Decided on October 27,2008

Ttk Health Care Services Pvt. Ltd Appellant
Y.Lalithamma Respondents


D.APPA RAO, J. - (1.) THIS is an appeal preferred by opposite party No. 2 against the order of the Distt. Forum, Nellore, directing it to pay Rs. 87,000 with interest @ 6% p.a., together with costs of Rs. 2,000.
(2.) THE case of the complainant is that herself and her husband obtained hospitalization and domiciliary hospitalization benefits policy dated 8.9.2005 for a sum of Rs. 1 lakh each and another policy for Rs. 2 lakh each covering the period from 8.9.2006 to 7.9.2007 from opposite party No. 1 United India Insurance Company Ltd. As per the policy the appellant has to process the claim of the complainant and settle the same and recover it from the Insurance Company. While so, the complainant underwent cataract operation at Agarwal Eye Institute at Chennai on 15.7.2006 incurred an expenditure of Rs. 9,800 towards operation charges, room rent, etc. She claimed the said amount. However, the appellant did not process the claim. Later, she was admitted at MIOT Hospital, Chennai for her left knee replacement. She was operated on 15.3.2007 and discharged from the hospital on 28.3.2007. She incurred an amount of Rs. 1,67,243. Though she sought prior approval for her treatment from the appellant which initially sanctioned an amount of Rs. 1,00,000 through letter dated 12.3.2007 failed to pay the remaining amount. Therefore, she claimed Rs. 87,000 towards medical expenses with interest and costs.
(3.) OPPOSITE party No. 1 the Insurance Company filed counter admitting that the policies were taken by the complainant. As per the terms of the policies, the appellant has to process the claim of the complainant and settle the claim, and recover from it. In fact, the appellant has processed the claim, paid a sum of Rs. 1 lakh by letter dated12.3.2007. If at all the complainant was entitled to the amount it was from the appellant. It has nothing to do with the payment of balance amount. It would reimburse the amounts paid by the appellant to its policy holders including the claim of the complainant. Therefore, it prayed for dismissal of the complaint. The appellant/opposite party No. 2 did not contest the matter before the Distt. Forum despite service of notice. It was set ex parte.;

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