directed the insurer to process the claim without determining the specific compensation amount, leading to a remand for proper adjudication
- Insurance – Overseas Travel Insurance Policy:
- The Ombudsman’s conclusion that the insurer’s willingness to cover overseas medical expenses implies liability for subsequent treatment in India was found to be flawed. The court held that merely agreeing to cover overseas expenses does not automatically extend liability for treatment in India, especially when the treatment was for a different condition. The findings were in disregard of the specific terms of the insurance contract
TATA AIG GENERAL INSURANCE CO. LTD. v. INSURANCE OMNBUDSMAN, 2024 PLRonline 14 = (2024-2)214 PLR 831 (SN) (Bom.) = [ID#442768]