DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD

Dated this the 9^th day of August, 2024

Present      :   Sri. Vinay Menon V., President

                    :   Smt. Vidya A., Member                        

                  :  Sri. Krishnankutty N.K., Member                                        Date of Filing: 24/04/2024  

                          CC/134/2024

A.Sasikumar,

S/o. N. Vijayamenon,

103, Jaideep Apartments,

Venketesapuram Colony,

Puthur Post, Palakkad                                               -                 Complainant

(By Adv. M/s P. Anil and Sheeba C.)

                                                                                                  Vs  

1. Care Health Insurance Ltd.,

Regd. Office:- 5^th Floor, 19 Chawla House,

Nehru Place, New Delhi – 110 019

2. Care Health Insurance Ltd.,

3^rd Floor, Door No.55/686, D1 & D2,

Vellathottam White Tower,

S.A.Road, Panampilli Nagar,

Kochi – 682 036                                                     -                      Opposite parties  

(O.P.s by Adv. P.Prasad)

                                   ORDER IN THE QUESTION OF MAINTAINABILITY

            By Sri. Vinay Menon V., President.

1. Complainant herein is aggrieved by the repudiation of claim for reimbursement of expenses incurred by the complainant for treatment of his wife on the ground of non-disclosure of material facts/pre-existing ailment at the time of proposal.  
2. Dispute filed by the complainant before the Insurance Ombudsman, Kochi, was already adjudicated and dismissed on merits upholding the repudiation of complainant’s claim.
3. Since the dispute was once taken up and heard by a Statutory Authority competent to adjudicate the issue, this complaint was posted for hearing on the question of bar of Res-judicata.
4. At the time of hearing, counsel for the complainant argued vehemently for the proposition that the Insurance Ombudsman was not a quasi-judicial body and that proceedings before the said body were voluntary in nature and that the orders of the said body lacked enforceability. Any proceedings before Ombudsman for Insurance were based on the willful compliance of the parties. In order to substantiate his pleadings, counsel for the complainant relied on the decision rendered by the Hon’ble Nation Commission in Kamaleshwari Prasad Singh Vs. National Insurance Co. Ltd.,  reported in (I(2005)CPJ107(NC))
5. Went through the above citation.
6. We find that this decision was pronounced approximately 2 decades back on 14/10/2004. Facts in the said case pertains to dismissal of a complaint based on a finding that the said complaint was barred by Res-judicata as a  decision was rendered by the Insurance Ombudsman constituted under the ‘Redressal of Public Grievances Rules, 1998’ framed under Sub-section (1) of S. 114 of the Insurance Act, 1938.  Hon’ble NCDRC had held that the Forum constituted under Consumer Protection Act, 1986 was competent to adjudicate matters adjudicated upon by the Ombudsman since Ombudsman constituted under the ‘Redressal of Public Grievances Rules, 1998’ lacked the trappings of a quasi-judicial body.
7. But the said Rules of 1998 was superseded and fresh Rules were framed and published as The Insurance Ombudsman Rules, 2017. Said Rules was published on 25/04/2017. Presently, Insurance Ombudsman are functioning under the aforesaid Rules. A reading of the provisions of the said Rules, especially Rule 17 relating to ‘Awards’, makes in clear that the nature of an award passed by the Ombudsman is not a direction drawing life from the willful compliance of the parties, but an Order wielding the authority of law.

We bank on the decisions rendered by the Hon’ble High Courts of Bombay and Kerala in Aditya Birla Sun Life Insurance Co. Ltd. Vs. Insurance Ombudsman, Goa reported in AIR 2022Bom 307 and Jyothi Madhavan U. Vs. Insurance Ombudsman reported in 2023(6) KHC 16, wherein gist of the decisions is to the effect that the Ombudsman constituted under the Rules of 2017 is a quasi-judicial authority.

8. Hence, we reject the arguments of the counsel for the complainant.
9. When a statutory authority, authorized, empowered and competent to look into a dispute which is the subject matter of the complaint herein has appreciated the facts on merits and has passed an Order holding the conduct of the OP to be proper and legal, it would not be in the best interests of judicial comity to reappreciate the evidence and arrive at a finding de-novo. Such a conduct would tantamount, in essence, to sitting in appeal over the finding of the Banking Ombudsman. Had the complainant any dispute with regard to the findings of the Banking Ombudsman, remedy available to the complainant was to file an Original Petition (Civil) before the Hon’ble High Court of Kerala, under Article 227 of the Constitution of India.

10.       Any foray by this Commission into a dispute already adjudicated on merits by the Insurance Ombudsman would be judicial impropriety   and any finding not in tune with the finding of the Ombudsman would be an absurdity.

11.       Therefore, we hold that this complaint is barred by Res Judicata. Complaint is accordingly dismissed.

 Pronounced in open court on this the 9^th  day of August, 2024

Sd/-                                                                                                                        

                                                                                                                Vinay Menon V

                                                                         President

                                                                               Sd/-

                      Vidya.A

                                              Member        

                         Sd/-

                Krishnankutty N.K.

                                                                                                                               Member           

NB : Parties are directed to take back all extra set of  documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020, failing which they will be weeded out.