1.       The complainant in order to extend medical benefits in general to all its retired employees under a Mediclaim Scheme 2014 invited bids, for which Request For Quotation (RFQ) was floated.  The terms and conditions while inviting the bids were unambiguously framed giving the period of coverage from 01.01.2014 to 31.12.2014, followed by a right to the complainant to extend the same for a further period of 3 months upto 31.03.2015 on the same terms and conditions.  This request was published on 14.11.2013 and the ultimate bid of the opposite party/National Insurance Co. Ltd. was accepted about which there is no dispute.  The relevant Clause of the RFQ on the basis whereof the contract was finalized and accepted is extracted hereunder:

“The contract period of the intended scheme viz. the SAIL Mediclaim Scheme-2014 will be one year. The scheme shall come into effect from 01.01.2014 (0000 Hrs IST) and remain valid upto 31.12.2014 (2400 Hrs. IST). SAIL, however, reserves the right to extend the contract for a further period of 3-months up to 31.03.2015 (2400 Hrs. IST) on the same terms and conditions within the contract period.”

2.       The terms and conditions under Clause-5 give a look out period to a bidder for a clarification of the RFQ.  The same is extracted hereunder:

“5.0 Clarification of RFQ: A prospective Bidder requiring any clarification of the RFQ may notify SAIL in writing or by fax / email at SAIL's mailing address indicated in the RFQ. SAIL will respond in writing or by fax / email to any request for clarification of the RFQ which it receives not later than five (5) days prior to the deadline for the submission of bids prescribed by SAIL.”

3.       A bidder intending to deviate from any of the terms was required to specify the same, if any, under Clause-12 which is extracted hereunder:

“12.0 Statement of Deviations:

12.1   Bids are solicited in conformity with the terms and conditions, without any deviations. However, if any Bidder is unable to accept any particular term or condition as incorporated in the RFQ, or proposes any deviation therefrom, the Bidder shall enclose alongwith his offer, a Statement of Deviations as per Annexure VIII, clearly spelling out the deviations proposed, which will be evaluated in accordance with provisions of RFQ Acceptance/Rejection of the deviations, if any, proposed by the Bidder(s), shall be at the sole discretion of SAIL.

12.2   The Bidder shall submit his Bid confirming his acceptance to all the terms and conditions of this Tender Documents, except for the deviations specifically proposed by him in his Bid. All the pages of this Bidding Document, duly signed by the Bidder, should be submitted alongwith the Bid, as a token of acceptance of SAIL's terms and conditions.”

4.       Clause-18 authorises the bidder for modification and withdrawal, if any, but before the deadline fixed for submission of bids.

5.       Since there was no request for any clarification or modification by the opposite party/Insurance Company, the letter of acceptance was executed and finalized in terms of Clause-23. 

6.       The premium payment terms in Clause-33 provide for 100% premium to be paid on equated monthly basis and the last premium/instalment was to be adjusted on the basis of final number of members expected for the year 2014. 

7.       Clause-39 specifically provides the contract period which is extracted hereunder:

“39.0 CONTRACT PERIOD: The contract period of the intended scheme viz. the SAIL Mediclaim Scheme 2014 will be one year. The scheme shall come into effect from 01.01.2014 (0000 Hrs. IST) and remain valid upto 31.12.2014 (2400 Hrs. IST). SAIL, however, reserves the right to extend the contract for a further period of 3- months upto 31.03.2015 (2400 Hrs. IST) on the same terms and conditions & premium, within the contract period.”

8.       The policy coverage provides for under Clause-40(b) that is relevant for the present controversy.  The same is extracted hereunder:

“40.0 POLICY COVERAGE

b.       The policy covers reimbursement of Hospitalization and also Cashless Facility and/or Out Patient Department (OPD) expenses within the prescribed limits under the policy for illness/diseases contracted or injury/sustained by the insured person. In the event of any claim becoming admissible under the policy, the Insurance Company will pay to the insured member (Reimbursement)/Hospital (For Cashless Treatment), the amount of such expenses as reasonably and necessarily incurred anywhere in India. For the purpose of SAIL Mediclaim Scheme, the ex-employee and his/her spouse, to be treated as two distinct members.

• IPD (Hospitalization) Benefits: Rs. 2 Lakhs per member per policy period with clubbing (floater) facility under hospitalization with his/her spouse which means that hospitalization benefit of Rs. 2 Lakhs per member can be clubbed between the Mediclaim members & their spouses (max clubbed limit Rs. 4 Lakhs per policy period).

• OPD Benefits:

• Rs.4,000/- per member, for members below 70 yrs of age as on 31.12.2013.
• Rs.8,000/- per member, for members aged 70 yrs or above, as on 31.12.2013.

Note Persons completing 70 years of age on 01.01.2014 will also be considered for enhanced OPD. Unlike IPD facility, the OPD facility cannot be clubbed between the ex-employee and his/her spouse.”

9.       The claim settlements are to be made through the Third Party Administrator (TPA) who was appointed for the said purpose.

10.     Since the present dispute relates only to the OPD benefit part, Clause-43 is extracted hereunder:

“43.0 OPD BENEFIT

43.1   Under no circumstances, the clubbing (Floater basis) of individual OPD limits of Rs.4,000/- or Rs.8,000/- (as the case may be) per head per policy period, will be permitted.

43.2   OPD treatment if availed in SAIL Plant Hospitals, the members are not required to pay any expenses. SAIL Plant Hospitals, will make claims with the Insurance Co. for any Treatment given to the member.

43.3   Dental Treatment can also be availed of within the existing limit of Rs.4000/- per member for the policy under OPD treatment. Cost of dentures will not be reimbursed.

43.4   Preventive Health Check-ups and Ophthalmic consultations for refractory error will be covered under OPD Benefits only.

43.5   Cost of spectacles/contact lenses shall not be reimbursed.

43.6   OPD Claims to be submitted by the Mediclaim member, to the Insurance company/TPA when the expenses exceed Rs.2000/- per person per policy period or within 90 days from the date of completion of the treatment, whichever is earlier.

43.7   In case of treatment of ear, cost of hearing aid is not reimbursable.”

11.     The mediclaims are required to be intimated to the agency appointed by the Insurance Company, namely, the Third Party Administrator (TPA).  The claims and the rates for each type of problems are also given in detail together with the exclusions in respect thereof.  The complainant had also a contract with the TPA that was to coordinate with the Insurance Company in order to process the claims thereafter.

12.     The Insurance Company has alleged that the complainant by giving incorrect particulars floated fresh invitations for offers when bids were invited for SAIL Mediclaim Scheme 2015 for the period from 01.01.2015 to 31.12.2015.  The allegation of the Insurance Company is that for obvious ulterior reasons no bids were accepted by the complainant inspite of responses to the notice inviting tenders and they did not proceed further for award of a fresh contract for the year 2015.

13.     On 31.12.2014 the complainant dispatched a letter to the opposite party/Insurance Company exercising its option of extension under the contract for the year 2014 for continuing the insurance coverage from 01.01.2015 to 31.03.2015.  This intimation obviously was keeping in view the terms and conditions as agreed upon and referred to hereinabove.

14.     The Insurance Company states that the SAIL authorities were called for negotiations and meetings were held, including one meeting on 21.01.2015 at the SAIL Corporate Office that was attended by the senior representatives of the Insurance Company, M/s E-Meditek, the TPA, as well as the officials of SAIL.  This fact is also included in the written submissions on behalf of the complainant.  However, there is nothing on record to indicate any consensus having been arrived at and it is urged by the learned counsel for the complainant that the Insurance Company was called upon to continue the policy with the extension of full coverage of IPD and OPD. 

15.     It appears from the record that the letter of extension was sent on 31.12.2014 which is as follows:-

“STEEL AUTHORITY OF INDIA LIMITED

No.PER/ITB & Med./Mediclaim/2015

31st December, 2014

M/s. National Insurance Co. Ltd.

Division No. XII: 3rd Floor, 6/90

Padam Singh Road

Karol Bagh

New Delhi-110005

Sub:   Extension of Work Order to operate SAIL Mediclaim Scheme from 1st January, 2015 to 31st March, 2015

Ref:    RFQ No. SAIL/Pers/ITB & Med/Mediclaim/2014 dated 14th Nov, 2013 and Work Order no. SAIL/Pers/ITB & Med/Mediclaim/2014 dated 19th Dec, 2013.

Dear Sir/Ma'am,

This has reference to the aforementioned Work Order awarded to M/s. National Insurance Co. Ltd. (NIC) to operate SAIL Mediclaim Scheme.

While exercising the powers reserved with SAIL, we are pleased to hereby extend the aforementioned contract with M/s. National Insurance Co. Ltd. for a further period of 3 months w.e.f. 01.01.2015 to 31.03.2015 (2400 hrs IST), to operate SAIL Mediclaim Scheme as per the terms and conditions of the existing contract (refer clause no.1 of the aforementioned Work Order and clause no.4 & 39 of the aforementioned RFQ).

It is relevant to mention that the following terms shall inter-alia be applicable to operation of SAIL Mediclaim Scheme during 01.01.2015 to 31.03.2015:

i.        IPD coverage - Rs. 2 lakhs per member with clubbing facility between the Mediclaim members and their spouses (maximum clubbed limit Rs. 4 lakhs).

ii.       OPD coverage -

• Rs.4,000/- per member for members aged below 70 years.

• Rs.8,000/- per member for members aged 70 years and above.

iii.      Other terms and conditions including cappings on implants/IOL/room rent/procedures, exclusions, payment details etc. shall be as per RFQ no. SAIL/Pers/ITB& Med./Mediclaim/2014 dated 14th Nov, 2013 and Work Order dated 19th Dec, 2013.

iv.      The following monthly premium inclusive of Service Tax on provisional membership basis (1,05,000 members), will be paid and reconciled at the end of the contract period on the basis of actual number of members covered under the Scheme during the period (1st Jan, 2015 to 31st March, 2015):-

• January 2015 - Rs.7.27 Cr.

• February 2015 Rs.7.27 Cr.

• The premium instalment for March 2015 will be adjusted on the basis of final number of members, expected during the period (1st Jan, 2015 to 31st March, 2015).

V.       The premium is inclusive of applicable taxes, duties and charges incurred, if any, including the charges towards Third Party Administrator (TPA), for servicing the policy/Contract.

vi.      The premium payment with respect to fresh enrolments during the aforesaid period (retiring employees and their spouses, during the pendency of the contract), would be paid on a pro- rata basis in addition to the premium mentioned at para iv) above; however, full coverage/benefits will be extended to the superannuating employees and their spouses.

In view of the above, you are requested to kindly take immediate necessary action in this regard.

Kindly acknowledge receipt.

Thanking you,

Yours faithfully

For Steel Authority of India Ltd.

Sd/-

Vaani Kapoor

AGM (Pers.-ITB & Med.)

XXX              XXX              XXX”

16.     The Insurance Company on 05.02.2015 sent a communication by mail whereby it agreed to the extension of the coverage upto 31.03.2015 with the full sum insured for the IPD facilities but reduced the sum insured proportionately in respect of OPD facilities.  This is the bone of contention between the parties and is the core question to be answered in this case. 

17.     As quoted above, the OPD facility for persons below 70 years of age was covered upto Rs.4000/- per person and for persons above 70 years of age was Rs.8000/-. This coverage was unilaterally reduced by the Insurance Company to Rs.1000/- in the case of persons below 70 years of age and to Rs.2000/- in the case of persons above 70 years of age.  The contention of the learned counsel for the complainant is that this was a clear violation and the complainant realized the same when it received written information with regard to the disposal of such claims at the reduced rate through the TPA.  Specific instances and documents have been placed on record to that effect.

18.     The aforesaid fact of reduction is not denied by the opposite party/Insurance Company and rather the letter dated 05.02.2015 has been defended.  The said letter is extracted hereunder:

“Extension of Work Order/Contract to operate SAIL Mediclaim Scheme expiring 31.12.2014

Thu, Feb 5, 2015 at 3:13 PM

Vandana@nic.co.in<Vandana@nic.co.in>

To: vaani.kapoor@gmail.com, sail.neerajseth@gmail.com

Cc:LK Aluria@nic.co.in, I.Sharma@nic.co.in,N. Banchur@nic.co.in, Anita Sahai@nic.co.in. verma@emeditek.com. 

sunil.sharma@emeditek.com

Dear Madam,

Please refer to our personal meetings along with telephonic discussion is subsequent to extension of SAIL GMC for a further period of three months, wherein we had requested for confirmation of:

a.       S I both under IPD and OPD during the period of extension of policy from 01.01.2015 - 31.03.2015.

b.       Minimum member enrolment during extension period.

Although we were assured of meeting with SAIL Finance department, but in the absence of the proposed meeting and subsequent tender for the policy 1st April 2015-3103.2016, we have sought clarification from our Corporate office, who have opined that during the extension period the two issues raised above shall be treated as follows:

a.       Full SI for IPD and Proportionate Sl for a period of three months for OPD.

b.       Minimum Lives as on 31.12.2014, i.e. 107656 shall be the basis for premium calculation and any addition/deletion to be covered and adjusted by specific endorsements under the policy.

Therefore, we are proceeding accordingly.

With due regards

Nician VANDANA

Regional Manager

National Insurance Company Limited

Delhi Regional Office-I,

‘Jeevan Bharati’ Tower-II, Level-IV,

124, Connaught Circus, New Delhi-110001

XXX              XXX              XXX”

19.     The complainant therefore immediately responded by intimating the Insurance Company that it should continue to extend services as per the original agreement on the same terms and conditions regarding the OPD facilities upto 31.03.2015.  The letter dated 06.02.2015 is extracted hereunder:

“STEEL AUTHORITY OF INDIA LIMITED

No.PER/ITB & Med./Mediclaim/2015

6th February, 2015

To

M/s. National Insurance Co. Ltd.

Division No. XII: 3rd Floor, 6/90

Padam Singh Road

Karol Bagh

New Delhi-110005

Sub:   Extension of Work Order to operate SAIL Mediclaim Scheme from 1^st January, 2015 to 31^st March, 2015

Dear Madam,

This has reference to the aforementioned Work Order awarded to M / s National Insurance Co. Ltd. (NIC) to operate SAIL Mediclaim scheme and your e-mail dated 5th February, 2015, in this regard.

2.       As you are aware, SAIL, vide its letter of even number dated 31st December, 2014 had extended the contract to operate SAIL Mediclaim Scheme with M / s National Insurance Co. Ltd. for a further period of 3 months w.e.f. 1st January, 2015 to 31st March, 2015 (2400 hrs. IST), as per terms and conditions mentioned in the referred Work Order and RFQ.

3.       Further to our telephone discussions on various occasions and meetings held prior to and after extension of Work contract, it is reiterated that the following terms shall inter-alia be applicable to operation of SAIL Mediclaim Scheme during the extended period:

i.        IPD Coverage Rs.2 lakhs per member with clubbing facility between the members and their spouses (maximum clubbed limit Rs. 4 lakhs).

ii.       OPD Coverage Rs.4,000/- per member for members below aged 70 years and Rs.8,000/ per member for members aged 70 years and above.

iii.      Other terms and conditions including cappings on implants/IOL/room rent/procedures, exclusions, payment details etc. shall be as per RFQ No. SAIL/Pers/ ITB & Med./Mediclaim / 2014 dated 14^th November, 2013 and Work Order dated 19th December, 2013.

4. We would also like to reiterate the following:

i.        The extending of the policy period for the period 1st January 31^st March, 2015, is totally in accordance and compliance with the terms and conditions of the RFQ and cannot be altered under any circumstances.

ii.       The premium being paid for the extended period is also based on the total membership enrolled under the scheme less the number of members, who died or discontinued during the period ending 31.12.2014. In this context it may be mentioned, that in case there is any discrepancy in premium pay-out, the same will be reconciled as soon as the final count of membership is established.

iii.      The issue of proportionate sum-insured w.r.t. OPD also cannot arise, as the premium paid is for 3 months' full coverage.

5.       In view of the above, it is being made abundantly clear that total coverage as elaborated at (3) above, may be provided to the members of SAIL, Mediclaim Scheme during the period 1st January 31st March, 2015, as per terms and conditions of RFQ for SAIL Mediclaim Scheme - 2014. 

With regards.

Yours sincerely

For Steel Authority of India Ltd.

Sd/-

6.2.15

(Vaani Kapoor)

AGM (P-ITB & Med.)”

20.     Learned counsel for the complainant has urged that since the quantification and the reimbursement was being implemented contrary to the terms of the contract, this being a deficiency, the present complaint was filed and the entire description of the incorrect reimbursement has been accounted for through the documents filed with the complaint.  

21.     It is urged that the calculations are based on the documents made available from the TPA who is the own agent of the opposite party/Insurance Company and the learned counsel has invited the attention of the Bench that the claim of Rs.2.69 Crores is based on the claim report furnished by the TPA operating the Scheme.  He therefore submits that the contention raised by the Insurance Company that the details are not founded on any documents or are not genuine claims is absolutely incorrect.  It is urged that no documents have been filed by the Insurance Company to contradict or dispute the calculations made.  The documents are in possession of the opposite party, inasmuch as the TPA was their own agency and was maintaining all such records.  Learned counsel urged that an adverse inference should be drawn against the Insurance Company which has failed to bring on record the documents which are in their possession to dispute the calculations submitted on behalf of the complainant.  It is urged that the total claim which was made was for Rs.7.20 Crores against which the TPA after scrutiny had recommended the payment for Rs.4.51 Crores but the same was reduced on account of the illegal unilateral reduction in the rates applied by the Insurance Company.  It is for this reason that the complaint has been raised for the realization of Rs.2.69 Crores as the payments have been made on the reduced rates as per the own documents of the opposite party.  It is this deficiency which has been claimed and it arises out of the calculations available with the TPA and the Insurance Company with whom all the documents are available.

22.     Responding to the submissions, Mr. Yogesh Malhotra, learned counsel for the opposite party/Insurance Company, urged that the policy is only for one year and the extended period was accepted by the Insurance Company by agreeing to reimburse the IPD claims in the interest of the employees looking to the emergencies of hospitalization on the same rates as per the contract, but it was made clear to the complainant in the meeting held on 21.01.2015 that reimbursement of OPD claims would be reduced as the claim rate had to be taken into account that was vitally affecting the business of the Insurance Company. He also submitted that the Insurance Company had been reimbursing the claims upto 169% of the premium received and therefore it cannot be said that the Insurance Company had not lived upto the expectations as per the contract.  He has urged that there has been no violation of the terms and conditions nor is there any deficiency in service and has cited the judgment of the Apex Court in the case of National Insurance Co. Ltd. Vs. Seema Malhotra and Ors. (2001) 3 SCC 151 to emphasise on what was indicated in paragraph-8 of the aforesaid judgment that is extracted hereunder:

“8.     The direction that the Insurance Company can now deduct the premium amount from the compensation to be fixed is no solace to the insurer. The essence of the insurance business is the coverage of the risk by undertaking to indemnify the insured against loss or damage. They agree to pay the damages arising out of any accident by taking a chance that no accident might happen. Motivation of the insurance business is that the premium would turn to be the profit of the business in case no damage occurs. Such business of the insurance company can be carried on only with the premium paid by the insured persons on the insurance policy. The only profit, if at all the insurance company makes, of the insurance business is the premium paid when no accident or damage occurs. But to ask the insurance company to bear the entire loss or damages of somebody else without the company receiving a pie towards premium is contrary to the principles of equity, though the insurance companies are made liable to third parties on account of statutory compulsions due to the initial agreement, entered between the insured and the company concerned.”

23.     He contends that the insurance business is not for profiteering but only to indemnify genuine losses and bonafide claimants and is not meant to enrich or extend profit making to claimants.  He has submitted orally that when such situations occur beneficiaries tend to seek double benefits, one from the company during the extension period and then again when any subsequent arrangements are made.

24.     He has then urged that in effect the complainant is seeking benefits through this complaint to which it is not entitled.         

25.     Learned counsel for the complainant in rejoinder submitted that the complaint has been refuted in the written version and the argument of the opposite party is that the complaint is not maintainable on the ground that this is a commercial venture of the complainant.  He submits that in view of the judgment of the Apex Court in the case of National Insurance Co. Ltd. Vs. Harsolia Motors and Ors. (2023) 8 SCC 362 the business of insurance has been held to be governed by the law of contracts of indemnity, inasmuch as an Insurance Company seeks to indemnify, and this undertaking is fulfilled which does not amount to a commercial venture.

26.     Having considered the submissions raised, the first issue with regard to the maintainability on the facts of the present case needs to be answered.  It is undisputed that the complainant (Steel Authority of India) for the benefit of its retired employees floated this Scheme which is not for its benefit or profit.  The sole purpose of such a provision is to comfort the retired employees and reimburse them to a certain extent while availing medical facilities which is neither for any profit nor for the benefit of the complainant.  It is a help and also a recognition of the devoted services rendered by employees to tide away their financial concerns in times of medical need.  In the opinion of this Commission, the complaint therefore in view of the law laid down in the case of National Insurance Co. Ltd. Vs. Harsolia Motors (Supra) is maintainable as observed in paragraphs 42 to 46 which are extracted hereunder:

“42. Thus, what is finally culled out is that each case has to be examined on its own facts and circumstances and what is to be examined is whether any activity or transaction is for commercial purpose to generate profits and there cannot be a straitjacket formula which can be adopted and every case has to be examined on the broad principles which have been laid down by this Court, of which detailed discussion has been made.

43. Applying the above principles in the present case, what needs to be determined is whether the insurance service had a close and direct nexus with the profit generating activity and whether the dominant intention or dominant purpose of the transaction was to facilitate some kind of profit generation for the insured or to the beneficiary and our answer is in the negative and accordingly we are of the view that the complaint filed by the respondent insured herein has no close or direct nexus with the profit generating activity and the claim of insurance is to indemnify the loss which the respondent insured had suffered and the Commission has rightly held that the respondent is a “consumer” under Section 2(1)(d) of the 1986 Act.

44. We further reiterate that ordinarily the nature of the insurance contract is always to indemnify the losses. Insurance contracts are contracts of indemnity whereby one undertakes to indemnify another against loss/damage or liability arising from an unknown or contingent event and is applicable only to some contingency or act likely to come in future.

45. This Court in United India Insurance Co. Ltd. v. Levis Strauss (India) (P) Ltd. [United India Insurance Co. Ltd. v. Levis Strauss (India) (P) Ltd., (2022) 6 SCC 1 : (2022) 3 SCC (Civ) 465] has held as under : (SCC p. 29, para 53)

“53. A contract of insurance is and always continues to be one for indemnity of the defined loss, no more no less. In the case of specific risks, such as those arising from loss due to fire, etc. the insured cannot profit and take advantage by double insurance. Long ago, Brett, LJ in Castellain v. Preston [Castellain v. Preston, (1883) LR 11 QBD 380 (CA)] said that : (QBD p. 386)

‘… the contract of insurance.… is a contract of indemnity,… and that this contract means that the assured, in case of a loss.… shall be fully indemnified, but shall never be more than fully indemnified.’ ”

(emphasis supplied)

46. Thus, it can be concluded that in the instant case hiring of insurance policy is clearly an act for indemnifying a risk of loss/damages and there is no element of profit generation and still what has been expressed by this Court is illustrative; it will always be open to be examined on the facts of each case, as to the transaction in reference to which the claim has been raised has any close and direct nexus with profit generating activity.”

27.     The second issue is the core of the submissions regarding the deficiency alleged against the Insurance Company by unilaterally reducing the rate of OPD reimbursements.  Learned counsel for the Insurance Company very fairly stated that there is no document on record to substantiate the outcome of the meeting on 21.01.2015 so as to demonstrate any acceptance by the complainant for the terms and conditions of a reduced rate of reimbursement for OPD facilities.  To the contrary, the proposal of reduction was vehemently resisted by the complainant after having received the communication from the Insurance Company on 05.02.2015.  This rejection of the reduction imposed by the Insurance Company was clearly spelt out in the reply of the complainant dated 06.02.2015, quoted hereinabove.

28.     The contract concluded with the terms spelt out in the bid documents offered by the opposite party/Insurance Company, for which neither any deviation or clarification or modification was sought during the bid proceedings or even thereafter.  It is only when the complainant intimated the opposite party of exercising its option of extension upto 31.03.2015 that the opposite party woke up to resist the same unilaterally.  The intimation by the opposite party through the letter dated 05.02.2015 for the proportionate reduction of the sum insured for the OPD facilities during the extended period was an entirely unilateral act of the Insurance Company, contrary to the terms and conditions of the tender bids that were accepted with which both the parties were bound.  The Insurance Company could not have altered the rates of OPD facilities for the extended period of 3 months which had been agreed upon to be on the same terms and conditions as disclosed in the acceptance of the contract.  The Insurance Company therefore was unjustified in reducing the said rate which amounts to a clear deficiency in service by the imposition of a reduced rate for OPD reimbursements unfairly. 

29.     Coming to the second contention with regard to the allegations of the learned counsel for the Insurance Company on the calculations submitted by the complainant and filed as annexure P-8, learned counsel for the Insurance Company critically analysed the calculations on the ground that the headings given in the said chart and the figures indicated below them do not make out any sense and therefore the calculations cannot be relied upon and the quantification of Rs.2.69 Crores is imaginary. 

30.     This calculation sheet is stated by the complainant to have been obtained from the data of M/s E-Meditek who were the TPA through whom the claims were to be negotiated as they were the agents of the Insurance Company.  The said calculations therefore ought to have been contradicted by the opposite party/Insurance Company by bringing on record any evidence which they could have produced.  The contention of the learned counsel for the Insurance Company that the said calculations are not supported by any bills, vouchers or any other documents is an argument which cannot be accepted, inasmuch as all such claims, including the bills and vouchers in respect thereof had to be routed through the TPA which appears to have been done as the TPA has given its calculations to the Insurance Company as against the claim set up by the complainant.  The TPA had advised the payment only for Rs.5.70 Crores but the Insurance Company further reduced it as a result whereof only Rs.3.01 Crores were paid and the balance of Rs.2.69 Crores had been withheld by the Insurance Company.  If the Insurance Company had any doubt about the calculations made by the TPA after the claim had been submitted by the complainant company, then in that event it was for the Insurance Company to establish that the calculations given by the TPA or by the complainant were incorrect.  No such material has been brought-forth before this Commission by the Insurance Company except questioning the correctness of the data filed by the complainant.  This denial and submission therefore cannot be countenanced as the aforesaid facts are reflected in the affidavit by way of evidence on behalf of the opposite party themselves in paragraph-21 as follows:

“21.    That I state that for the period from 01.01.2015 to 31.03.2015, a total number of 51049 OPD claims were received by the TPA which were considered by the TPA and out of such OPD claims 40312 had been settled. It is manifest that the maximum benefit of OPD claims have been sought during the period 01.01.2015 to 31.03.2015. It is the case of the complainant that large number of members under the scheme had raised OPD claims with the TPA. I deny that the said claims under OPD coverage comes to Rs.5.7 crores, as alleged by the complainant or that the TPA has recommended only Rs.3.01 crores payment to the members, as alleged. I state that as on 19.08.2015 the respondent company had already paid a sum of Rs.3,76,87,063/- towards OPD claims of the members of the complainant for the relevant period from 01.01.2015 to 31.03.2015 while a further sum of Rs.4,10,478/- was in process. I state that the OPD claim summary Annexure P-8 filed by the complainant claiming a sum of Rs.2.69 crores is totally wrong and false and the same cannot be relied upon. I state that the complainant is put to strict proof of each and every entry made therein.”

31.     Learned counsel for the complainant has urged that the amount referred to in the aforesaid paragraph which has been paid establishes that the details of the claims had been sifted and it is only on the ground of the reduced rates that a sum of Rs.2.69 Crores has been withheld.  There is no error in the calculations and the argument that the claimants are put to strict proof of each and every entry made in the charts appended along with the complaint is an argument in desperation without any document to contradict the claims which could have been placed by the Insurance Company itself.  These charts indicate that the OPD claims were wrongly reviewed by the Insurance Company on their own by unilaterally imposing revised rates of Rs.2000/- and Rs.1000/- respectively as indicated above.  Thus, the argument that the quantum has been erroneously claimed does not stand to reason.  The oral arguments cannot be accepted without there being any evidence led to the contrary.     

32.     Consequently, the complaint is allowed.  Let a sum of Rs.2.69 Crores which has unjustifiably and unauthorizedly been withheld by the Insurance Company be released together with 9% interest thereon with effect from 01.04.2015.