Bombay high court
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.
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.
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. 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.