SUDHAKAR TIWARI Vs. NEW INDIA ASSURANCE CO. LTD.

JUDGEMENT

(1.) The dispute between the parties arises out of a medical insurance policy known as the "New India Mediclaim Policy" (hereinafter, "the policy"), purchased by the petitioner from the respondent. The petitioner is aggrieved by a communication dated 05.04.2020 by which the respondent has declined to cover the petitioner's claims under the policy.

(2.) The petitioner first purchased the policy (bearing no. 311600- 341625-00000498) in the year 2002. It came into effect on 11.09.2002. The sum assured under the policy was then Rs. 5,00,000/-. The policy was renewed annually. In the year 2017, the respondent offered the petitioner an enhancement of the sum assured, which the petitioner accepted. The sum assured under the policy was thus enhanced to Rs. 8,00,000/- with effect from 11.09.2017, and the policy document to this effect was issued on 04.09.2017.

(3.) The genesis of the present dispute is that the petitioner was diagnosed with metastatic squamous cell carcinoma in cervical lymph nodes in January 2020, and is undergoing treatment at Medanta Hospital, Gurugram, and Apollo Hospital, Delhi. In accordance with the procedure under the policy, the petitioner applied for the "cashless facility". However, the third-party administrator appointed by the respondent (hereinafter, "the TPA") rejected the petitioner's request. In a communication dated 30.03.2020 addressed by the TPA to Apollo Hospital, the reason cited for the rejection was that the maximum eligible sum insured of Rs. 5,00,000/- had been exhausted.