Karnataka High Court
K R Srinivasan vs The Oriental Insurance Company Limited on 6 August, 2025
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NC: 2025:KHC:30505
WP No. 23057 of 2017
HC-KAR
IN THE HIGH COURT OF KARNATAKA AT BENGALURU
DATED THIS THE 6TH DAY OF AUGUST, 2025
BEFORE
THE HON'BLE MR. JUSTICE R. NATARAJ
WRIT PETITION NO. 23057 OF 2017 (GM-RES)
BETWEEN:
K.R. SRINIVASAN
ADVOCATE
S/O. LATE K. RAMAN
AGED ABOUT 57 YEARS
RESIDING AT NO.571
II BLOCK, II MAIN ROAD
RAJAJINAGAR
BANGALORE-560010
...PETITIONER
(BY SRI. K.R. SRINIVASAN, PARTY-IN-PERSON)
AND:
1. THE ORIENTAL INSURANCE COMPANY LIMITED
REPRESENTED BY ITS DIVISIONAL MANAGER
DIVISIONAL OFFICE:12, NO.1001/56
JAYALAKSHMI MANSON, 2ND FLOOR,
Digitally
signed by DR. RAJAKUMAR ROAD
SUMA 4TH BLOCK, RAJAJINAGAR
Location: BANGALORE-560010
HIGH
COURT OF 2. M/S. GOOD HEALTH PLAN LIMITED
KARNATAKA BY ITS MANAGER,
NO.31, 2ND MAIN, 7TH CROSS,
BINNAMANGALA EXTENSION
NEAR BDA COMPLEX,
INDIRANAGAR, 1ST STAGE
BANGALORE-560038
...RESPONDENTS
(BY SRI. C.R.RAVISHANKAR, ADVOCATE FOR RESPONDENT NO.1;
NOTICE SERVED ON RESPONDENT NO.2)
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NC: 2025:KHC:30505
WP No. 23057 of 2017
HC-KAR
THIS WP IS FILED UNDER ARTICLES 226 AND 227 OF THE
CONSTITUTION OF INDIA PRAYING TO QUASH THE TERM "ENTITLED
CATEGORY VIS-A-VIS- ROOM RENT" UNDER CLAUSE 1.2 A AFTER (b)
UNDER HOSPITALIZATION BENEFITS OF THE MEDICLAIM
INSURANCE POLICY (INDIVIDUAL)-AT ANNEXURE-B OF THE FIRST
RESPONDENT COMPANY AND ETC.
THIS PETITION, COMING ON FOR PRELIMINARY HEARING IN
'B' GROUP, THIS DAY, ORDER WAS MADE THEREIN AS UNDER:
CORAM: HON'BLE MR. JUSTICE R. NATARAJ
ORAL ORDER
The petitioner has sought for a writ in the nature of Certiorari to quash a term contained in a mediclaim insurance policy issued by the respondent No.1. He has also sought for a writ in the nature of mandamus to the respondents to reopen claim No.35087 and to pay balance amount of Rs.8,192/- towards consultant charges, operation theatre charges, medicines etc., incurred by him during hospitalization and to direct the respondents to pay a sum of Rs.50,000/- towards damages for the time and energy spent.
2. (i) The petitioner contends that he had availed a mediclaim insurance policy from the respondent No.1 for coverage upto a sum of Rs.1,00,000/- during the year 2016 - -3-
NC: 2025:KHC:30505 WP No. 23057 of 2017 HC-KAR 2017. The petitioner developed severe pain in the left hand ring finger, hence, he consulted an orthopedic surgeon, who advised him to undergo a surgical procedure, which he underwent on 18.03.2017 in a non-network hospital. He submitted prescribed claim form on 24.03.2017 claiming reimbursement of Rs.17,220/-. However, the respondent No.1 partially allowed the claim and processed it for a sum of Rs.7,389/-. The petitioner contends that aggrieved by the said determination, he filed an appeal before the respondent No.2. The respondent No.2 addressed an email stating that the claim of the petitioner is processed as per the 'eligible room category'. It therefore held that the claim processed by the respondent No.1 is in order. The petitioner contends that the 'eligible room category' is not defined in the terms and conditions of the insurance policy and therefore, rejecting his claim on the ground that the petitioner was entitled to proportionate amount based on the 'eligible room category', is illegal and arbitrary. He contends that when once the respondents have undertaken to cover the medical expenses under the mediclaim insurance policy, the respondent No.1 is bound to reimburse the actual expenses incurred by the -4- NC: 2025:KHC:30505 WP No. 23057 of 2017 HC-KAR petitioner. He therefore, contends that the clauses prescribed in the policy of the insurance which allows the claims only to the extent of 'eligible room category' is without any basis.
(ii) The petitioner who is appearing in-person submits that the petitioner had paid a sum of Rs.9,000/- towards consultant charges, a sum Rs.4,500/- towards OT charges and a sum of Rs.1,050/- towards medicines. However, the respondent No.1 has processed the claim and reimbursed a sum of Rs.3,914/-, Rs.1,957/- and Rs.487/- respectively towards aforesaid actual claim. He contends that in the claim form it is stated that the petitioner is only entitled to 1% of the insured value towards room rent and therefore, the other expenses have to be reimbursed by the respondent No.1.
3. The respondent No.1 submits that the parties are governed by the terms of contract and therefore this Court cannot exercise jurisdiction under Article 226 of the Constitution of India. He also submits that the claim is based on 'entitled room category' and hence, the respondent No.1 has rightly reimbursed the expenses incurred by the petitioner. -5-
NC: 2025:KHC:30505 WP No. 23057 of 2017 HC-KAR
4. In so far as the maintainability of this writ petition, it is relevant to note that the petitioner has challenged the validity of a clause contained in an insurance policy as arbitrary. It is trite that relief of the above nature can only be granted by a Court exercising jurisdiction under Article 226 of the Constitution of India, more particularly, when the respondent is a State or other authority. Even otherwise, this Court refraining from exercising power under Article 226 of the Constitution of India in the face of an alternative remedy is a self imposed rule and not a strait jacket. Whenever this Court comes across an arbitrary act or arbitrary exercise of power, the shackles of the self imposed rule can be broken to grant relief to a citizen. Therefore, the threshold contention of the respondents against maintainability of the writ petition is liable to be rejected.
5. The terms of mediclaim insurance policy issued by the respondent No.1 indicates hospitalization benefits and the relevant portion is extracted below:
A HOSPITALISATION BENEFITS
Expenses covered Limits of Covered Expenses
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WP No. 23057 of 2017
HC-KAR
a. Room, Boarding and Nursing Not exceeding 1% of the Sum
Expenses as provided by the insured per day.
Hospital/Nursing Home
b. Intensive Care Unit (ICU) Not exceeding 2% of the Sum
expenses as provided by the Insured per day.
Hospital/Nursing Home
Number of days of stay under 'a' and 'b' above should not exceed total number of days of admission in the hospital. Admissibility of all related expenses (c and d), except for medicine / pharmacy bills and body implants, shall also be as per the entitled category vis-à-vis room rent.
6. The petitioner who had undergone a procedure submitted a bill which was processed and partially paid by respondent No.1 and the relevant reasons for disallowing the entire expenses are as stated below:
Sl. Particulars Claimed Disallowan Approve Reasons for No of Claim amount ce d Disallowance . amount 1% SI ROOM
1. ROOM RENT RENT 2,300.00 1,300.00 1,000.00
2. CONSULTANT RESTRICTED PAID 9,000.00 5,086.00 3,914.00 AS PER ENTITLED
3. LABORATORY 70.00 39.00 31.00 ROOM CATEGORY MEDICINES PAID AS PER
4. ENTITLED ROOM BY HOSPITAL 1,050.00 563.00 487.00 CATEGORY
5. OT CHARGES 4,500.00 2,543.00 1,957.00 GLOVES,
6. OTHERS 300.00 300.00 0.00 BETADINE, ARM TOTAL 17,220.0 9,831.00 7,389.00 POUCH CHARGES 0 N/P PAID AS PER DISCOUNT ENTITLED ROOM AMOUNT 0.00 CATEGORY NET REGISTRATION PAYABLE 7,389.00 CHARGES N/P 7,389.00 -7- NC: 2025:KHC:30505 WP No. 23057 of 2017 HC-KAR
7. The reason for disallowing the claim of the petitioner in so far as consultant charges was paid as per the entitled room category. Likewise, in respect of OT charge, the bill was processed based on the entitled room category.
8. A perusal of the hospitalization benefits as extracted above, shows that the petitioner was entitled to reimbursement of related expenses which was as per the entitled category vis-à-vis room rent. However, what was the entitled category was not defined but it is not disputed by the petitioner that consultant charges may vary depending upon the room occupied by the petitioner. If the petitioner is entitled for reimbursement at the rate of the insurance amount towards room rent, then the consultant charges applicable to such room category should be reimbursed. This is definitely just.
However, in so far as the operation theatre charges are concerned, the petitioner cannot be deprived of the same by applying the 'entitled room category' as the operation is not conducted in the room. Therefore, the respondent No.1 is liable to be hauled up for not settling the OT charges as mentioned in the bill submitted by the petitioner in its entirety. -8-
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9. In that view of the matter and since the issue does not involve any huge sum of money and the petition is pending for nearly 08 years, no purpose would be served in driving the petitioner before another authority.
10. In that view of the matter, this petition is allowed- in-part. The respondent No.1 is directed to pay a sum of Rs.2,543/- being the disallowed OT charges as per the bill submitted by the petitioner. In order to enable the respondent No.1 to pay the amount, the petitioner is directed to furnish a copy of this order along with a copy of the bill (Annexure-C) to respondent No.1 within a period of one month from the date of receipt of a certified copy of this order. The respondent No.1 shall within a p eriod of 15 days pay the same.
Sd/-
(R. NATARAJ) JUDGE HJ List No.: 1 Sl No.: 44