State Consumer Disputes Redressal CommissionNew India Assurance Co. Ltd. vs Gurmala Devi & Anr. on 6 September, 2022STATE CONSUMER DISPUTES REDRESSAL COMMISSION,\n         PUNJAB, CHANDIGARH.\n\n                           First Appeal No.513 of 2021\n\n                               Date of institution : 29.12.2021\n                               Reserved On         : 12.08.2022\n                               Date of decision : 06.09.2022\n\nThe New India Assurance Company Ltd., Divisional Office No.5, G.T.\nRoad, Miller Ganj, near Manju Cinema, Ludhiana, through its Senior\nDivisional Manager, now through its duly Constituted Attorney Sh.\nAmrit Pal Singh, Manager.\n                                  ....Appellant/Opposite Party No.1\n                                   Versus\n\n1.     Gurmala Devi w/o Sh. Suresh Gupta, R/o Flat No.305, Basera\n       Heights, South City, Ludhiana.\n                                      ....Respondent/Complainant\n2.     Raksha TPA Pvt. Ltd., SCO 181, Sector 7-C, Chandigarh.\n                                   ....Respondent/Opposite Party No.2\n                         First Appeal underSection 41of the\n                         Consumer Protection Act, 2019 against the\n                         order dated 02.11.2021 passed by the\n                         District Consumer Disputes Redressal\n                         Commission, Ludhiana.\nQuorum:-\n       Hon'ble Mrs. Justice Daya Chaudhary, President\n                 Mrs. Urvashi Agnihotri, Member.1) Whether Reporters of the Newspapers\n         may be allowed to see the Judgment?         Yes/No2) To be referred to the Reporters or not?      Yes/No3) Whether judgment should be reported\n        in the Digest?                               Yes/No\n\nPresent:-For the appellant       :   Sh. Paul S. Saini, Advocate\n       For respondent No.1 :       Sh. Chandan Deep Singh, Advocate\n       For respondent No.2 :       None.First Appeal No.513 of 2021                                            2JUSTICE DAYA CHAUDHARY, PRESIDENT\n\n             Appellant/opposite   party   No.1   i.e.   The   New   India\n\nAssurance Company Limited has approached this Commission by way\n\nof filing the present appeal underSection 41of the Consumer\n\nProtection Act, 2019 against the order dated 02.11.2021 passed by the\n\nDistrict Consumer Disputes Redressal Commission, Ludhiana (in\n\nshort, "the District Commission") in CC No.567 of 2013, whereby the\n\ncomplaint filed by the respondent/complainant namely Gurmala Devi\n\nwas allowed by directing the opposite parties to consider and pay four\n\nclaims i.e. ₹1,12,857/- (₹24,523/-, ₹30,053/-, ₹26,838/- and ₹31,443/-)\n\nto respondent No.1/complainant stating to be in accordance with the\n\nterms and conditions of the policy along with interest at the rate of\n\n6.5% per annum from the date of filing of the complaint till its payment.The opposite parties were also directed to pay compensation of\n\n₹5,000/- to the complainant. The compliance of the order was to be\n\nmade within a period of 40 days from the date of receipt of copy of the\n\norder.2.           It would be apposite to mention here that hereinafter the\n\nparties will be referred as have been arrayed before the District\n\nCommission.3.           Briefly, the facts of the case as made out by the\n\nrespondent/complainant before the District Commission are that he\n\npurchased a 'Hospitalization & Domiciliary Hospital Benefit Policy' fromFirst Appeal No.513 of 2021                                             3the appellant/opposite party No.1 for the first time on 12.05.2008. Said\n\npolicy was renewed by the opposite party No.1 on payment of\n\npremium. Thereafter, again the policy was renewed from 09.06.2010\n\nto 08.06.2011 after examination of the complainant by the doctors of\n\nopposite party No.1 as per medical report dated 02.06.2010. The\n\npolicy was further renewed from 09.06.2011 to 08.06.2012. It has\n\nfurther been mentioned in the complaint that the complainant\n\nlodged/submitted her claim of treatment expenses of ₹24,523/-\n\nincurred while remained admitted in the CMC Hospital, Ludhiana from\n\n14.01.2011 to 15.01.2011 on account of treatment of bilateral watering\n\nof eyes. The complainant was operated on 14.01.2011 for Right\n\nEndoscopic Dacrocystorhinastomy under G.A.4.           The claim lodged by the complainant was not settled by the\n\nopposite     parties    within   the   reasonable   period   in-spite   of\n\nrecommendation by the opposite party No.1 to reconsider. However,\n\nvide letter dated 16.09.2011 the opposite party No.2 called upon the\n\ncomplainant to provide the certificate of the continuation of the policy\n\nwithout any delay. The claim was again lodged for reimbursement of\n\nmedical expenses in respect of her treatment from 14.04.2011 to\n\n16.04.2011 for a sum of ₹30,053/- in CMC & Hospital, Ludhiana but\n\nstill the opposite parties did not settle/pay the claim. It was further\n\nmentioned in the complaint that the complainant further lodged another\n\nclaim in respect of her treatment from 07.11.2011 to 08.11.2011 withFirst Appeal No.513 of 2021                                           4CMC & Hospital, Ludhiana for an amount of ₹26,838/-. Said claim was\n\nillegally and arbitrarily repudiated on flimsy grounds by opposite party\n\nNo.2 vide letter dated 28.12.2011 on the ground that the complainant\n\nsuffered from Left Chronic Dacrocystitis and treatment of said disease\n\nwas under the first two years of exclusion clause and was not payable\n\nas per Clause 4.3 of the terms and conditions of the policy. It has\n\nfurther been mentioned that the complainant also lodged a claim in\n\nrespect of her treatment from 03.04.2021 to 04.04.2013 with Advanced\n\nENT Endoscopy, Chandigarh for an amount of ₹31,443/-. Said claim\n\nwas also illegally repudiated vide letter dated 11.06.2013 on the\n\nground that the complainant was a known case of Dacrocystitis and\n\nwas suffering from the ailment from the last three years whereas the\n\nperiod of policy was less than three years and the claim was not\n\npayable as per clause 4.1 of the policy. Accordingly, the four claims\n\namounting to ₹1,12,857/- were wrongly and illegally repudiated by the\n\nopposite parties.5.           Stating it to be a case of 'deficiency in service' and\n\n'unfair trade practice' on the part of the opposite parties, the prayer\n\nwas made in the complaint for directing the opposite parties to pay\n\namount of all the claims i.e. ₹1,12,857/- with interest @12% per\n\nannum and also to pay compensation of ₹50,000/-.6.           The complaint filed by the complainant was opposed by the\n\nappellant/opposite party No.1 by way of filing written statementFirst Appeal No.513 of 2021                                                          5wherein certain preliminary objections were raised. The claim was also\n\nopposed on merits as well. Respondent No.2/opposite party No.2 did\n\nnot appear before the District Commission and was proceeded ex\n\nparte vide order dated 18.03.2014.7.           On perusal of contents of the complaint and written\n\nstatement filed by the opposite party, the complaint filed by the\n\ncomplainant was allowed vide impugned order dated 02.11.2021. The\n\nrelevant portion of the impugned order as mentioned in Para-14\n\nthereof is reproduced as under:"14. As a result of above discussion, the complaint is allowed with an\n        order that OPs shall consider and pay the four claims of\n        Rs.1,12,857/- (Rs.24,523/-, Rs.30,053/-, Rs.26,838/- and Rs.31,443/-\n        ) to the complainant strictly in accordance with the terms and\n        conditions of the policy within 40 days from the date of receipt of\n        copy of the order along with interest @6.5% per annum from the date\n        of filing of complaint till actual payment. OPs shall further burdened\n        to pay a composite compensation of Rs.5,000/- (Rupees Five\n        Thousand only) to the complainant. Payment of compensation shall\n        be made within a period of 40 days from the date of the receipt of the\n        copy of this order. Copies of order be supplied to parties free of costs\n        as per rules. File be indexed and consigned to record room."8.           Being aggrieved by the said impugned order 02.11.2021\n\npassed by the District Commission, the appellant/opposite party has\n\napproached this Commission by way of filing the present appeal by\n\nraising a number of arguments.9.           Mr.     Paul      S.    Saini,     learned      counsel      for      the\n\nappellant/opposite party submits that the mediclaim policy was issued\n\nto the complainant on 12.05.2008 and it was expired on 11.05.2009.\n\nSaid policy was not renewed by the complainant and thereafter the\n\nfresh policy was obtained after a gap of six days i.e. on 17.05.2009,First Appeal No.513 of 2021                                               6which was valid up to 16.05.2010. Learned counsel further submits\n\nthat the complainant did not renew the said policy but after a\n\ngap/break of 23 days from the date of expiry of the previous policy, a\n\nfresh mediclaim policy was obtained on 09.06.2010 which was valid up\n\nto 08.06.2011. Said policy was for an enhanced sum insured of ₹3 lac.\n\nLearned counsel further submits that the said policy was not a renewal\n\nof the earlier policy and it was a fresh/new policy but with enhanced\n\nsum insured of ₹3 lac. Learned counsel also submits that no\n\ncumulative bonus was given to the complainant for that policy being\n\nthe fresh policy. The terms and conditions of the policy were also\n\nsupplied to the insured and the same were binding upon both the\n\nparties. It is also the argument of learned counsel for the appellant that\n\nin case of gap between two policies, the subsequent policy would be\n\nconsidered as a fresh policy and not a renewal of the earlier policy.\n\nThe claim was not payable to the complainant for the amount claimed\n\nin the complaint in view of the provisions of Clause 4.3 of the terms\n\nand conditions of the policy as it was falling within first two years of the\n\nExclusion Clause of the terms and conditions of the policy. Learned\n\ncounsel further submits that the third claim of ₹26,838/- was also not\n\npayable under the provisions of Clause 4.3. It was rightly repudiated\n\nby TPA vide letter dated 28.12.2011 (Ex.R-30). Similarly, fourth claim\n\nof ₹31,443/- was also not payable in view of provisions of Clause 4.1First Appeal No.513 of 2021                                             7of the terms and conditions of the policy as the expenses were\n\nincurred for treatment of a pre-existing disease/injuries/conditions.10.          After thorough investigation and scrutiny of documents\n\nsubmitted by the complainant, the claim was not paid as it was not\n\nadmissible in view of medical record of the complainant as well as the\n\nterms and conditions of the policy. The reasons of repudiation were\n\nalso explained to the insured. Learned counsel also submits that the\n\nDistrict Commission has not taken into consideration the evidence\n\nproduced by the appellant and has allowed the complaint by ignoring\n\nthe documents available on the file as well as the terms and conditions\n\nof the policy. At the end, learned counsel submits that the controversy\n\ninvolved in the present case is squarely covered by the judgments of\n\nthe Hon'ble National Commission in the case titled as Ram Swaroop\n\nAggarwal v. New India Assurance Co. Ltd. I (2014) CPJ 615 (NC)\n\nas well asParamjit Kaur v. Life Insurance Corporation of India IV(2014) CPJ 132 (NC). Learned counsel also relied upon following\n\ncases in support of his contentions:i)     Oriental Insurance Co. Ltd. v. K. Anandam2007(2)CPC567\n       (NC);ii)    Col.T.S. Bakshi v. Star Health and Allied Insurance Co.2014\n       (3)CPC26 (NC);iii)   Reena Kansal v. United India Ins. Co. Ltd. 2015 (1) CPJ 523\n       (NC);iv)    Niraj Maheshwari v. United India Insurance Co. Ltd.AIR 2011\n       (Jharkhand) 132;First Appeal No.513 of 2021                                          8v)      New India Insurance Co. Ltd. v. Nanak Singla I(2015) CPJ\n        599 (NC);vi)     M/s Suraj Mal Ram Niwas Oil v. United India Insurance Co.(2010) 10 SCC 567;vii)    M/s Industrial Promotion & Investment Corporation of\n        Orissa Ltd. v. New India Assurance Company Ltd. & Anr.\n        Civil Appeal No.1130 of 2007 decided on 22.08.2016;viii)   United India Insurance Company Ltd. v. Orient Treasure\n        Private Limited(2016) 3 Supreme Court Cases 49;ix)     United India Insurance Co. Ltd. v. M/s Harchand Rai\n        Chandan Lal 2005 (1) CLT 215;x)      New India Assurance Co. Ltd. v. Panchsheel Jewellers I(2013) CPJ 38 (NC);xi)     Ravneet Singh Bagga v. M/s KLM Royal Dutch Airlines &\n        Anr. (2000) 1 PLR 182;xii)    Shiv Trading v. New India Assurance Company II (1996) CPJ\n        197 (NC); andxiii)   Life Insurance Corporation of India v. Lily Rani Roy I (1997)\n        CPJ 46 (NC).11.          Mr. Chandan Deep Singh, learned counsel for the\n\nrespondent/complainant submits that the impugned order passed by\n\nthe District Commission is based on proper appreciation of evidence\n\nand as per the terms and conditions of the policy and as per various\n\njudgments of the Hon'ble Supreme Court and Hon'ble National\n\nCommission cited by the District Commission. A detailed finding has\n\nbeen recorded in the impugned order passed by the District\n\nCommission by considering the relevant provisions including the terms\n\nand conditions of the policy as well as the relevant judgments. LearnedFirst Appeal No.513 of 2021                                          9counsel also submits that the alleged break/gap in renewal of the\n\npolicy cannot be made a ground to deny the claim by invoking the\n\nexclusion clause of the policy, as the same was condoned by the\n\nopposite party itself while issuing the subsequent policy. At the end,\n\nlearned counsel submits that the amount of compensation has rightly\n\nbeen awarded for causing mental agony and harassment suffered by\n\nthe complainant and no interference is required in the impugned order.\n\nLearned counsel has relied upon following judgments in support of his\n\ncontentions:i)      M/sModern Insulators Ltd. v. Oriental Insurance Co. Ltd.2000 (I) CPJ 1 (SC);ii)     Oriental Insurance Co. Ltd. v. Madan Kumar Dutta 2008 (2)\n        CPJ 366 (NC);iii)    Oriental Insurance Co. Ltd. v. Parkash Devi2008 (2) CPJ 267\n        (NC);iv)     Leena Trivedi (Dr.) v. Oriental Insurance Co. Ltd. 2009 (3)\n        CPJ 60 (Madhya Pradesh State Commission);v)      Iffco Tokio General Insurance Co. Ltd. v. Permanent Lok\n        Adalat (Public Utility Services) Gurgaon2013 ACJ 1448\n        (Punjab and Haryana High Court);vi)     LIC of India v. Pardasani2012 (2) CPJ 41 (Rajasthan State\n        Consumer Commission);vii)    National Insurance Co. Ltd. v. Kulbir Singh2010 (III) CPJ 276\n        (NC);viii)   National Insurance Co. Ltd.v. Sarlaben Jyantibhai Patel 2015\n        (IV) CPJ 94 (NC);ix)     New India Assurance Co. Ltd. v. Ishu Motwani2015 (III) CPJ\n        570 (NC);First Appeal No.513 of 2021                                                 10ix)     National Insurance Co. Ltd. v Mona Ohri 2011 (II) CPJ 383\n        (This Commission);x)      National Insurance Co. Ltd. Vinay Kumar Calla 2007 (I) CPJ\n        106 (Rajasthan State Consumer Commission);xii)    Ganesh Ram Chandrakar v. Oriental Insurance Co. Ltd.2006 (II) CPJ 296 (Chhattisgarh State Consumer Commission);\n        andxiii)   Torrent Securities Pvt. Ltd. v. National Ins. Co. Ltd. 2007 (II)\n        CPJ 251 (NC).12.          Heard the arguments of learned counsel for the parties.\n\nWe have also carefully perused the impugned order dated 02.11.2021\n\npassed by the District Commission, written submissions of the parties\n\nand all other documents available on the file.13.          Facts regarding filing of the complaint by the complainant\n\nbefore     the   District     Commission,   reply   thereto   filed   by   the\n\nappellant/opposite party No.1, allowing of said complaint and\n\nthereafter filing of the present appeal by the appellant/opposite party\n\nare not disputed.14.          The impugned order dated 02.11.2021 passed by the\n\nDistrict Commission has been challenged by the appellant/opposite\n\nparty No.1 on the grounds that the policy issued to the complainant on\n\n12.05.2008 had expired on 11.05.2009. Thereafter, it was renewed by\n\nthe complainant but after a gap of six days and fresh policy Ex.R-22\n\nwas obtained on 17.05.2009 which was valid up to 16.05.2010. The\n\ncomplainant did not renew the said policy but after a gap/break of 23\n\ndays from the date of expiry of the earlier policy, a fresh policy wasFirst Appeal No.513 of 2021                                             11obtained and it was of enhanced sum insured of ₹3 lac. Said policy\n\nwas not renewal of the previous policy but it was a fresh policy. The\n\nimpugned order has also been challenged only on the ground that the\n\nDistrict Commission, while allowing the claim/complaint of the\n\ncomplainant, has not considered this aspect of the matter and\n\nconsidered as if the subsequent policy was in continuation of the\n\nearlier policy. The impugned order passed by the District Commission\n\nis contrary to the terms and conditions of the policy. It is also\n\nmentioned in the grounds of the appeal that the expenses for\n\ntreatment of the ailment were not payable during first two years of the\n\ndate of issuance of the policy and accordingly, the claim was\n\nrepudiated by TPA vide letter dated 28.12.2011. Neither the\n\narguments raised on behalf of the appellant nor the terms and\n\nconditions of the policy were considered by the District Commission\n\nand the impugned order was passed without proper appreciation of the\n\nevidence. It is also mentioned in the grounds of the appeal that it is a\n\nsettled principle of law that it is not open to the Court to add, delete or\n\nsubtract any words in construing the terms of a contract of insurance.15.          On perusal of the impugned order and the arguments\n\nraised by the learned counsel for the appellant as well as respondent\n\nNo.1/complainant and also the judgments relied upon by both the\n\nparties, the issue to be determined is as to whether there was any\n\ngap/break between the policy(s) obtained by the complainant or not?First Appeal No.513 of 2021                                                      1216.            Clauses 4.3 and 6.0 of the Insurance Policy are relevant in\n\nthe present context and the same are reproduced as under:"4.3: Waiting period for specified disease/conditions:From the time of inception of the cover, the policy will not cover the\n        following diseases/ailments/conditions for the duration shown below.\n        This exclusion will be deleted after the duration shown, provided the\n        policy has been continuously renewed with our Company without any\n        break:Sr. No.                 Name                          of   Duration\n                                 Disease/Ailment/Surgery not\n                                 covered for\n         1.                      Any skin disorder                  Two years\n         2.                      All internal & external benign     Two years\n                                 tumors, cysts, polyps of any\n                                 kind including benign breast\n                                 lumps\n         3.                      Benign ear, nose, throat           Two years\n                                 disorder\n         4.                      Benign prostate hypertrophy        Two years\n         5.                      Cataract & age related eye         Two years\n                                 ailments\n         6.                      Daibetes mellitus                  Two years\n         7.                      Gastric/Duodenal Ulcer             Two years\n         8.                      Gout & Rheumatism                  Two years\n         9.                      Hernia of all types                Two years\n         10.                     Hydrocele                          Two years\n         11.                     Hypertension                       Two years\n         12.                     Hysterectomy                 for   Two years\n                                 Menorrhagia/Fibromyoma,\n                                 Myomectomy and Prolapse of\n                                 uterus\n         13.                     Non infective arthritis            Two years\n         14.                     Piles, fissures and fistula in     Two years\n                                 anus\n         15.                     Pilonidal sinus, sinusitis and     Two years\n                                 related disorders\n         16.                     Prolapse inter vertebral disc      Two years\n                                 unless arising from accident\n         17.                     Stone in gall bladder & Bile       Two years\n                                 duct\n         18.                     Stones in urinary systems          Two years\n         19.                     Unknown Congenital Internal        Two years\n                                 disease/defects\n         20.                     Varicose Veins and Varicose        Two years\n                                 Ulcers\n         21.                     Age related Osteoarthritis &       Four years\n                                 Osteoporosis\n         22.                     Joint replacements due to          four yearsFirst Appeal No.513 of 2021                                                          13degenerative condition\n\n        "6.0: Renewal of Policy:(a)   The Company sends renewal notice as a matter of courtesy. If\n              the insured does not receive the renewal notice it will not amount\n              to any deficiency of service.(b)   The Company shall not be responsible or liable for non-renewal of\n              the policy due to non-receipt/delayed receipt of renewal notice or\n              due to any other reason whatsoever.(c)   Decision to accept or reject the coverage of any person at renewal\n              of this insurance shall rest solely with the Company. The\n              Company may at its discretion revise the premium rates and/or\n              the terms and conditions of the policy every year upon renewal\n              thereof. Renewal of this policy is not automatic. Premium due\n              must be paid to the Company before the due date.If the policy is to be renewed for enhanced sum insured then the\n              restriction as applicable to a fresh policy will apply to additional\n              sum insured as if a separate policy has been issued for the\n              difference. In other words, the enhanced sum insured will not be\n              available for an illness, disease, injury already contracted under\n              the preceding policy periods."17.           Admittedly, respondent No.1/complainant had challenged\n\nthe repudiation of her four claims. First claim relates to the treatment of\n\nBilateral Watering of Eyes taken at CMC & Hospital, Ludhiana w.e.f.\n\n14.01.2011 to 15.01.2011 for an amount of ₹24,523/-. The\n\ncomplainant       was      operated       upon     for    'Right     Endoscopic\n\nDacrocystorhinastomy under G.A. Said claim was rejected by\n\ninvoking Clause 4.3 of the terms and conditions of the policy. Perusal\n\nof policy document Ex.R-30 reflects that the problem of Dacrocystitis\n\nwas not included in the list of category of diseases for which the\n\nexpenses for treatment were not payable within a period of first twoFirst Appeal No.513 of 2021                                             14years of the date of issuance of the policy. The claim relates to the\n\nperiod 14.01.2011 to 15.01.2011 whereas the policy was issued on\n\n12.05.2008. Accordingly, it is apparent that the period of two years\n\nfrom the date of inception of the policy had already expired on\n\n12.05.2010. Meaning thereby Clause 4.3 of the terms and conditions\n\nof the policy has wrongly been invoked by the opposite parties while\n\nrejecting the claim of the complainant.18.          The second claim of ₹30,053/- was relating to the period of\n\nhospitalization of the complainant in CMC & Hospital w.e.f. 14.04.2011\n\nto 16.04.2011. Said claim was rejected on the ground that it was not\n\npayable in terms of Clause 4.3 of the policy. In the letter of repudiation,\n\nit has been mentioned that the patient was suffering from 'Left Chronic\n\nDacrocystitis (Benign ENT Disorders)' and the said claim came under\n\nthe first two years Exclusion Clause and the same was not payable as\n\nper provisions of Clause 4.3 of the policy.19.          On perusal of Clause 4.3 of the policy and other terms and\n\nconditions of the policy, the repudiation of that claim was not justified\n\nas said claim was lodged in respect of the treatment taken w.e.f.\n\n14.04.2011 to 16.04.2011 and was not falling under the first two years\n\nof the policy i.e. 12.05.2008. The District Commission has specifically\n\nobserved that the repudiation of this part of the claim on the part of the\n\nopposite parties was not justified and the same was liable to be set\n\naside.First Appeal No.513 of 2021                                           1520.          As far as the third claim of ₹26,838/- is concerned, the\n\nsame was relating to hospitalization of the complainant in the hospital\n\nw.e.f. 07.11.2011 to 08.11.2011. Said claim was rejected by TPA vide\n\nletter dated 28.12.2021 (Ex.R-30) on the ground that the treatment of\n\nLeft Chronic Dacrocystitis (Benign ENT Disorders) was not payable in\n\naccordance with Clause 4.3 of the policy as the treatment of said\n\nailment was not payable for the first two years of the policy. However,\n\nsince the said claim was not lodged within first two years from the date\n\nof inception of the policy i.e. 12.05.2008, so the ground of repudiation\n\nof the said claim is also illegal.21.          The repudiation of aforesaid claim by the TPA is also\n\nagainst the settled law. Health Services to be provided by the TPA\n\nhave been specified in IRDAI (THIRD PARTY ADMINISTRATORS-\n\nHEALTH SERVICES) REGULATIONS, 2016, issued vide Notification\n\nF. No.IRDAI/REG/5/117/2016 dated 14.3.2016, which is reproduced\n\nas under:-"Health services by TPA\n      (1) A TPA may render the following services to an insurer under\n      an agreement in connection with health insurance business:a. servicing of claims under health insurance policies by way of\n         pre-authorization of cashless treatment or settlement of claims\n         other than cashless claims or both, as per the underlying\n         terms and conditions of the respective policy and within the\n         framework of the guidelines issued by the insurers for\n         settlement of claims.b. servicing of claims for Hospitalization cover, if any, under\n         Personal Accident Policy and domestic travel policy.\n      c. facilitating carrying out of pre-insurance medical examinations\n         in connection with underwriting of health insurance policies:First Appeal No.513 of 2021                                          16Provided that a TPA can extend this service for life insurance\n         policies also.d. health services matters of foreign travel policies and health\n        policies issued by Indian insurers covering medical treatment\n        or hospitalization outside India.e. servicing of health services matters of foreign travel policies\n        issued by foreign insurers for policyholders who are travelling\n        to India:Provided that such services shall be restricted to the health\n        services required to be attended to during the course of the\n        visit or the stay of the policyholders in India.\n    f. servicing of non-insurance healthcare schemes as mentioned\n        inRegulation 22 (3)of these Regulations\n    g. any other services as may be mentioned by the Authority.\n(2) While performing the services as indicated atRegulation 3\n     (1)of these regulations, a TPA shall not\n    a. Directly make payment in respect of claims\n    b. Reject or repudiate any of the claims directly\n    c. Handle or service claims other than hospitalization cover\n       under a personal accident policy\n    d. Procure or solicit insurance business directly or indirectly\n    e. Offer any service directly to the policyholder or insured or to\n       any other person unless such service is in accordance with\n       the terms and conditions of the policy contract and the\n       agreement entered into in terms of these regulations.\n(3)     A TPA can provide health services to more than one\n        insurer. Similarly an insurer may engage more than one\n        TPA for providing health services to its policyholders or\n       claimants."22.        On perusal ofRegulation 3(2) (b)of the above health\n\nservices to be provided by TPA specifically reveals that while\n\nperforming the services as indicated atRegulation 3(1)of these\n\nRegulations, a TPA shall not reject or repudiate any of the claims\n\ndirectly.   It can only recommend for settlement/repudiation of the\n\nclaim. Therefore, the TPAs have no authority to reject the claim and\n\nsuch power lies exclusively with the Insurance Companies. The TPAFirst Appeal No.513 of 2021                                            17can only process the claim and forward the same to the Insurance\n\nCompany and the competent authority of the Insurance Company was\n\nto decide the same.23.           In the present case the aforesaid claim of the complainant\n\nhas been repudiated was denied by the TPA vide letter dated\n\n28.12.2011 which is in violation of the above said Regulations of the\n\nIRDAI.24.          The fourth claim of ₹31,443/- was relating to hospitalization\n\nof the complainant in Advanced ENT Endoscopy, Chandigarh from\n\n03.04.2013 to 04.04.2013, which was repudiated on the ground that\n\nthe policy was less than three years old and the claim was not payable\n\nas per Clause 4.1 of the policy. Said Clause provides that the\n\ntreatment expenses in respect of a pre-existing disease were not\n\npayable for the first four consecutive years of the policy. However, the\n\nclaim was of the month of April, 2013 and the date of inception of the\n\npolicy was 12.05.2008. The period of four years had already expired\n\nwhen the said claim was lodged.25.          By considering the averments made in the complaint and\n\nthe findings recorded by the District Commission, it is apparent that in\n\nthe policy (Ex.C-58), the date of issuance of the first policy is\n\nmentioned as 12.05.2008. Said policy cannot be said to be a new\n\npolicy. In case there was any gap between two policies, that gap\n\nperiod has been condoned by the appellant/opposite party No.1 whileFirst Appeal No.513 of 2021                                            18issuing the subsequent policy. The break or gap of a few days\n\nbetween two policies cannot be made a ground to deny the claim by\n\ninvoking the exclusion clause when the subsequent policy was in\n\ncontinuation of the earlier policy.26.          It   is   also   relevant   to   mention   here   that   the\n\nappellant/opposite party No.1 had filed an application for amendment\n\nof the written statement filed by it before the District Commission on\n\nthe ground that certain facts and documents could not be\n\nmentioned/produced in/along with          the written statement. Said\n\napplication filed by opposite party No.1 was dismissed by the District\n\nCommission vide order dated 05.05.2015 by observing that opposite\n\nparty No.1 wanted to make altogether different assertions from the\n\nstand already taken by it in the written statement. It was further\n\nobserved by the District Commission that the matter was fixed for\n\nevidence of the opposite parties and in case the proposed amendment\n\nwas allowed, it would amount to denovo trial and opposite party No.1\n\ncould not be allowed to fill up lacuna in the case already pleaded by it.27.          Since the application filed by opposite party No.1 for\n\namendment of the written statement was already dismissed, so the\n\npleas and documents of opposite party No.1, which were not part of\n\nthe written statement filed before the District Commission, cannot be\n\nconsidered in the appeal.First Appeal No.513 of 2021                                           1928.          By considering these aspects and by recording a\n\ncategorical finding by the District Commission, the complaint filed by\n\nthe complainant was allowed. A detailed and well reasoned order has\n\nbeen passed by the District Commission. Therefore, we do not find\n\nany illegality and infirmity in the impugned order passed by the District\n\nCommission as the findings have been recorded on the basis of\n\nevidence produced by both the parties and by considering the\n\narguments raised by both the side as well as case law. The authorities\n\nrelied upon by learned counsel for the appellant are not applicable to\n\nthe facts and circumstances of the present case.29.          Accordingly, we do not find any merit in the\n\ncontentions raised by the learned counsel for the appellant and\n\nthe appeal being without any merit is hereby dismissed and the\n\nimpugned order dated 02.11.2021 passed by the District\n\nCommission is upheld.30.          Since the main case has been disposed of, so all the\n\npending Miscellaneous Applications, if any, are accordingly disposed\n\nof.31.          The appellant has deposited a sum of ₹25,000/- at the time\n\nof filing of the appeal. Another amount of ₹1,79,738/- was deposited\n\nvide receipt dated 14.01.2022 in compliance of order dated 31.12.2021\n\npassed by the District Commission. Said amounts, along with interest\n\nwhich has accrued thereon, if any, shall be remitted by the Registry toFirst Appeal No.513 of 2021                                            20the District Commission forthwith. Respondent No.1/complainant may\n\napproach the District Commission for the release of the same and the\n\nDistrict Commission may pass appropriate order in this regard in\n\naccordance with law.32.           The appeal could not be decided within the statutory period\n\ndue to heavy pendency of court cases and pandemic of COVID-19.(JUSTICE DAYA CHAUDHARY)\n                                             PRESIDENT\n\n\n\n\n                                        (URVASHI AGNIHOTRI)\n                                             MEMBER\nSeptember 06, 2022.(Gurmeet S)