Complainant Alakh Niranjan Prasad filed this case for claim of Rs. 29,701/- and compensation of Rs. 25,000/- for mental harassment and litigation cost of Rs. 10,000/-.

2          The case of the complainant in short is that he is a retired SAIL employee and has taken mediclaim scheme of SAIL, as member on payment of premium having MIN No. 4738145. Mediclaim scheme is covered through Group Mediclaim Policy of the insurance company for the year 2014.

            Complainant was admitted in Yashoda Hospital Secunderabad from 06.05.2014 to 09.05.2014 having complaint of breathlessness on exertion associated with heaviness and giddiness. On admission complainant informed the O.P. E-Meditek and claim was registered as Claim No. 100051403514 and asked for certain documents. During the treatment, the doctor conducted C.T. Scan, Angiography and other tests and finally diagnosed “Stable Angina”.

            After discharge, complainant has submitted the claim of Rs. 29,701/- with duly filled claim form along with other documents to O.P. E-Meditek on 28.05.2014, but the claim of the complainant has been repudiated on the ground of exclusion clause 6 (vi) of terms and conditions and C.T. Coronary Angiography is not payable .

            Complainant has also filed on line grievance to O.P. E-Meditek but no reply is received.

            Hence this complaint is filed as deficiency in service.

3          Complainant has filed following documents in support:-

Anx-1 Copy of Provisional Discharge Summary.

Anx-2 Copies of Investigation reports

Anx-3 to 3/2 Copies of deposit voucher and invoice and OPD fee

Receipt.

Anx-4 Copy of claim registration and demand of documents.

Anx-5 to 5/1 Copies of claim form and receipt by O.P. E-Meditek.

Anx-6 Copy of Repudiation letter.

Anx-7Copy of online complaint.

4          O.P. No.1 E-Meditek appeared and filed W.S. and has submitted that this O.P. is merely a Third Party Administrator and only processed the claim settlement for insurance co. as per their guideline and the liabilities for re-imbursement is on the insurance co. and therefore, not liable being agent of the insurance co.

5          O.P. No.2 M/s National Insurance Co. Ltd. appeared and filed W.S.

            It is submitted that complaint is not maintainable as the complainant is not a consumer and has suppressed the material facts.

            It is submitted that the claim has rightly been repudiated as per clause 6 (vi) of the terms and conditions and there is no deficiency in service.

            O.P. No.2 filed copy of Repudiation letter Anx-A (Anx-6 of the complainant) and Anx-B copies of terms and conditions.

                                                             F  I N D I N G S

6          On perusal of the complaint, we hold that complainant is a consumer as being beneficiary under Group Mediclaim Scheme of SAIL on payment of premium for the policy which is not denied by the O.P. insurance Co.

7          We perused the Anx-6 (Anx-A) Repudiation letter of the claim and referred clause 6 (vi) of the terms and conditions.

            Clause 6 (vi) referred as- “ The hospitalization   charges in which Radiological/Laboratory investigations/other diagnostic studies have been carried out which are not consistent with or incidental to the diagnosis of treatment of positive existence or presence of any ailment, sickness or injury for which confinement at any hospital/Nursing Home has taken place”.

            From the facts and Anx-1 and Anx-2, we are of the view that without any investigation, a doctor cannot give a definite opinion whether the result is Negative or Positive. The clause 6 (vi) is against the principle of Natural Justice because what test is required or not, it is upto the doctor to decide, not the patient. As regards whether any hospitalization is necessary or not for more than one day, it is the duty of the doctor to decide. Therefore, we cannot accept the ground taken for repudiation of the claim and as such we see deficiency in service on the part of O.P. No.2 and liable to pay the claim of the complainant.

8          Thus, we allow the claim of the complainant and we direct the O.P. M/s National Insurance Co. Ltd. to pay Rs. 29,701/- (Rs. Twenty nine thousand seven hundred one) only within 60 days of this order and the further direct to pay Rs. 2000/- (Rs. Two thousand) only as compensation and Rs. 1000/- (Rs. One thousand) only as litigation cost, failing which 8% (eight percent) interest shall be payable on the main claim till realization.