NEW INDIA ASSURANCE CO LTD Vs. RAJEEV TOGNATA

JUDGEMENT

(1.) Shri Rajeev Tognata, the complainant, took medi-claim insurance policy from m/s United India Insurance Company Ltd. on 24.8.2001. The complainant was transferred from Jaipur to Delhi. He opted for transfer of the policy from United India Insurance Company Ltd. to New India Assurance Company Limited, which provides more benefits.

(2.) The facts in brief are that the complainant was admitted in Sir Ganga Ram Hospital on 26.11.2004. Angiography and other medical tests were performed and he was operated upon for bye-pass surgery. He filed a medi-claim of Rs.1,61,630/-, which was reimbursed. On 26.12.2006, he received a letter from M/s Raksha TPA, appellant-4 asking the complainant to refund an amount of Rs.1,61,630/-, as his case was now covered with the New India Assurance Company Ltd.

(3.) Subsequently, the complainant suffered from hepatitis and preferred a claim for an amount of Rs.2,24,561/-. New India Assurance Company and its functionaries, OP 1 to OP 3 deducted the amount of Rs. 1,61,630/- from the amount of Rs.2,24,561/- and paid balance amount of Rs.62,931/- to the complainant. The contentions of OPs 1 to 3 is that there exists an exclusion clause in their policy, which was explained vide letter dated 12.04.2007.