The Ernakulam District Consumer Disputes Redressal Commission has ruled that the denial of a health insurance claim filed by a consumer who sought treatment after a road accident on the grounds that it was not an emergency constituted a deficiency in service and an unfair trade practice by the opposite parties.
The Commission ordered the opposite parties to pay a sum of ₹94,276 with interest at 9% per annum from 14 August 2023, the date of rejection, until realisation, along with ₹20,000 as compensation for mental anguish and inconvenience and ₹5,000 for litigation costs to the complainant.
The order was made in a complaint filed by Muhiyadeen KM, a native of Pallarimangalam, Ernakulam, against Oriental Insurance Company and the Health Insurance Scheme for Government Employees and Pensioners (Medisep). The insurance company rejected the claimant’s claim for medical expenses incurred after the accident.
The court, presided over by DB Binu, issued the order and criticized Medisep and the insurance company for rejecting the compensation claim. The commission noted that “behind every file is a person whose daily life is disrupted when legitimate claims are delayed or denied.”
The opposing party argued that the complainant’s case was not maintainable and that Medisep provides grievance redressal at the district and state level, each claim having to be judged strictly according to the system’s terms, exclusions and limits. He added that Medisep is a cashless system and compensation was generally inadmissible except in narrowly defined extraordinary events.
Published – 07 Dec 2025 19:59 IST
