Complainant Umesh Prasad has filed this complaint for a claim of Rs. 3,62,504/- 18% interest since 06-08-2015, the date of submission of hospital bill and compensation of Rs. 25,000/-

2          The case of the complainant is that he was covered under the Mediclaim Insurance Policy No. 041100/48/15/41/00000002 having MIN No 04716782.

            Complainant was admitted at Tata Memorial Centre Mumbai on 06-12-2015 for treatment of cancer and discharged on 12-12-2015 and incurred expenditure of Rs. 3,62,504/-. The Claim was submitted on 06-08-2015 in the office of O.P. No.2, E-Meditek Bokaro, but O.P. repudiated the claim on the ground that Robotic Surgery not payable as per policy terms and condition. Several requests were made by the complainant for settlement of the claim but no action was taken by O.P.

            Therefore a legal notice was sent on 07/06/2016 but O.P. has failed to settle the claim. This is deficiency in service, hence this case.

3          Following documents have been filed in support.

Anx-1&1/1 Copy of letters of  E-Meditek 29-12-2015 and 02-02-2016 for demand of documents 

Anx-2- Copy of discharge summary

Anx-3- Copy of Final bill of TMH.

Anx-4- Copy of certificate of break-up of Robotic Surgery Consumables dated 13-02-2016

Anx-5- Copy of letter of repudiation dated 20-02-2016.

Anx-6- Copy of letter of complainant to E-Meditek dated 21-03-2016.

Anx-7- Copy of letter of complainant to Final Settlement Dept. Bokaro Steel Plant dated 28-03-2016.

Anx-8 To 8/2  Copy of sales receipts dated 07-12-2015

Anx-9- Copy of legal notice to E-Meditek dated 06-05-2016.

4          O.P. No.3 United India Insurance Co. Ltd. appeared and filed W.S. it is submitted that this case is not maintainable as there is no cause of action against this O.P. The Policy is admitted for the period 01-04-2015 to 31-03-2016 and O.P. No.3 has given justified and correct reason for repudiation of the claim in connection with important exclusion clause 5:16, Robotic Surgery/ Robotically assisted Surgery, not payable. Therefore there is not at all deficiency in service; hence the complaint is liable to be dismissed.

5          Anx-A- Copy of Policy Certificate for Group Mediclaim Policy and Anx-B- Copy of Policy has been filed by O.P. No.3 in support.

6          O.P. No.1 and O.P. No.2, E-Meditek (TPA) Services Ltd. also appeared and filed W.S. stating therein that this O.P. is only agent of insurance co. to act as Facilitator. There is no contract of insurance between the complainant and this O.P. who is merely a TPA. Therefore this complaint is not maintainable against this O.P. and liable to be dismissed with heavy cost.

            No document is filed by O.P. E-Meditek.

FINDINGS

7          We perused the record. There is no doubt that complainant is the member of Mediclaim Policy of SAIL, paid premium being beneficiary under the scheme, as such he is a consumer and the dispute is consumer dispute.

            The O.Ps have admitted the policy for retired employees and their spouse under the contract of Mediclaim Insurance with SAIL Bokaro.

8          The ground taken by O.Ps for denial of the claim of complainant is highly technical and against the natural justice and O.P. the United India Insurance Co. Ltd. can be held liable for deficiency in service because it is not the choice of the patient to decide, how the operation in such a critical disease can be held taking contemporary procedure or Robotic procedure for the operation. Therefore by mere putting Robotic Surgery in a blanket of exclusion terms and condition without leaving any circumstances to be decided for better treatment given to the patient. This type of exclusions by the Insurance Co. is against the natural justice and cannot be accepted.

            Accordingly we allow the claim of the complainant and we direct the O.P. United India Insurance Co. Ltd. to pay Rs. 3,62,504/- (Three Lac Sixty Two Thousand Five Hundred Four Only) to the complainant with interest of 10% P.A. from the date of repudiation i.e 20-02-2016 till realization.

            O.P. Insurance Co. is further directed to pay compensation of Rs 10,000/-(Ten Thousand Only) for mental harassment and Rs. 3,000/-(Three Thousand) towards litigation cost.

            All the payments must be paid within 60 (Sixty) days  from passing of this order failing which the rate of interest shall be enhanced to 15%  on the main claim Rs. 3,62,504/-, till realization.