The Ernakulam District Consumer Disputes Redressal Commission has ruled that rejecting a health insurance claim filed by a consumer who sought treatment after a road accident, on the grounds that it was not an emergency, constitutes a deficiency in service and an unfair trade practice by the opposite parties.
The Commission ordered that the opposite parties pay a sum of ₹94,276 with interest at 9% per annum from 14 August 2023, the date of repudiation, until realisation, along with ₹20,000 as compensation for mental agony and inconvenience, and ₹5,000 towards litigation costs to the complainant.
The order was made in a complaint filed by Muhiyadeen K.M., a native of Pallarimangalam, Ernakulam, against Oriental Insurance Company and the Medical Insurance Scheme for State Employees and Pensioners (Medisep). The insurance company had rejected the claim submitted by the complainant for medical expenses incurred after he met with an accident.
The court, chaired by D.B. Binu, gave the order and criticised Medisep and the insurance company for repudiating the reimbursement claim. The Commission observed that “behind every file lies a person whose daily life is disrupted when rightful claims are delayed or denied.”
The opposite party maintained that the complainant’s case was not maintainable and that Medisep provides grievance redressal at district and State levels, with every claim to be adjudged strictly according to the scheme’s terms, conditions, exclusions and limits. It added that Medisep is a cashless scheme, and reimbursement was generally impermissible except in narrowly defined emergencies.
Published – December 07, 2025 07:59 pm IST
