BEFORE THE TELANGANA STATE CONSUMER DISPUTES REDRESSAL COMMISSION:HYDERABAD (ADDITIONAL BENCH)

FA. No. 258/2021 AGAINST ORDERS IN CC. No. 614/2019 ON THE FILE OF DISTRICT FORUM-III, HYDERABAD Between :

1. United India Insurance Company Ltd., IBA Cell, rep. Its Manger, Vulkan insurance Building, Ground floor, 77, VN Road, Church gate, Mumbai.

…….Appellant/Opposite party No.1

2. United India Insurance Company Ltd., Rep by its Deputy General Manager, Bank assurance division, 3-5-817 & 818, 7th flood, United India towers, Basheerbagh, Hyderabad-500029. .….Appellant/Opposite party No.2 And

1. Mrs. Jyoti Nyalkalkrar, w/o Raghavendra age 62 years, occupation housewife R/o H.No.4-5-606, Qutbiguda, Koti Hyderabad,Telangana State

500025.

………..Respondent/Complainant

2. Medsave Helath Insurance TPA, Services ltd., rep by authorized, person plot No.49 Nagarjuna Hills, Punjagutta, Hyderabad-500082 Telangana State.

……….Respondent/opposite party No.3 Respondent No.2 is not necessary party in the appeal

Counsel for the Appellant : M/s. Shanker

Counsel for the Respondent : Santhoshi Kumari

QUORUM: Hon’ble Sri K.Ranga Rao - Presiding Officer-

Member- (Judicial).

&

Hon’ble Smt.R.S.Rajeshree, Member (Non Judicial).

WEDNESDAY, THE TWENTY SIXTH DAY OF MARCH, TWO THOUSAND TWENTY FIVE *****

Order : (Per Hon’ble Sri K.Ranga Rao- Presiding Officer-

Member - (Judicial).

1. This appeal is filed by the Appellant/opposite parties No.1 and 2 U/s.41 of the Consumer Protection Act, 2019, praying this State Commission to allow the appeal and to set aside the impugned order of the District Commission-III, Hyderabad, passed in CC. No. 614/2019 dt.05.03.2021 and consequently to dismiss the complaint with the costs throughout.

2. For the sake of convenience, the parties are referred to as arrayed in the complaint. The appellants 1 and 2 herein were opposite parties 1 and 2 and the Fist respondent was the complainant and the Second Respondent was opposite party No.3 in the complaint bearing No.CC 614/2019 filed by the complainant and the file of District Commission-III, Hyderabad.

3. The brief averments of complaint are as follows:-

As per the averments of the complaint, the complainant, who is 62 years old has obtained a Health Insurance Policy No. 5001002818P111251702 under the State Bank of India employees group insurance from the Opposite Party No. 1 by paying premium amount of Rs 28,792/- for insurance coverage of Rs. 1,00,000/for a period of one year from 1/11/2018 to mid-night 31/10/2019 (Ex A-2 Policy Id). Apparently, the complainant was taken to Kamineni hospital, King Koti late evening on 1/2/2019 as she developed severe back pain, where she was immediately admitted in the ICU, Cardiology for various medical investigations/diagnostic tests suspecting cardiac problem and provided treatment with IV nitroglycerine, antihypertensives, antiplatelets, statins, antidiabetic and antacids. (Ex A-4 Discharge Summary), on payment of Rs 5000/-by the complainant's husband vide receipt No.REC-IP-11300. The complainant's husband also paid the total bill of Rs 27,119/ and submitted the bill to the Opposite Parties on 15/2/2019 for reimbursement under the Insurance Policy availed by the complainant and her husband vide Policy No.

5001002818P11251702.

The above medical insurance claim of the complainant was repudiated on 18/3/2019 stating that the “claim is not admissible since hospitalization is for less than 24 hours and does not quality for exceptions mentioned in the terms as per terms and conditions of the policy (Ex A-7). The complainant submits that as per Clause 2.21, Medical Expenses means those expenses that an insured person has necessarily and actually incurred for medical treatment on account of illness or accident on the advice of a medical practitioner, as long as these are no more than would have been payable if the insured person had not been insured and no more than other hospitals or doctors in the same locality would have charged for the same medical treatment and as per Claus