PER MADHU MUTNEJA, MEMBER

                The instant complaint has been filed by Sh. Chander Shekhar Tyagi and Sh. Narinder Tyagi father of Sh. Chander Shekhar Tyagi against Aviva Life Insurance Co. & Others, under Section 12 of the Consumer Protection Act. 

                The facts of the case are as under:

1]             The Complainant No. 1 was an employee of Aviva Life Insurance Co. from 10.7.2006 to 6.3.2009. Along with terms and conditions of appointment, the Complainant No.1 was also provided with a health insurance cover for himself and his family members, which included self, spouse, children and dependent parents. As per the Scheme, an annual “Family Floater” cover upto a maximum of Rs.3,00,000/- per annum for all diseases, except specified diseases, was provided.  The Complainants have attached copies of the “Aviva Compensation Structure 2006-2007” and “2008-2009”, wherein the amounts to be paid under different headings including insurance have been mentioned.

                On 18/19.1.2009, Complainant No.2 who is the father of the Complainant No.1 was admitted in Emergency of the Hospital of OP No.4 with acute pain in right lower quadrant abdomen.  The Complainants have given a complete detail of his clinical position and treatment at that time.  In a nutshell, the Complainant No. 2 was suffering from ‘Hernia’. The total medical expenses incurred on his treatment, including stay in the Hospital came to Rs.1,62,438/-. The bill and discharge receipt has been annexed along with the complaint.

                The Complainants have alleged that OP No.4 deliberately and with a malafide intention, while filling the history sheet and details of treatment, filled the amount of total expenses incurred on the treatment at Rs.35,000/- only, instead of Rs.1,62,438/- and forwarded the same to OP No. 2 for approval. Thereafter, an amount of Rs.30,000/- was sanctioned and paid by OP No.3 to Complainants. 

                Not satisfied with the claim, the Complainants have contacted the OPs number of times for the remaining amount. On their persistence, the OPs further paid Rs.13,000/- in addition to the amount already disbursed.  According to the Complainants, the balance amount is still pending and payable by the OPs.

                The Complainants have alleged that they have filled in Rs.1,62,438/- in the claim form and given all the required documents demanded by OP No.2, but the OPs have not yet settled their claim. They have, thus, filed the instant complaint, claiming refund of the balance amount, along with compensation and costs of litigation.

2]             After admission of the complaint, notices were sent to the OPs.

                Summons sent to OPs No. 3 & 4 were duly received. However, on 27.7.2009, neither the Director nor any authorized Agent appeared on their behalf. Therefore, OPs No. 3 & 4 were proceeded against exparte on this date.

                In the reply filed by OPs No.1 & 2, the OPs have taken certain preliminary objections about maintainability of the claim.

                On merits, the OPs have submitted that the Complainant No.1 was their employee and by virtue of his employment, he was provided with a health insurance policy for his family. OP No.3 was a Third Party Administrator (TPA) for the insurance cover provided by New India Assurance Company.

                Further, they have admitted that Complainant No.2 was admitted in the Hospital of OP No. 4 and was diagnosed with ‘Hernia’. After his treatment, the claim form to the extent of Rs.30,000/- sanctioned by OP No.3 was received for approval by the OPs. As per the relevant portion of the e-mail received from Mr.Pravin Subba of Human Resources Deptt.of Aviva Life Insurance Co. India Ltd., Group Medi- Claim Policy for all employees for the year 2008-09, was limited as under:-

“Expenses for persons aged greater than 35 years (* For Hernia not exceeding Rs.30,000/-).

                The said facts also find mention in the pre-approval certificate dated 18.1.2009, issued by OP No.3. It is clearly mentioned in the certificate that the authorized limit was Rs.30,000/- and full and final payment, as per terms and conditions, have been made to the Complainants. Therefore, at this stage, the OPs contend that no amount is due to the Complainants from their side and their allegations for deficiency in service are not justified. 

                It is also submitted that the policy has been granted by New India Assurance Co. for the benefit of the employees, who are its beneficiaries and coverage to individual employees is subject to policy terms and conditions only.  The Complainants have already been informed by OP No.3 that Rs.30,000/- only is payable. They have placed their reliance on letters dated 18.1.2009 and 22.1.2009 issued by OP No. 3 to OP No. 4, wherein the authorized limit for treatment of hospitalized patients for the said disease (Hernia) was fixed at Rs.30,000/-. Denying all other contentions of the Complainants, the OPs have submitted that the complaint is void of merits and is an abuse of law. No further amount is due. The OPs have, therefore, prayed for dismissal of the complaint.

3]             We have heard the learned counsel for the parties and have also perused the evidence & documents led by the parties in support of their contentions.

4]             The learned counsel for the Complainants, at the time of arguments, placed sole reliance on the “Aviva Compensation Structure 2006-2007” and “2008-2009” already mentioned above. The relevant clause for medical claims is reproduced hereinbelow:-

                He insisted that since ‘Hernia” was covered under the general diseases category for claim of upto Rs.3,00,000/- per family. The amount claimed by him should have been allowed and passed totally. The OPs, as per Annexure-A, have referred to a letter received by e-mail from Mr. Pravin Subba of Human Resources Deptt. Of Aviva Life Insurance Co. India Ltd., where medi-claim policy for all employees have been renewed and the limit for ‘Hernia’ was fixed at Rs.30,000/-. However, in their reply, they have not specifically denied the “Aviva Compensation Structure 2006-2007” and “2008-2009” placed on record by the Complainants, wherein the maximum limit for payment was Rs.3,00,000/-.

5]             The OPs have also relied on Annexure-B, which is a letter of E-Meditek Solutions Ltd. (OP No.3), wherein OP No. 4 was authorized to admit Complainant No. 2 for estimates expenses of Rs.35,000/- only. The authorized limit has been mentioned as Rs.30,000/-. These two sums seem contradictory in the letter itself. It has further been mentioned that if the hospitalization expenses exceed the authorized limit, then an additional request letter should be sent to E-Meditek Solutions Ltd. (OP No.3).

                Relying on the above letters, the Complainants were sanctioned Rs.30,000/- only by the OPs.

                It is interesting to note, however, that even though the limit was fixed at Rs.30,000/-, the OPs on a representation by the Complainants have paid Rs.13,000/- more. Hence, the Complainants has so far received Rs.43,000/-.

6]             The OP has contended that their limit for ‘hernia’ is Rs.30,000/- only as per the letter at Annexure A.  But, again, the Policy handed over to the Complainants named “Aviva Compensation Structure 2006-2007” and “2008-2009”  shows that the limit is Rs.3,00,000/-. If, the limit had been fixed at Rs.30,000/-, then why have the OPs paid Rs.13,000/- more to the Complainants.  How did they go beyond this limit. And if they have paid Rs.13,000/- more, then why should they not pay the rest of the amount also. The bills of OP No.4 have been placed on record by the Complainants to show the actual expenditure on the medical treatment of Complainant No.2.  This amount is less than Rs.3,00,000/-.

7]             It seems that the OPs are not fully clear about how much amount should be reimbursed to the Complainants. Even the letters placed at Annexure-A and B are only e-mails. They have not placed on record the actual Group Medi-Claim Policy issued for the employees. Since the Policy has not been attached by the OPs, we have to place reliance on the Policy placed on record by the Complainants. As per this Policy, their contention is correct and the complaint has to be allowed in their favour.

8]             Relying on the above facts, we are of the opinion that the Complainants should be reimbursed the balance amount raised by them for medical claim, after deducting Rs.43,000/- which has already been paid to them.

9]             In view of above, this complaint is allowed with directions to the OPs to pay Rs.1,19,438/- (Rs.1,62,438.00 – Rs.43,000.00) to the Complainants.  No costs.

10]               This order be complied with by OPs within 30 days from the date of receipt of its certified copy, failing which they shall pay the aforesaid decreed amount of Rs.1,19,438/-, along with interest @12% per annum from the date of receipt of this order till the date of realization.

11]            Certified copies of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.