PRESENT

                   Complainant by Adv. Shri. D.S.Manerkar present.                                                         

                  Opponent No. 1 by Adv. Shri.Vijay Manon present.

                   Opponent No.3  Absent.                        

ORDER

(Per- Mr. S. D. MADAKE, Hon’ble President. )

1. The complainant has filed the complaint as per section 12 of the Consumer Protection Act 1986 against Opponents for deficiency in services.
2. The complainant  is member of Unit Trust of India, bearing membership certificate SC9710010001706 and he is registered holder of 2900 as per Senior citizen’s unit plan 1993.
3. The Complainant states that the EECP treatment was taken as per advice of expert doctors and submitted claim on 2/06/2011 along with bills for settlement of medi-claim to the opposite parties.
4. The complainants submitted to opposite party No.2  total claim of Rs. 1,52,229/- but opposite parties paid Rs. 29,483/- and rejected the claim of Rs. 1,22,746/- on 19/08/2011
5. The complainant states  that the opposite party No.2 wrongfully rejected the claim and failed to comply with the terms and condition. It is contended that there are certain responsibility and liabilities of the opposite parties in respect of the SCUP plan.
6.  The complainant prayed for direction to opponents to settle the mediclaim and pay compensation 1, 00,000/- with cost.
7.  The opponent No.1 filed written version and specifically denied all the allegations made in the complaint. It is stated that opponent no. 1 had entered in to a tripartite agreement dated 25/08/1993 with the opposite party no.2 and empaneled hospitals.
8. The opponent no 1 stated that complainant is eligible for medical cover and the main purpose of scheme was to make available the benefit of medical cover to the members after their attaining age of 58 years.
9. The Opponent stated that claim papers received from complainant were sent to opponent no.2 to settle the claim and forward claim cheque at the  earliest. All other  allegations  are denied and prayed for dismissal of the complaint  with cost.

10.    The opponent No.2 filed written version and specifically denied all the allegations made in the complaint. It is submitted that as per the agreement “The NIAC shall not be liable to settle the claims where the hospitalization is for less than 24 hrs.”

11.     The opponent no.2 submitted  that, the liability of opponent no.2 is a contractual liability and based upon the certain express terms and condition between the parties for covering the risk through the Unit Trust of India and the claim is rejected on merits.

12.        The opponent no. 2 submitted  that, neither the pleading of complainant nor the discharge summery of the said hospital reveals the hospitalization of the complainants is for 24 hrs.

13.       The Opponent No.2 stated that all the statements made, which are contrary or inconsistent to what is stated in written version are firmly denied. The complainant is not entitled for any relief claimed  by him. It is prayed, that the complaint  be dismissed with cost.

14.       We have perused the copy of policy, payment receipt  repudiation of claim, letter of complainant to insurance company. complaint, written version,  affidavit and written notes  of  argument.

15.    The documents on record show that treatment EECP was taken during insurance period  We have perused the literature on EECP which is non surgical mechanical procedure consisting of  35 one hour sessions  6 days in a week, over period of 6 weeks.  To achieve desire benefit, it is essential to complete the entire course  of therapy.   

16.     The Opponent has not produced on record any document which shows that Medical Council of India has disproved the said treatment. There are no guidelines given by any cardiology association regarding approval or disapproval of said treatment. The Directorate of the general health services also not disproved the EECP.

17.   As per law, the opponent New India Insurance Company is an instrumentality of Government and falls under the definition of state within the meaning of the Article 12 of the constitution of India. Hence  insurance company has considered the claim of some persons on this ground so this claim will also have to be allowed on the principle of equality.

18.       The District forums in Mumbai allowed similar applications as stated in the complaint.   We have come to the conclusion that EECP treatment is safe and the insurance company is not justified to reject the same on a technical ground that complainant was not hospitalized  for 24 hrs. We therefore allow the claim with interest. The interest is awarded by way of compensation.

19.      The opponent no.1 has submitted the claim to insurance company within reasonable time requesting opponent no.2 to settle at the earliest. We do not find any deficiency on the part of opponent no.1.

20.     In the result, we pass the following order.

                                                O R D E R

1.       RBT Complaint No. 204/2012 is partly allowed.

2.       The New India Insurance Company is directed to pay Rs. 1, 22, 746/- (one lakh twenty two  thousand seven hundred and forty

          six only)to Complainant with interest @ 6 % p.a. from the date of admission of complaint  i.e. 21/06/2012 till payment.

3.       No order as to cost.

4.       Copy of this order be sent to both parties.