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Patna High Court · body

2013 DIGILAW 616 (PAT)

Usha Jhunjhunwala v. Oriental Insurance Company

2013-05-14

JAYANANDAN SINGH

body2013
ORDER Petitioner has filed this writ application for quashing the letter dated 08.08.2011 (Annexure-6 with the writ application) issued by respondent No.3, the Divisional Manager of the Oriental Insurance Company Limited, by which her husband was informed that her claim was not found payable on the ground that “Injection Lucentis is not payable under the scope of the Policy.” However, by the letter “one more opportunity” was given to substantiate her claim within 2 weeks from the date of receipt of the letter, before a final decision was taken, failing which her claim was to stand repudiated on the said ground, without further advices from them. She has also made a prayer in the writ application for quashing the letter dated 17.08.2011 (Annexure-8) issued on behalf of respondent No.4, The Medicare T.P.A. Services (I) Pvt. Ltd., Kolkata, by which she was informed that her medical claim documents were processed, but, as per the opinion of its adjudication department and the doctors’ panel, her claim was adjudicated as “No claim” in nature because of the reason that “Treatment/procedure related to inj Lucentis is not covered as per Insurance Co guidelines. Hence the claim repudiated.” It was also mentioned in the letter that “the respective Divisional Officer has recommended repudiation vide letter dated 30.06.2011. Therefore the claim stands rejected.” 2. These two letters show that, as far back as on 30.06.2011, the respondent Divisional Manager had recommended to respondent No. 4 for repudiation of claim of petitioner, on which respondent no. 4 acted, resulting into issue of Annexure-8. Still respondent Divisional Manager issued letter dated 08.08.2011, Annexure-6, by which, though holding that her claim was not found payable, she was given “one more opportunity” to substantiate her claim. Petitioner, in response of the said letter of the respondent Divisional Manager, Annexure-6, indeed, availed that opportunity and filed her application dated 01.09.2011 (Annexure-7). A reply dated 27.10.2011 of the respondent Divisional Manager of her said application, addressed to her husband, is Annexure 5 with the counter affidavit. The present writ application was presented in the Stamp Report Section of the High Court on 09.11.2011. Still the application is conspicuously silent about this reply, nor there is a pleading that petitioner had not received any final decision of the Insurance Company on her said application, Annexure-7. The present writ application was presented in the Stamp Report Section of the High Court on 09.11.2011. Still the application is conspicuously silent about this reply, nor there is a pleading that petitioner had not received any final decision of the Insurance Company on her said application, Annexure-7. Since all previous communication and stand of the respondents stand merged in this final reply of the respondent Divisional Manager dated 27.10.2011, petitioner was required to challenge the same also before this Court, either through a prayer in the main writ application, or through an I.A. for liberty to do so, at least after filing of the counter affidavit in the case, which she has apparently not done. 3. Be that as it may, coming to the merits of the case and issues involved, this Court finds that there is no dispute of the fact that, as appearing from the doctor’s prescription dated 04.10.2010 (Annexure-1) also, petitioner was examined at Infiniti Eye Hospital at Mumbai. The diagnosis and advice to her was as under:- “Mrs. Usha Jhunujhunwala was diagnosed as Wet ARMD with Mixed CNVM. She was advised FFA followed by Intravitreal Inj of Antivegf in each eye separately. Both Inj Lucentis and Avastin were discussed with her. She was traveling to Europe and wished to undergo the procedure after 10-12 days.” 4. The above diagnosis and advice contains medical terms and abbreviations. Hence, with the help of internet and medical books this Court could find their full form or explanations as under:- ARMD – Age Related Macular Degeneration CNVM – Choroidal Neo-Vascular Membrane FFA – Fundal Fluroscein Angiography Inj – Injection Intravitreal – Posterior chamber Antivegf – Anti-vascular endothelial growth factor. (Antivegf medications are a group of drugs used in the treatment of wet type AMD.) (These drugs work by blocking the effects of a growth factor that blood vessels need in order to form and keep leaking and are most effective when used in the early stages of the condition. The anti-VEGF drugs stop the growth of new blood vessels, thereby reducing the risk of scarring and further sight loss) 5. The anti-VEGF drugs stop the growth of new blood vessels, thereby reducing the risk of scarring and further sight loss) 5. This is also not in dispute in the case, as also evident from Annexure – 2 series and Annexure – 3 series with the writ application, that petitioner received treatment in the left eye on 11.10.2010 and in the right eye on 13.10.2010, which was repeated on 11.11.2010 and 13.11.2010. As per discharge slips, the treatment was labeled as “operation”, and was “intravitreal inj Lucentis in Operation Theatre”. The discharge slips also show that on the first day petitioner was admitted and was discharged the next day only. Pleading of the petitioner is that she was admitted, hospitalized, and after operation remained under supervisions and post-operative care for a day. Issue is, in these circumstances, whether petitioner is legally entitled, or not, for reimbursement of her all expenses of treatment under the terms and conditions of the Mediclaim Insurance Policy she was having with the respondent Insurance Company. 6. Though, with the writ application, petitioner has annexed a chart (appears to have been prepared by the Regional Training Centre of respondent Insurance Co.) containing comparison of “MEDICLAIM INSURANCE OLD AND NEW POLICY w.e.f. 15.06.2006” as Annexure-9, but in the pleadings she has not referred to any particular clause, of either the old or the new policy, in support of her case of entitlement for her mediclaim. It also appears that neither in the initial application dated 01.12.2010 (Annexure-4), nor in the reminder dated 18.01.2011 (Annexure-5) sent by her husband, nor in her detail representation dated 01.09.2011 (Annexure-7), any specific clause of the policy was referred to or relied upon in support of her claim. Likewise, the respondent Divisional Manager also, in his impugned letter dated 08.08.2011 (Annexure-6), did not refer to any particular clause of the policy to deny the claim of the petitioner, except saying that “Injection Lucentis is not payable under the scope of the Policy.” Respondent No. 4 also, in its impugned letter dated 17.08.2011 (Annexure-8) has not referred to any particular clause of the Policy, except saying that “TREATMENT/PROCEDURE RELATED TO INJ LUCENTIS IS NOT COVERD AS PER INSURANCE CO GUIDELINES. HENCE CLAIM IS REPUDIATED.” and “THE RESPECTIVE DIVISIONAL OFFICE HAS RECOMMENDED REPUDIATION VIDE LETTER DATED 30.6.2011. HENCE CLAIM IS REPUDIATED.” and “THE RESPECTIVE DIVISIONAL OFFICE HAS RECOMMENDED REPUDIATION VIDE LETTER DATED 30.6.2011. THEREFORE THE CLAIM STANDS REPUDIATED.” It is the last letter of the respondent Divisional Manger addressed to the husband of the petitioner, Annexure-5 dated 27.10.2011 annexed with the counter affidavit, which contains the observations in the panel doctors’ report of TPA (respondent-4) and throws some light in respect of the grounds for rejection of petitioner’s claim. The same are as follows:- “For treatment of ARMD and CNVM, drugs like Lucentis/Macugen/Avastin etc. is given as Intravitreal injection. No hospitalization as in-patient is required for administration of this drug. It is an OPD treatment and is not covered as per clause 2.3(C) of policy terms and conditions, which is as follows: “The procedure/treatments usually done in out-patient department are not payable under the policy even if converted to day care surgery/procedure or as in patient in the hospital for more than 24 hours.”” 7. The respondent Insurance Company, in its counter affidavit, has referred to clause 4.6 and 4.23 (under “Exclusion”) of the new Policy effective from 15.09.2006 (appearing in Annexure-9 to the writ petition ) to claim that surgery for correction of eye sight, OPD, medical or surgical procedures or treatments, non-prescribed drugs and medical supplies are not covered under the Policy’. Hence it has been contended that petitioner’s case and treatment clearly fell under the category of “Exclusions” as per the terms and conditions of the “Mediclaim Insurance Policy”. 8. Learned counsel for the petitioner, on the other hand, during the course of his arguments as well as in his written arguments, has referred to and relied upon clause 2.3(iv) of the Policy, annexed as Annexure-5/A with the counter affidavit, as well as on clause 2.2 and the said clause 2.3(C) and has denied application of clause 4.6 of “Exclusion”, appearing in Annexure-9 with the writ application. 9. Thus the issue which crystallizes in this case for consideration is as to whether the insurance claim of the petitioner is covered and payable in reference to clause 2.3(iv) of the Policy, (annexed as Annexure 5/A with the counter affidavit) read with clause 2.2. and 2.3(C) or is not covered and hence not payable in reference to clause 2.3(C) of the Policy and as covered under 4.6 and 4.23 of the “Exclusion” part of the new Policy effective from 15.09.2006. and 2.3(C) or is not covered and hence not payable in reference to clause 2.3(C) of the Policy and as covered under 4.6 and 4.23 of the “Exclusion” part of the new Policy effective from 15.09.2006. Since, now the question which emerges for considerations is the applicability, or otherwise, of one or the other clause of the Policy, as relied upon by either of the parties, it is appropriate to reproduce the said clauses in this order together at this stage. They are:- “2.2 – “Surgical Operation” means manual and/or operative procedures for correction of deformities/defects and injuries, cure of diseases, relief of suffering and prolongation of life.” “2.3 – HOSPITALISATION PERIOD: Expenses on Hospitalization are admissible only if hospitalization is for a minimum period of 24 hrs. However, (A) This time limit will not apply to following specific treatments taken in the Network Hospital / Nursing Home where the Insured is discharged on the same day. Such treatment will be considered to be taken under Hospitalization Benefit. - - - - - - iv. Eye Surgery - - - - - - ” “2.3(C) – This condition of minimum 24 hours Hospitalization will also not apply provided (i) The treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available only in hospitals, BUT (ii) Due to technological advances hospitalization is required for less than 24 hours. AND / OR (iii) Surgical procedure involved has to be done under General Anaesthesia. ABOVE ARE ADMISSIBLE SUBJECT TO TERMS & CONDITIONS OF THE POLICY. NOTE: PROCEDURES /TREATMENTS USUALLY DONE IN OUT PATIENT DEPARTMENT ARE NOT PAYABLE UNDER THE POLICY EVEN IF CONVERTED TO DAY CARE SURGERY / PROCEDURE OR AS IN PATIENT IN THE HOSPITAL FOR MORE THAN 24 HOURS.” (The above have been extracted from Annexure-5/A with the counter affidavit) “EXCLUSION 4.6 Surgery for correction of eye sight cost of spectacles, contact lenses, hearing aid etc. 4.23 Out-patient Diagnostic, Medical or Surgical procedure or treatment, non-prescribed drugs and medical supplies, Hormone replacement therapy, Sex change or treatment which results from or is in any way related to sex change.” (The above have been extracted from Annexure-9 with the writ application as appearing under the head “NEW MEDICLAIM INSURANCE POLICY w.e.f. 15.9.2006”) 10. 4.23 Out-patient Diagnostic, Medical or Surgical procedure or treatment, non-prescribed drugs and medical supplies, Hormone replacement therapy, Sex change or treatment which results from or is in any way related to sex change.” (The above have been extracted from Annexure-9 with the writ application as appearing under the head “NEW MEDICLAIM INSURANCE POLICY w.e.f. 15.9.2006”) 10. However, before entering into any further discussion on the issue involved in this case, this Court has tried to find out further details of the ailment suffered by the petitioner and the prescribed treatment for it. In course of search, this Court found the web-site of “Royal National Institute of Blind People” (for short “RNIB”) (www.rnib.org.uk). This Institute initially came into existence in 1902 in England as a company incorporated under the Companies Act with the name “British and Foreign Blind Association”. In course of time it became a national body under Royal Charter of England. It was constituted as a body corporate with its own by-laws and to function as a Charity. After successive Charters, it has got its present name. On its web-site, under the caption “Anti-VEGF treatment for wet AMD (Macugen, Lucentis and Avastin)” this Court could get all the details of the ailment suffered by the petitioner, described in simple English and in lay man’s terms. Since the ailment of the petitioner is not in dispute, this Court does not consider it necessary to go into details of the same in this order. But, as the procedure for treatment of the ailment, and its being covered, or not, under the Insurance Policy of respondents, is the core issue in this case, this Court considers it appropriate to go into the procedure involved, for which, this Court can do no better than copy and paste the method of treatment of the said ailment described on the web-site of the RNIB here under:- “ How anti-VEGF treatment is given The ophthalmologist may give you antibiotic eye drops to use for a few days before the treatment to help prevent infection. Alternatively, the ophthalmologist may give an antibiotic drop into the eye just prior to the first treatment. Anti-VEGF drugs are given as an injection into the vitreous (the jelly-like substance inside the eye). However, the injection will enter through the sclera (the white part of your eye). Alternatively, the ophthalmologist may give an antibiotic drop into the eye just prior to the first treatment. Anti-VEGF drugs are given as an injection into the vitreous (the jelly-like substance inside the eye). However, the injection will enter through the sclera (the white part of your eye). It may be done in an operating theatre or a room designed for treatments like this one. The needle used is very sharp, small and short. The injection itself only takes a few seconds and feels like a tiny scratch. Eye drops will be administered into your eyes to dilate your pupils. This will allow the back of the eye to be examined more easily. Local anaesthetic eye drops will be placed into the eye which is to be treated so that the injection itself will be painless. The eye and skin around it will be cleaned to prevent infection, and your face and the area around the eye will be covered by a drape to keep the area sterile. A small clip (a 'speculum') will be used to keep the eye open. Further anaesthetic drops are put into the eye to numb it and prevent you feeling pain. A few minutes later, the injection is given. Your eye pressure will be measured approximately 30 minutes following treatment. The eye pressure may go up for a few hours and, if it remains high, treatment may be required. Your vision may be blurry for several hours afterwards due to the dilating eye drops but this should improve by the next day. You will be given antibiotic eye drops to use for a few days following your treatment to prevent infection. Your eye may be red where the injection was given but that should disappear in a few days. Your eye will feel comfortable by the next day and you may notice black swirls in your vision for a few weeks. ” 11. This Court could also find on internet a diagram and a photograph showing the method of treatment administered to a patient suffering from wet ARMD (or AMD) with mixed CNVM and has considered it appropriate to copy and paste the same also herein below in this order itself:- 12. ” 11. This Court could also find on internet a diagram and a photograph showing the method of treatment administered to a patient suffering from wet ARMD (or AMD) with mixed CNVM and has considered it appropriate to copy and paste the same also herein below in this order itself:- 12. Now looking to the diagram and the photograph, and the method of treatment, as reproduced above, this becomes instantly clear that the standard treatment for “Wet AMD” by administering an anti-VEGF drug is not a surgical process. The treatment, as administered to petitioner also, is to inject an anti-VEGF drug (in the present case it was Lucentis) in vitreous (jelly-like transparent substance filled in the eye) through the sclera (the white part of the eye). The drug stops the growth of new fragile blood vessels under the retina and in or around the macula, which otherwise leak fluid and blood which, if untreated, can then lead to scarring in the macula and irreversible sight loss. Question is, is this method of treatment, administered in the eye, no doubt a very sensitive part of the human body, covered under the insurance policy of the respondents ? Question also will be if a process of inducement of a drug in the vitreous of the eye through injection can be treated as surgery and covered under the policy, will all the processes of inducement of a drug through injection in other parts of a human body has also necessarily to be put in the category of surgery ? 13. The definition of “general surgery” available on web-site www.surgeryencyclopedia.com is “the treatment of injury, deformity, and disease using operative procedures.” General surgery has, with passage of time, and with development of medical science, grown into different branches and specialties, and people involved in the process have developed more and more expertise in connection with specific fields. But golden thread running underneath any branch of surgery is that it involves some sort of operative procedure, either on the surface of the human body or even within. This operative procedure involves some interference with some part of human body, over it, or within, as a corrective or remedial measure. But golden thread running underneath any branch of surgery is that it involves some sort of operative procedure, either on the surface of the human body or even within. This operative procedure involves some interference with some part of human body, over it, or within, as a corrective or remedial measure. This is in contrast to the method of treatment of injury, deformity and disease by putting a drug, in the body in general, or pinpointed to the affected part of the body, by means of a needle of a syringe, or otherwise. This method does not involve interference with the body or the affected part of the body by means of any instrument or equipment, and is aimed to let the body or the affected part of the body react itself, with the drug acting as catalyst, and remedy or cure itself. In the opinion of this Court, this method of treatment, by no stretch of imagination, can be brought into the definition of surgery. Treatment received by the petitioner for her “Wet-ARMD/AMD with Mixed CNVM” falls into this category of treatment, and therefore, was clearly not surgery. Argument was that the process involved (use of anaesthetic drops and sterilization of the eye and the area, etc.) was akin to process normally adopted for a surgical operation. Hence the treatment should be held covered by the definition of “surgical operation”. This Court regrets that it cannot accept the said view of learned counsel for the petitioner. The process involved nonetheless, the treatment itself is simply delivering a drug through a needle in the vitreous (to reach the affected part of the body), which takes less than a minute, may be with some extra precaution and care due to sensitive nature of the part of the body (eye). 14. Coming to the different clauses of the Policy, relied upon by the parties, this Court finds that the respondents have relied upon Clauses 4.6 and 4.23 under “Exclusion” in their counter affidavit, to contest the claim of the petitioner. From Clause 4.6 under “Exclusion”, as reproduced above, it appears that surgery for correction of eye sight, cost of spectacles, contact lenses, hearing aid etc. are excluded from the cover of the policy. From Clause 4.6 under “Exclusion”, as reproduced above, it appears that surgery for correction of eye sight, cost of spectacles, contact lenses, hearing aid etc. are excluded from the cover of the policy. Treatment received by the petitioner was not surgery, as this Court has found above, but was also not for correction of eye sight, rather, it can be said that it was to prevent loss of vision. Hence this clause is not applicable in the case of petitioner. The part of said Clause 4.23 of “Exclusion”, which the respondents appear to be taking aid of against the petitioner, is “Out-patient Diagnostic, Medical or Surgical procedure or treatment”, - - -”, inferring thereby that, any diagnostic, medical of surgical procedure or treatment will not be covered by the Policy if it has been received by the insured as an “out-patient”. Here lies the fault in the approach of the respondents in their policy. A “diagnostic”, “medical” or “surgical” procedure or treatment is to be administered to the party as “out-patient” or as “in-patient” is a matter of subjective satisfaction of the person (doctor) administering it. A doctor, by nature more cautious, careful, having patience and more conscious of medical principles, may apply the same “procedure” or “treatment” on a party as “in-patient”, whereas another doctor, over-confident, having less patience, in a hurry to dispose of the party quickly, may apply the very same “procedure” or “treatment” on another party as “out-patient”. Then again the “procedure” and “treatment” may by applied on a party of young age as out-patient”, whereas the same may be applied to another party of advanced age and/or suffering with other ailments as “in-patient”. It cannot be denied that in medical field there is no mandatory mathematical rule of “procedure” or “treatment” for particular disease, ailment or complication binding on all doctors, holding any other “procedure” or “treatment” as unethical and violative of Hippocratic Oath. This Clause 4.23 shows that emphasis in the Policy is on patient being an “in-patient” or an “out-patient” during the period “treatment” being administered to him/her or the “procedure” being applied to him/her, and not on the ailment and the treatment itself being applied to relieve him/her of the same. A really strange approach of the insurance companies and an apparent fraud with the insured ! 15. A really strange approach of the insurance companies and an apparent fraud with the insured ! 15. Now coming to the specific ground for rejecting the claim of the petitioner, this Court finds that it was the said report of panel of doctors (extracted above) of respondent no. 4, as reproduced in Annexure-5 with the counter affidavit (a letter of Insurance Company to the petitioner), which clinched the issue against the petitioner. The report (opinion) of the “panel of doctors”, extracted in the said letter, shows that they did not dispute that the only treatment of ARMD and CNVM was an intravitreal injection of drugs like Lucentis/Macugen/Avastin. What they opined was that “No hospitalization as in-patient is required for administration of this drug. It is an OPD treatment and is not covered as per clause 2.3(C) of policy terms and conditions”. Then, as extracted in the said letter, Annexure-5, they refer to the Note under the clause 2.3(C), which has already been reproduced herein above in this order. However, it may be useful to again reproduce it here below for easy reference:- “The procedure/treatments usually done in out-patient department are not payable under the policy even if converted to day care surgery/procedure or as in patient in the hospital for more than 24 hours.” (emphasis supplied) 16. Now, it has to be noticed that this was only an opinion of the „panel of doctors? of respondent no. 4 and was not an authoritative pronouncement of any authority established under law. Whether opinion of one “panel of doctors” will be binding on all the doctors of the Country and will govern their judgment in the matter of administering treatment to their patient, is itself a debatable issue. It cannot be ruled out that another panel of equally competent doctors may opine that it may be safer and advisable to administer intravitreal injection of drugs like Lucentis/Macugen/Avastin by hospitalization of the patient as “in-patient”, keeping in mind his/her age, health conditions, his/her medical history and clinical reports and specialized infrastructural facilities available in the particular hospital. It has also to be noticed that in the note below clause 2.3(C), as extracted above, the expression “usually” has been used between “procedure/treatment” and “done”. The word “usually” is used in contradistinction to the expression “compulsorily”, “necessarily” or “essentially” and is synonymous to the word “generally”. It has also to be noticed that in the note below clause 2.3(C), as extracted above, the expression “usually” has been used between “procedure/treatment” and “done”. The word “usually” is used in contradistinction to the expression “compulsorily”, “necessarily” or “essentially” and is synonymous to the word “generally”. Hence what may be “usually” done, may not be “necessarily” done or may not be required to be “compulsorily” or “essentially” done in each and every case. The natural corollary is that, depending on the circumstances, the age, condition of patient, the approach of the treating doctor and what infrastructural facilities may be available in out-patient department, a particular treatment may be administered to a patient as “in-patient”, though normally it may be possible to administer it in an “out-patient” department. At this juncture this Court may notice a document produced by learned counsel for the petitioner, but not placed on record through a proper affidavit, which is a CMD Sectt. Master Circular No. 026/2010-2011; 20th October, 2010 of the “Health Insurance Management Department, Head Office, of National Insurance Co., another public sector company of the Central Government like the respondents. In this circular, in a nut-shell, the treatment, like received by the petitioner, has been held fit to be allowed under its policy with certain conditions. Had this document been put on record through a proper affidavit, with service of a copy on the learned counsel of the respondents, they would have been under legal obligation to justify their stand on the issue different from the same. 17. This Court, to its distress, finds that the entire focus of the respondent Company in its mediclaim policy, and may be of other insurance companies also, is on the type of treatment being administered to the patient. Now, it a well-known fact that, due to technological advancements in the medical field, the method of treatment of many ailments have undergone a drastic change. Whereas, earlier an ailment, which was treated by a major incision in the body and required hospitalization as “in-patient” for days, and may be weeks, is now treated with a button-hole surgery and, at times, only by a needle pierced in the affected part of the body or a vein/artery and does not need a full-fledged hospitalization. Whereas, earlier an ailment, which was treated by a major incision in the body and required hospitalization as “in-patient” for days, and may be weeks, is now treated with a button-hole surgery and, at times, only by a needle pierced in the affected part of the body or a vein/artery and does not need a full-fledged hospitalization. Thus, to the merriment of the insurance companies, more and more methods of treatment of ailments are getting out of the policy coverage due the catch provided in policy through the said clauses. The buyer of the policy, at the time of entering into agreement, believes in the bonafide of company, and particularly in the case of public sector companies, totally oblivious of the fact that, in the bulky policy document, the company has provided enough catches to enable it to repudiate his claims at any future point of time. 18. A mediclaim policy of any insurance company is aimed at covering the insured against expensive treatment of his ailment, which otherwise he may not be in a position to afford, and meet his end on account of it. It is a welfare concept and must work towards the benefit of the people and should not be used as only a money making venture of, at least, the government companies. The whole concept revolves around the ailment of the insured and his/her capacity to its treatment. The method of treatment is hardly important in the matter. Moreover, as said earlier also, with the technological advancements in medical field, methods of treatments are undergoing drastic changes every day. Hence, the method of treatment, in view of this Court, cannot be and should not be the guiding and deciding factor of settling a claim of the insured. In the circumstances, in the opinion of this Court, the whole approach of the respondent company, and may be of other companies also, laying down the terms and conditions of a mediclaim policy is misdirected and against the welfare of the people and solely to enrich themselves. This Court is conscious of the fact that a blanket coverage cannot be granted to the insured as the cost of treatment substantially varies from hospital to hospital. This Court is conscious of the fact that a blanket coverage cannot be granted to the insured as the cost of treatment substantially varies from hospital to hospital. For this the insurance companies can, and they do, provided a list of hospitals with specialized facilities as their “network hospitals” or “empanelled hospitals”, treatment in which only may be covered, barring exceptional circumstances. 19. What has not been considered in this order is the role of respondent no. 4, the Medicare T.P.A. Services(I) Pvt.Ltd., Kolkata, in the whole affair, as the learned counsels for the parties did not advance any argument, whatsoever, in this respect at the time of hearing of the case. However, on the basis of some materials supplied by learned counsel for the petitioner later on, it appears that, it is a private limited company licenced by the Insurance Regulatory and Development Authority (for short “the IRDA”) under the “INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY (THIRD PARTY ADMINISTRATORS – HEALTH SERVICES) REGULATIONS, 2001. From scheme of things, in a nut-shell, it prima facie appears that, the role of a TPA (Third Party Administrator), licenced by the IRDA, is to act as coordinator/intermediary between the insurer (insurance company), insured and the service provider (a hospital/nursing home) and to facilitate cashless service to the insured at the time of hospitalization and, in turn, to make the processing of bills of the service provider, on the one hand, and the settlement of claims of the insured, on the other, hassle free. The insured opting for it, has to pay for services of the TPA and it is included in the premium charged by the Insurance Co. The Insurance Co. offers discount in premium to those who do not opt for it. Questions could arise in this case as to how far the respondent no.4, an independent private limited company, licenced to act as administrator only, had legal authority to influence the decision of the respondent Insurance Co.; how far opinion of its “panel of doctors” and its department was binding on it; how far it could act on behalf of the respondent Insurance Co., take decisions and communicate it to petitioner, etc. A question could also arise whether, petitioner, having not opted for its services, and allowed discount by the respondent Insurance Co. A question could also arise whether, petitioner, having not opted for its services, and allowed discount by the respondent Insurance Co. for it, causing loss to respondent no.4 in turn, became a victim of some malafide design of respondent no.4 ? These questions remain unconsidered in this order as learned counsel of the petitioner did not go into this aspect of the matter. 20. At the end, this Court must clarify that many issues, noticed in this order, are spontaneous thoughts and views of the Court and are tentative as no party had advanced its submissions inviting any opinion by this Court from those angles. Hence, this Court considers it appropriate that, instead of giving findings on the rival claims of the parties, the matter should be referred to the IRDA, a statutory independent authority setup under a Parliamentary Act (Act 41 of 1999) to regulate and monitor the insurance sector in the Country, for it to take a re-look to the entire scheme and concept of health insurance in the Country. This Court does that. In the process, the IRDA shall also review the claim of the petitioner and the validity of decision of repudiation of her claim by the respondent Insurance Company. 21. Writ application is disposed of.