Page 47 - Insurance Times March 2017 Sample

risk especially when carried in an open motorcycle. The the claim amount and an award is, therefore, passed direct-
repudiation of the claim as per policy condition 3 was, there- ing the insurer to pay the eligible claim amount of Rs.3,905/
fore, held to be in order. - with interest @ 8% p.a. and a cost of Rs.500/-.

Office of the Insurance Ombudsman, Chennai Ombudsman Centre

Kochi Case No.IO(CHN) 11.04.1339 / 2008-09
Complaint No.IO/KCH/GI/11-004-251/2008-09 Mr. G. Vasikaran

Shri T.X.Sebastian Vs
Vs United India Insurance Co. Ltd

United India Insurance Co.Ltd. Award No.112/2008-09
Award dated 17.12.2008
Mr Vasikaran, a practicing architect, had paid the premium
A Universal Health Insurance Policy was issued to Win Cen- for a professional indemnity policy for the past two years.
tre, a social and charitable organization for the period In the first year, he had received only the receipt and for
01.07.2007 to 30.06.2008 covering 2,144 BPL families in- the second year not even the receipt was received. The
cluding that of the complainant. On 28.11.2007, the insurer did not issue policy document for both the years.
complainant's son Sharon was admitted in Indira Gandhi The complainant contends that in 2005-06, he had not sub-
Hospital and treated an in-patient up to 01.12.2007, where mitted any proposal and policy was issued.
the disease was diagnosed as epilepsy. The claim was repu-
diated on the ground of preexisting disease. It was submit- No doubt there is laxity on the part of the field official of the
ted by the insurance company that the illness set in within insurer but the complainant being a well informed person and
5 months of taking the policy. who required the insurance protection as part of his profes-
sional dealings with large scale construction activities, should
The treating doctor has not filled in the column regarding have demanded the proposal form to ensure that he had the
the history of illness. Hence the disease might have been requisite protection. After all, a professional indemnity policy
congenital or preexisting. So they have referred the file to is a pre requisite for any architect to undertake projects in the
a panel doctor who also opined that the illness may be state/country and not merely a token to be produced before
congenital or pre-existing. Based on these, they have re- government and other international agencies.
pudiated the claim invoking condition 4.1 of the policy. It
was submitted by the insured that his son is now aged 10 As per the available records, an amount said to be premium
and he never had this illness before. They also produced a has been deposited into the personal savings bank account
certificate from the treating doctor who is a MD in Medi- of a company official who is in charge of a "one Man Of-
cine and Neuro, stating that the illness occurred for the first fice" of the insurer. In these circumstances, since the in-
time and not a congenital or pre-existing disease. surer has not received premium, there is no deficiency on
the part of the insurer in issue of the policy. However, the
It can be see that the panel doctor of insurance company actions of a responsible official of a leading Public Sector
has not given a definite opinion whereas the treating doc- insurer, has been thoroughly unprofessional. On the other
tor, who is a specialist, has given a definite opinion that it is hand, the dealings and transactions are of personal nature
not pre-existing or congenital. Hence the opinion of treating and are to be resolved between the individuals to be ad-
doctor has to be considered rather than the desktop opinion dressed through other forums including the higher authori-
of panel doctor. The complainant is, therefore, eligible for ties of the insurer. As such, the Complaint is dismissed. 

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