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TTK Health Care Services Pvt. Ltd. v/s Y. Lalithamma & Another

    F.A. 1198 of 2008

    Decided On, 27 October 2008

    At, Andhra Pradesh State Consumer Disputes Redressal Commission Hyderabad

    By, MEMBER

    For the Appellant: Ms. Richa Saxena, Advocate, P.I.P. For the Respondents: E. Venugopal Reddy, Advocate.

Judgment Text

D. Appa Rao, President:


1. This is an appeal preferred by opposite party No. 2 against the order of the Distt. Forum, Nellore, directing it to pay Rs. 87,000 with interest @ 6% p.a., together with costs of Rs. 2,000.

2. The case of the complainant is that herself and her husband obtained hospitalization and domiciliary hospitalization benefits policy dated 8.9.2005 for a sum of Rs. 1 lakh each and another policy for Rs. 2 lakh each covering the period from 8.9.2006 to 7.9.2007 from opposite party No. 1 United India Insurance Company Ltd. As per the policy the appellant has to process the claim of the complainant and settle the same and recover it from the Insurance Company. While so, the complainant underwent cataract operation at Agarwal Eye Institute at Chennai on 15.7.2006 incurred an expenditure of Rs. 9,800 towards operation charges, room rent, etc. She claimed the said amount. However, the appellant did not process the claim. Later, she was admitted at MIOT Hospital, Chennai for her left knee replacement. She was operated on 15.3.2007 and discharged from the hospital on 28.3.2007. She incurred an amount of Rs. 1,67,243. Though she sought prior approval for her treatment from the appellant which initially sanctioned an amount of Rs. 1,00,000 through letter dated 12.3.2007 failed to pay the remaining amount. Therefore, she claimed Rs. 87,000 towards medical expenses with interest and costs.

3. Opposite party No. 1 the Insurance Company filed counter admitting that the policies were taken by the complainant. As per the terms of the policies, the appellant has to process the claim of the complainant and settle the claim, and recover from it. In fact, the appellant has processed the claim, paid a sum of Rs. 1 lakh by letter dated12.3.2007. If at all the complainant was entitled to the amount it was from the appellant. It has nothing to do with the payment of balance amount. It would reimburse the amounts paid by the appellant to its policy holders including the claim of the complainant. Therefore, it prayed for dismissal of the complaint.

4. The appellant/opposite party No. 2 did not contest the matter before the Distt. Forum despite service of notice. It was set ex parte.

5. The complainant in proof of her case filed her affidavit evidence and Exs. A1 to A14, discharge summary and bills, etc. Opposite party No. 1 Insurance Company filed Ex. B1 policy schedule mentioning that the complainant and her husband were insured for Rs. 2 lakh each.

6. The Distt. Forum after considering the evidence placed on record opined that having taken the policy for an amount of Rs. 2 lakh and she having spent an amount of Rs. 1,87,000 towards treatment evidenced by discharge summary and bills issued by respective hospitals and the appellant having paid Rs. 1,00,000 directed it to pay Rs. 87,000 with interest @ 6% p.a., together with costs of Rs. 2,000. It has dismissed the complaint against the Insurance Company by observing that the appellant could as well collect the said amount from the Insurance Company after payment of the amount to the complainant.

7. Aggrieved by the said decision the appellant preferred this appeal contending that the Distt. Forum did not appreciate the facts in correct perspective. In fact, it could not contest the matter since the official who received the summons resigned his job, failed to hand over the same to his successor. It was kept in dark. In fact, it would act on the instructions from the Insurance Company, and is accountable to it, for the settlement of the claims. It ‘administers’ the liability of the Insurance Company to settle the claims. The Insurance Company had taken inconsistent stand. The repudiation by it was justified. Therefore, it prayed that the appeal be allowed.

8. It is an undisputed fact that the complainant was covered by the insurance policy to a tune of Rs. 2 lakh covering the period from 8.9.2006 to 7.9.2007 evidenced under medi-claim policy Ex. A14.

9. Ex. B1 policy schedule shows that the mediclaim policy has been renewed from time-to-time right from 8.9.2000. Earlier it was for an amount of Rs. 1 lakh. As per the terms of the policy, the appellant TTK health care services (TPA) processes the claim, settle the amount and recover it from the Insurance Company. The complainant underwent cataract operation on her left eye on 15.7.2006 incurred an amount of Rs. 9,800 vide bills Exs. A3 and A4. During the said period the policy is in subsistence for an amount of Rs. 1 lakh. Again on 15.3.2007 she was operated for replacement of left knee incurred an amount of Rs. 1,65,000 vide in-patient bill Ex. A11. In fact, the very appellant issued an approval letter estimating at Rs. 1 lakh prior to the operation evidenced under Ex. A12. It was undoubtedly a preliminary estimation of the amount. She had incurred Rs. 1,65,000 evidenced under Ex. A11 bill issued by MIOT hospital, Chennai where she underwent treatment. When the complainant submitted her bills, the appellant did not settle. The notices issued by her under Exs. A1 and A2 claiming the amount towards eye operation was not responded. Equally, the claim towards the operation charges for her left knee. On that she filed the complaint. Since she was entitled to the amount in view of the insurance coverage, the Dist. Forum has rightly observed that she was entitled for reimbursement of amount by virtue of terms of the policy Ex. B1. The appellant without contesting it before the Dist. Forum, now for the first time, in the appeal alleging that one of its officers has received the notice, he failed to inform them and, therefore, they could not contest. The affidavit of the officer was not filed. It is not known as to the action that was taken against the erring official, when it came to know the impugned order was passed directing it to pay the amount.

10. It is easy for any person to take such a plea without substantiating the same. For the fault of its officer, the complainant should not be penalized. Even otherwise, the appellant did not allege the ground on which it had repudiated the claim. On the other hand it accuses the Insurance Company by stating that it ought to have engaged an Advocate on its behalf. Except alleging that the repudiation of claim by it was justified, and not in accordance with the terms and conditions of the policy, it did not expatiate the exact condition or term under which it could repudiate. Having admitted that it administers the liability to the Insurance Company to settle the claims, no reason whatsoever was mentioned as to why the claim was rejected.

11. Learned Counsel for the appellant contended that by the date of treatment only an amount of Rs. 1 lakh was liable to be paid. The said policy would come into force one year thereafter. We have perused the terms and conditions of the policy and we do not find any term to that effect. When the insurance policy is covered during the period for which the complainant had taken treatment, necessarily the appellant has to process the claim and in turn submit it to the Insurance Company. When the very Insurance Company pleads that as per the contract, the appellant has to process the claim and settle and recover from it, there is no reason why it did not pay the amount and recover it from the Insurance Company. In para 5 of the counter of the Insurance Company it was categorically stated that, 'In respect of the balance claim made by the complainant, the 2nd opposite party has to process the same and pay compensation to the complainant, if the complainant is

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eligible for the same. The liability of the opposite party is only to reimburse the compensation amounts paid by the 2nd opposite party to its policy holders including the complainant. Thus the opposite party is not a proper and necessary party to this complaint.' 12. It is not as though it did not receive the claim. It has repudiated it. However, it did not give any valid reason. When the Insurance Company was willing to pay the amount, there is no reason why the appellant did not process and settle the amount. This amounts to deficiency in service. We do not see any mis-appreciation of fact or law in this regard. We do not see any merits in the appeal. The appeal is liable to dismissed. 13. In the result the appeal is dismissed with costs computed at Rs. 2,000. Time for compliance four weeks. Appeal dismissed.