DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi- 110016
Case No.252/2018
Ms. Sudha Saial
W/o Sh. Astul Kumar
R/o 156-157/E, Anand Puri,
Tank Road, Karol Bagh,
Delhi- 110005
….Complainant
Versus
East West Assist TPA Pvt. Ltd.
404 & 602, DLF Place Saket, 4th Floor,
Mall Office Block, Distt. Centre Saket,
New Delhi- 110017
National Insurance Co. Ltd.
6/90, 3rd Floor, Padam Singh Road,
Karol Bagh, New Delhi- 110005
….Opposite Parties
Date of Institution : 31.08.2018
Date of Order : 27.06.2022
Coram:
Ms. Monika A Srivastava, President
Ms. Kiran Kaushal, Member
Sh. U.K. Tyagi, Member
ORDER
Member: Shri U.K. Tyagi
Complainant has prayed for directing the East West Assist TPA Pvt. Ltd. and National Insurance Co. Ltd (hereinafter referred to as OP-1 & OP-2 respectively) to release the payment of pending claim amount i.e. Rs.19,214/- alongwith interest @24% per annum: (ii) to award compensation of Rs.50,000/- for mental agony and harassment; (iii) a sum of Rs.55,000/- as litigation cost etc.
Brief facts of the complaint are as under:-
The Complainant was having the Mediclaim Policy under the name of “Baroda Health Policy” of the OP-2 for the period 15.02.2018 to 14.02.2019. It was a Family Floater Policy which can be used by any of the family members. OP-1 is the TPA appointed by OP-2 for processing the claim of the subscribers. Complainant’s husband got admitted in B.K. Kapoor Memorial Hospital for fever on 28.04.2018 and was diagnosed with Typhi Dot Positive. During the stay at hospital, the total hospitalized bill was to the tune of Rs.79,282/-. The OPs cleared the amount of Rs. 56,618/- in lieu of claim under the above mentioned policy. The Complainant approached OP-1 for the balance claim of Rs.22,644/-. An amount of Rs.4,215/- was approved as post-hospitalization expense and rest of the claim was rejected. The ground of rejection was taken that CT-Scan was not required. However, the Complainant placed a certificate of doctors requiring the test. Hence, the complaint.
OPs on the other hand filed the Written Statement inter-alia taking some preliminary objections. The complaint does not disclose any cause of action. The liability of the OPs cannot be fastened on them and same is falling outside the scope of such policy. In the matters of New India Assurance Co. Vs Hasmat Begum, AIR 1994 J&K , it has been held that the liability of the insurer is only to the extent as contained in the insurance policy. Further, it is held in the matter of United India Insurance Co. Ltd. Vs Lakshmi AIR 1990 Madras 108, that “in order to fix liability on the insurance company, the liability must be established first against the insured and only thereafter the liability of the insurance company would arise.”
It was asserted by OPs that CT-Scan was not related to the diagnosis. Hence, the bill against CT-Scan was rejected. As per clause 4.13 of the Policy i.e. irrelevant investigation charges not payable as per terms & conditions of the policy. Hence, the claim was rejected.
Both the parties have filed Written Submissions and evidence-in-affidavit. Written Statement is on record so is the rejoinder. Oral arguments were heard and concluded.
This Commission thoroughly examined the material placed on record. Due consideration was also given to the arguments. The Complainant has tried to establish his case stating that the fever of the husband of the Complainant was not coming down hence, in order to ascertain the reason for failure of the antibiotics, the doctors decided to conduct the CT- Scan and it was to find out additional pathology. It was for the treating doctors to decide to control the fever and his decision cannot be questioned at the particular point of time. The Complainant also assailed the clause 4.13 as contended by the OPs in their reply. The Complainant also questioned the applicability of the ratios of the judgement as advanced by the OPs in their Written Statement as it has no relevance to the facts of the present case. The case of New India Assurance Vs Hasmat Begum as quoted by the OP, says that liability of the insurer is only to the extent as contained in Insurance Policy. The Complainant has asserted that the instant policy was a floater policy and the sum insured was Rs.5,00,000/- which had not been exhausted at the time of admission. Therefore this judgement is not applicable in the present case. The other judgement in the case of United India Insurance Vs Lakshmi is also not relevant to the present case as no liability is to be fixed upon the insured because the insurer had not denied the validity of the insurance policy.
This Commission also tried to find out the relevant clause 4.13 which states that irrelevant investigation charges not payable as per terms & conditions of the policy as the above contention was put forth by the OPs in their reply and arguments. The Complainant also vide its arguments stated that no such clause exists in the Policy. Hence, the above averment/defence of the OPs are not considered. It would be seen that the treating doctors have also given certificate to this effect stating that the CT- Scan had become necessary to ascertain the cause of fever as the fever of the husband of the Complainant was not coming down.
Having considered the facts, circumstances and contentions, this Commission is of the considered view that the OPs are found deficient in service and accordingly, the OP is directed to release the pending claim of Rs.19,214/- alongwith interest @6% per annum from the date of institution of case here in this Commission within three month from the date of receipt of this order, failing which rate of Interest shall be levied @9% per annum till its realization.
File be consigned to the record room after giving a copy of the order to the parties as per rules. Order be uploaded on the website.
