Kochin Ombudsman Centre
Case No. IO / KCH / GI / 11.003.070 / 2004-05
Sri. P. K. Vasudevan
Vs.
National Insurance Co. Ltd.
The complaint under Rule No. 12(1)(b) read with Rule 13 of the RPG Rules 1998 is consequent to the repudiation of a mediclaim by the insurer under Pol. No.570700 / 47 / 2001 / 3801054. The complainant was the beneficiary under GPA policy issued in favour of Anugraha Welfare Service, Thrissur.
It is said that the complainant had met with a bike accident on 15.4.2002 and his claim for the medical expenses was refused by the insurer citing that there was no evidence to the alleged accident: As per the claim, the complainant’s treatment was for a damaged nasal septum. The insurer had also found out that the hospital records produced by the claimant emanated from a Maternity Hospital although the Doctor was an ENT Surgeon. The insurer also found out a number of other doubtful inconsistencies in the records and it was more probable that the nasal septum defect was an existing deformity for which a surgical intervention was done. There was nothing on record to prove the accident and hence the claim was rejected. The contentions of the insurer were found to be on reliable grounds and the complainant not being able to prove the alleged motor accident, the repudiation of the claim was upheld by the insurance Ombudsman.
