Complainant Pardeep Kumar through the present complaint filed under Section 12 of the Consumer Protection Act, 1986 (for short, ‘the Act’) has sought issuance of necessary directions to the titled opposite parties (jointly ‘the OP’ and individually as the OP1 insurers, the OP2 TPA and the OP3 Bank, in the titled order) to release/ pay him the medical expenses incurred qua the insurance Claim in terms of the related Policy along with a compensation of Rs.20,000/- for causing harassment as well as costs of litigation, in the interest of justice.  

2.       The case of the complainant in brief is that he has been the holder of the one medical claim National Swastiya Bima Policy purchased since the year 2010 from the opposite parties and has been renewing the same from time to time. As per his medical needs and medical advice he got his left eye subjected to ‘cataract-surgery’ in Nov.’ 2013 to which somehow the cash-less pre-authorization was refused by the OP2 TPA and therefore he filed his reimbursement claim of Rs.26,000/- after the medical treatment. Since the OP1 insurers did not settle the claim even at the face of his two subsequent request reminders etc., he has preferred the present complaint with the desired relief duly prayed, as reproduced hereinabove.

3.       Upon notice, the OP1 insurers appeared and filed its written reply through the counsel taking the routine preliminary and other objections revolving around the prime objection that the present applicable Policy in question was renewed with a gap of 38 days from the previous Policy and thus cannot be considered to be in the requisite continuity to enable them to legitimately pass the impugned claim that already stood denied by the OP2 TPA vides their letter of 01.11.2013 addressed to the complainant under copy to them (the OP1). All other averments made in the complaint have also been duly rebutted and lastly, the complaint has been prayed to be dismissed with heavy costs. The OP2 TPA preferred to put up ‘absence’ despite due-service of summons/ notice and thus were ordered to be proceeded against ex-parte vide Forums’ orders dated 23.07.2014. Similarly, the OP3 Bank also appeared and filed its reply through the counsel admitting the complainants’ SB account with the Branch and also the payments of the insurance premia (of the Policy in question) duly paid/ remitted to the OP1 insurers to the debit of the said Bank account. However, the OP3 Bank admitting to be acting only as the agent of the OP1, has expressed its inability/ refusal to shoulder any responsibility/liability of the insurance claim and lastly the present complaint has been prayed to be dismissed with compensatory costs in its favour.       

4. All the Parties produced their respective affidavits and documents in support and to prove their respective claims/counter claims etc. The counsel for the complainant tendered into evidence affidavit of the complainant Ex.C1 duly deposing the pleadings/averments and the evidence produced on his behalf; along with the other documents exhibited here as: Ex.C2 to Ex.C15. On the other hand, the OP1 insurers tendered into evidence the affidavit Ex.OP1/1 of its Divisional Manager Tarsem Lal duly deposing the objections raised and the evidence produced etc; and other documents exhibited as: Ex.OP1/2 to Ex.OP1/3 to prosecute the defense. Similarly, the OP3 Bank filed its affidavit Ex.OP3/1 of Ravinder Kaul Manager and Ex.OP3/2 the statement of account of the related Bank account to support its defense. We have examined all the documents/ evidence produced on record and have also duly considered and perused the arguments duly put forth by the learned counsels of both the sides, while adjudicating the present complaint.
5. We observe with the judicial precision (that the majesty of constitutional justice bestows upon the Indian Court) that the OP1 insurers here have suo-moto pleaded (and vocally though with somewhat latent guilt, too in the 4th paragraph of the written version & also through the affidavit Ex.OP1/1) that, … there was a gap of 38 days in the renewal of the previous policy no. 401208 /48/11 /8500001121 with the current policy and as such the policy of the complainant cannot be considered in continuity with the previous policy and as such the claim of the complainant is not payable as per the terms …….”. However, the OP1 insurers have somehow conspicuously abstained from stamping/ labeling the applicable Policy as the ‘fresh- one’. And, that tells the complete story. The OP1 insurers have indeed renewed/ issued the Policy in question (in renewal) to the continuing Policies (with the first one issued on 19.01.2010 and valid up to 18.01.2011) but with a gap of 38 days i.e., 08 days after the end of 30-day grace-period and the same understanding/ perception was passed on/ carried out to the complainant and the Policy was never treated as ‘fresh-Policy’ by them; till the time the OP2 TPA (third party administrator), advising on the Policy claim treated it as the ‘fresh policy’. But, the contract of insurance being between the complainant and the OP1 insurers; the inception-concept of ‘Policy-renewal with 38-days Gap’ shall prevail for all purposes. The advice/ ruling of the OP2 TPA shall be confined to the ‘technical’ matters pertaining to ‘classification/ exclusions & other-like issues’ only and not on the ‘Policy-issuance’ basic matters (i.e., renewal and/ or fresh etc) that shall be based upon the terms of ‘issuance’ of the Policy and in which the TPA agency has no role to play. And, thus the issue gets adjudicated classifying the Policy in question as a ‘continuing renewed Policy’ entitling the assured Complainant of all its benefits available in its 4th year of continuity; of course the cover being not available for the intervening 38-days gap period.   
6. In the light of the all above, we hold the OP insurers’ claim repudiation-decision as arbitrary, and thus ORDER them to settle and pay to the complainant the full insurance-claim amount as eligible under the extant terms of the Policy (in its 4th year of continuity), besides to pay him Rs.3,000/- as compensation and Rs.2,000/- as cost of litigation; within 30 days of receipt of the copy of these orders, otherwise the aggregate awarded amount shall become payable with interest @ 9% PA form the date of filing of the complaint till actually paid.
7. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.

                                                                                           (Naveen Puri)

                                                                                                    President.                                                                                                             

ANNOUNCED:              (G.B.S.Bhullar)                (Jagdeep Kaur)

Feb. 11, 2015                               Member.                       Member.

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