V. SENTHILNATHAN Vs. UNITED INDIA INSURANCE CO. LTD

JUDGEMENT

(1.) OP 1 is a public sector general insurance company incorporated in 1938. It obtained the business of Mediclaim Insurance for the CanCard Holders under group insurance from the year 2005 -06. Earlier, CanCard management utilized the services of M/s. New India Assurance Co. Ltd., New Delhi, for the same medi -claim insurance. At the time of filing of the information, the Third Party Administrator for OP 1 was stated to be M/s. E -Meditak (TPA) Services Ltd. (OP 2). Prior to year 2005 -06, the TPA for New India Assurance Co. Ltd was M/s. Medi Asst India (P) Ltd., Bangalore.

(2.) TPAS were introduced by Insurance Regulatory and Development Authority (IRDA) in the year 2001 to ensure better services to policy holders. Their basic role is to function as an intermediary between the insurer and the insured and facilitate cashless service at the time of hospitalization as well as processing of claims. Insurance companies, in order to improve the processing of claims, appoint TPAs, licensed by IRDA. The selection of TPAs from amongst the licensed rests with the Insurance Company and no criteria / procedures are specifically laid down for such selection by IRDA. The selection of TPAs and terms and conditions of the Agreement between the Insurer and TPAs are decided by the respective Insurance Companies only.

(3.) AS per the informant, OP 2 failed to fulfil its obligations stated under various clauses of the agreement with OP 1 which benefited the policy holders. The Informant pointed out certain clauses in the agreement not being complied by OP 2. The clauses pertained to renewal/termination of the policy, denial of preauthorization, claim intimation, repudiation of claim etc.