The Tata AIG General Insurance Co. Ltd. filed a petition against the award by the Insurance Ombudsman. The case centers on a travel insurance policy claim for medical expenses incurred both overseas and in India. The Ombudsman directed the insurer to process the claim, but the insurance company contested, citing policy terms that exclude medical expenses incurred in India. The Bombay High Court found that the Ombudsman’s decision did not properly consider the policy’s terms and set aside the award, remanding the case back to the Ombudsman for reconsideration.

1. Introduction and Background

The case involves Tata AIG General Insurance Co. Ltd. (the insurer) challenging the decision of the Insurance Ombudsman. The dispute arose from an overseas travel insurance policy that the insured purchased, which led to a claim for medical expenses incurred during and after the trip.

2. Facts of the Case

The insured took an overseas trip to Europe and developed symptoms of vertigo. After returning to India, he was treated for a different condition and subsequently made a claim for both overseas and Indian medical expenses. The insurer rejected the claim for Indian expenses, citing policy exclusions.

3. Ombudsman’s Decision

The Insurance Ombudsman ruled that the insurer must process the entire claim, arguing that the Indian treatment was a continuation of the overseas treatment. The Ombudsman directed the insurer to process the claim within 30 days.

4. Insurer’s Argument

Tata AIG argued that the policy terms do not cover medical expenses incurred in India. The company contended that the Ombudsman incorrectly interpreted the insurer’s willingness to cover overseas expenses as an admission of liability for Indian expenses.

5. Court’s Judgment

The Bombay High Court held that the Ombudsman’s decision was legally flawed, as it failed to account for the specific terms of the policy. The court noted that the Ombudsman did not conclusively determine the compensation as required under Rule 17 and overlooked the policy terms that exclude Indian medical expenses.

6. Outcome and Directions

The court set aside the Ombudsman’s award and remanded the case back for a fresh decision in line with the insurance policy terms and legal principles, without being influenced by previous findings.