THIRUVANANTHAPURAM: The State Consumer Disputes Redressal Commission (SCDRC) has rapped Bajaj Allianz General Insurance Co. Ltd. and its Third Party Agent (TPA) for rejecting the claims by an elderly couple. The commission severely criticised the TPA for going beyond its intended role and directly rejecting the claims.
The complainants were a retired employee of the Steel Authority of India Limited (SAIL) and her husband. They were covered by a group medi-claim insurance policy for retired employees of SAIL issued by Bajaj Allianz for a premium of Rs 4,597. The respondents were E-Meditek (TPA) Services and Bajaj Allianz.
The complainants had undergone IP treatment at Amrita Ayurveda Hospital in Kollam. The husband was treated from 19.07.2013 to 05.08.2013 and paid a bill for Rs 23,256 as bill. The woman sought treatment from 12.08.2013 to 02.09.2013 for Rs 35,907. The TPA repudiated their claims on the ground that they were admitted for diagnostic purposes alone.
The Ernakulam District CDRC had earlier rejected the couple’s petition approving the respondents’ claim that it did not have territorial jurisdiction. According to the respondents, the treatment was availed in Kollam, the couple was residing in Alappuzha, and the insurer’s headquarters was in Pune.
The State Commission’s order came on an appeal petition filed by the couple. It was heard by a bench comprising Justice K Surendra Mohan, president, Ajith Kumar D, judicial member and Radhakrishnan K R, member.
Besides the jurisdictional issue, the respondents argued before the SCDRC that the claims were not payable as per an exclusion clause which read: “Charges incurred at hospital or nursing home primarily for diagnostic, X-ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a hospital/nursing home.”
The commission’s order said the clause was to “exclude those charges/inpatient claims relating to diagnostic/investigative procedures alone.” “Expenses for diagnostic procedures are also admissible if there is any positive existence of illness which requires hospitalisation. The respondents have conveniently taken or rather omitted a portion of the clause for justifying the repudiation of the claims,” it said. The district commission had jurisdiction since the TPA’s office was in Kochi, it said.
The order slammed the insurance company for leaving claims to the "whims and fancies of TPAs." Repudiation of claims should be done by the insurer only as per IRDAI regulations. TPAs are only facilitators and they cannot go beyond their role by directly rejecting the claims.
The commission directed both the respondents to reimburse the bill amounts of the couple with 8 pc interest from the date of filing of the complaint. They were also directed to pay Rs 10,000 as compensation and Rs 15,000 as costs to each petitioner.