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2018 DIGILAW 618 (CAL)

E-Meditek Insurance (TPA) Ltd. v. National Insurance Co. Ltd.

2018-08-29

TAPABRATA CHAKRABORTY

body2018
JUDGMENT : TAPABRATA CHAKRABORTY, J. 1. The subject matter of challenge in the present writ petition is a notice for suspension of services dated 27th February, 2018 issued by the General Manager, National Insurance Company Limited (in short, NIC) to the Chairman, E-Meditek Insurance (TPA) Limited. 2. Shorn of unnecessary details the facts are that the E-Meditek Insurance (TPA) Limited, being the petitioner herein, is a licensed Third Party Administrator (in short, TPA) under the Insurance Regulatory and Development Authority (TPA-Health Services) Regulations, 2016 (in short, the said Regulations). NIC, being the respondent no.1 herein, entered into a health Service Level Agreement (in short, SLA) with the petitioner from time to time since the year 2002. The tenure of the present SLA, which was entered into on 11th August, 2016, is for a period of two years. By an e-mail dated 26th October, 2016 NIC reported that SAIL Group Mediclaim policies for the period from 1st January, 2014 to 31st December, 2014 and for the period from 1st January, 2015 to 31st December, 2015 were serviced by the petitioner and that upon conducting a special audit followed by an audit by the Vigilance department several irregularities and overpayments were noticed and by the said letter the petitioner was asked to deposit an amount of Rs.1,45,43,599/-and to explain as to why its services shall not be discontinued. In reply thereto, the petitioner by an e-mail dated 18th November, 2016 stated inter alia that an amount of Rs.47.61 lakhs has already been paid to NIC and assured that it would comply with all its contractual obligations. Subsequent thereto, a further letter was issued by NIC on 5th April, 2017 stating inter alia that it had suffered loss due to unprofessional handling and payment of fraudulent claims. Subsequent thereto, the petitioner issued a letter dated 20th April, 2017 undertaking to indemnify NIC for the demand of Rs.79,30,850/-subject to production of details and proof and as regards the remaining claim the petitioner requested for mediation or for appointment of an arbitrator. By a further letter dated 1st May, 2017 the petitioner intimated NIC that it is committed to honour all its obligations under the SLA and that in the event the dispute cannot be resolved the matter may be referred for mediation under the Clause 27 of SLA 2014-16 and Clause 22 of SLA 2016-18. By a further letter dated 1st May, 2017 the petitioner intimated NIC that it is committed to honour all its obligations under the SLA and that in the event the dispute cannot be resolved the matter may be referred for mediation under the Clause 27 of SLA 2014-16 and Clause 22 of SLA 2016-18. By a subsequent letter dated 2nd August, 2017 the petitioner intimated NIC that a few of its employees have colluded to perform some illegal acts which include manipulating claims and that some of the said employees have been identified and that a police complaint had been lodged against eight employees. NIC thereafter issued a notice of suspension for services on 27th February, 2018. Soon thereafter the petitioner had a discussion with the management of NIC and submitted a further representation on 6th March, 2018. In the midst thereof, the IRDAI issued an order of suspension of certificate of registration on 20th March, 2018. The said order was challenged by the petitioner and by an order dated 23rd March, 2018 the learned Security Appellate Tribunal stayed the impugned order. 3. Mr. Kar, learned senior counsel appearing for the petitioner-submits that the amount as claimed by the letter dated 26th October, 2016 is based upon a random sampling of claims and the impugned notice dated 27th February, 2018 was issued without taking into consideration the reply submitted by the petitioner on 18th November, 2016 wherein it was categorically indicated that the petitioner had already paid an amount of Rs. 47,61,892/-. The factum of payment of such amount also stands admitted in the subsequent letter issued by NIC on 5th April, 2017. 4. He contends that the petitioner has already indemnified NIC to the extent of approximately Rs.80 lakhs, which amount has been accepted by NIC without any demur and that as regards the other claims of NIC, the petitioner has offered to secure the same by providing a bank guarantee of Rs.50 lakhs or such amount as may be determined by NIC. 5. He argues that the issues which form the subject matter of the impugned notice dated 27th February, 2018 had been the subject matter of discussion between the parties since the year 2014 and the SLA which was operative at the said juncture had already expired. Thus on the basis of the said dispute, NIC had no authority to issue the impugned notice. Thus on the basis of the said dispute, NIC had no authority to issue the impugned notice. Such dispute could have been decided on the basis of the arbitration clause in the SLA of the years 2014 and 2015 as it is well settled that the arbitration clause which forms the part of the contract has to be treated as an agreement independent of the other terms of the contract and that it survives even after the agreement expires. In support of such contention reliance has been placed upon the judgments delivered in the case of M/s. Reva Electric Car Co. P. Ltd. –vs- M/s. Green Mobil, reported in 2012(2) SCC 93 (para 51) and in the case of Enercon (India) Ltd. & Others –vs- Enercon GMBH & Another, reported in 2014(5) SCC 1 (paras 83, 84). 6. He further submits that in the present SLA between NIC and the petitioner there is no provision for suspension. The absence of such power as an express term in the contract would mean that NIC had no authority to issue the impugned notice and as such the impugned notice suffers from a jurisdictional error. In support of such contention reliance has been placed upon a judgment delivered in the case of Management of Hotel Imperial, New Delhi & Ors vs. Hotel Workers’ Union, reported in AIR 1959 SC 1342 . 7. He further contends that the impugned order of suspension involves affectation of fundamental right of the petitioner guaranteed under Article 19(1)(g) of the Constitution of India and Article 14 thereof. The issues involved in the present writ petition are also in the domain of public law element and therefore existence of arbitration clause in the contract cannot be a fetter to maintainability of the writ petition. In support of such contention he has placed reliance upon the judgment delivered in the case of Popcorn Entertainment and Another –vs- City Industrial Development Corpn. and Another, reported in (2007) 9 SCC 593 . 8. According to Mr. Kar the impugned notice seeks to rely upon the criminal cases filed by the petitioner against certain ex-employees as an “admission” on charges of irregularities. and Another, reported in (2007) 9 SCC 593 . 8. According to Mr. Kar the impugned notice seeks to rely upon the criminal cases filed by the petitioner against certain ex-employees as an “admission” on charges of irregularities. The entire approach of NIC is erroneous inasmuch as if the contention of NIC is to be accepted, no insurance company/TPA would ever be in a position to initiate enquiry or adopt appropriate proceedings in law for the purpose of discovering any fraud in relation to insurance claims. NIC had misconstrued the contents of the letters dated 20th April, 2017 and 1st May, 2017 to be admission on the part of the petitioner to avail the dispute resolution clause under the present agreement. 9. Per contra Mr. Chatterjee, learned senior counsel, assisted by Mr. Bhattacharya, learned senior counsel, appearing on behalf of NIC submits that the terms and conditions of the SLA dated 11th August, 2016 need to be considered together and not in isolation. A cumulative reading of all the clauses of the agreement would reveal that the notice dated 27th February 2018, was drawn in meticulous regard to the provisions of the SLA. A particular clause cannot be taken up and highlighted. It has been categorically stated in Clause 12.2.6 of the said agreement that NIC has the authority to cancel the agreement by sending the TPA a thirty days’ notice. The wider power of termination of the agreement includes by necessary implication the lesser power of temporary termination by way of suspension. In support of such contention reliance has been placed upon the judgment delivered in the case of Hindusthan Petroleum Corporation Ltd. & Ors. –vs- Shyam Sundar Ganeriwala, reported in (1988) 2 CHN 233 . 10. He contends that no public law element is involved in the said agreement. The same is a private contract of the insurance company with the intermediary for private service. By the said agreement the petitioner was engaged for providing health services as mentioned under the said Regulations on agreed fees. The scope of judicial review in respect of disputes falling within the domain of contractual obligations is very limited. In support of such contention reliance has been placed upon the judgment delivered in the case of K.K. Saksena –vs- International Commission on Irrigation and Drainage and Others, reported in (2015) 4 SCC 670 . 11. The scope of judicial review in respect of disputes falling within the domain of contractual obligations is very limited. In support of such contention reliance has been placed upon the judgment delivered in the case of K.K. Saksena –vs- International Commission on Irrigation and Drainage and Others, reported in (2015) 4 SCC 670 . 11. He further submits that the said agreement itself provides a dispute resolution clause being Clause 22. The dispute which has occasioned is as to whether NIC could have issued the impugned notice of suspension. For resolution of such dispute the petitioner ought to have availed remedy as provided under Clause 22 of the SLA instead of preferring the present writ petition. 12. He further submits that the SLA executed on 11th August, 2016 is in continuation of the previous agreement with the petitioner and such fact stands admitted by the petitioner in paragraph 4 of the writ petition. In view thereof, the petitioner cannot insist for resolution of the dispute through arbitration in terms of the previous SLA as the claim of NIC pertains to a period prior to the execution of the present agreement on 11th August, 2016. 13. Drawing the attention of this Court to a letter dated 30th June, 2016 at page 319 in the affidavit-in-opposition, Mr. Chatterjee submits that the petitioner failed to pay all the arrears to NIC and upon special audit report it was found that 99 reimbursement claims amounting to Rs.1,16,78,215/- were fictitious as the names of the persons to whom the reimbursement payments were made are different from the names of insured/ patients/nominees. Such fact partly stands admitted by the petitioner, as would be explicit from the petitioner’s letter dated 20th April, 2017 wherein the petitioner had undertaken to immediately indemnify NIC as regards the demand of Rs.79,30,850/- subject of production of relevant supporting details and proof. In the said letter it was also stated that as regards the balance claim of an amount of Rs.18,11,545/- the petitioner had already furnished the details and had requested the Delhi Regional Office-1 for mediation of an independent agency or appointment of an arbitrator. 14. In the said letter it was also stated that as regards the balance claim of an amount of Rs.18,11,545/- the petitioner had already furnished the details and had requested the Delhi Regional Office-1 for mediation of an independent agency or appointment of an arbitrator. 14. He further submits that there is no infirmity in the notice impugned inasmuch as the same has been issued with the sole objective of promoting the legitimate interests of the policy holders as NIC is the repository and custodian of the funds of the policy holders. The fund of all the policy holders is at stake and the NIC has lost its faith and confidence upon the petitioner. 15. He further argues that in view of the personal nature of the service and relationship between the parties, a contract of health service as the one entered into between the petitioner and NIC, is incapable of specific performance and to enforce the performance thereof would be inequitable and NIC cannot be compelled to enter into a relationship involving mutual faith, confidence and continued trust against its will. In support of such contention reliance has been placed upon the judgment delivered in the case of Percept D’Mark (India) (P) Ltd. –vs- Zaheer Khan and Another, reported in (2006) 4 SCC 227 . 16. In reply, Mr. Kar submits that the letter dated 30th June, 2016 is an internal communication and the same has not been issued upon hearing the petitioner and as such no reliance can be placed upon the same. The impugned notice has been issued merely on the basis of a suspicion and mere suspicion cannot be a deterrent towards continuance of relationship with the petitioner. The judgment delivered in the case of Hindustan Petroleum Corporation Ltd. (supra) has no manner of application in the instant case inasmuch as in the same the Court has not decided the issue that a clause towards termination includes suspension. 17. Upon conducting a special audit followed by an audit by the vigilance department, it was ascertained that ninety nine reimbursement claims appeared to be fictitious as the names of persons to whom reimbursement payments were made are different from the names of insured/ patients/ nominees. 17. Upon conducting a special audit followed by an audit by the vigilance department, it was ascertained that ninety nine reimbursement claims appeared to be fictitious as the names of persons to whom reimbursement payments were made are different from the names of insured/ patients/ nominees. Such fraudulent practice as surfaced was the basis towards issuance of the notice dated 26th October, 2016 by which the petitioner was called upon to deposit an amount of Rs.1,45,43,599/- and to explain why NIC shall not discontinue utilizing the services of the petitioner. By a letter dated 2nd August, 2017 issued to NIC the petitioner has stated that a few of its employees have colluded to perform some illegal acts which include manipulating claims and that some of the said employees have been identified and that a police complaint had been lodged against eight employees. In the backdrop of such facts, the argument of Mr. Kar that such incident cannot be a deterrent towards continuance of relationship is not acceptable to this Court. It would be iniquitous to persuade NIC to continue its relationship with the petitioner when it had lost its faith and trust. As such the directions as prayed for in the instant petition would tantamount to grant of a premium to a recalcitrant party to the contract. 18. In paragraph 4 of the writ petition, it has been stated that “the Service Level Agreement was for a period of two years from 8th July, 2014 to 7th August, 2016. Subsequently the petitioner and Respondent entered into a Health Services Agreement dated 11th August, 2016 to continue the effect of the aforesaid agreement dated 8th July, 2014 in compliance with the IRDAI regulations by which the Petitioner agreed to provide services listed therein”. From such averments it is explicit that the SLA of 2016-18 is in continuation of the SLA of 2014-16. By a letter dated 20th April, 2017 the petitioner undertook to indemnify NIC for the demand of Rs.79,30,850/-subject to production of details and proof and as regards the remaining claim the petitioner requested for mediation or for appointment of an arbitrator. From such averments it is explicit that the SLA of 2016-18 is in continuation of the SLA of 2014-16. By a letter dated 20th April, 2017 the petitioner undertook to indemnify NIC for the demand of Rs.79,30,850/-subject to production of details and proof and as regards the remaining claim the petitioner requested for mediation or for appointment of an arbitrator. Subsequent thereto, by a further letter dated 1st May, 2017 the petitioner has intimated NIC that it is committed to honour all its obligations under the SLA and that in the event the dispute cannot be resolved the matter may be referred for mediation under the Clause 27 of SLA 2014-16 and Clause 22 of SLA 2016-18. In the backdrop of the said facts, the petitioner’s contention that the dispute pertaining to the policies of the years 2014 and 2015 cannot be brought within the ambit of Clause 22 of the SLA of the of 2016-18 and that the impugned notice suffers from a jurisdictional error is not acceptable to this Court and the judgment delivered in the case of Popcorn Entertainment and Another (supra) has no manner of application in the present case. 19. No mala fide or arbitrariness can be attributed to the action of the respondents. The dispute as agitated in the present writ petition pertains to a contract and involves serious disputed questions of fact, which are complex in nature. The said dispute cannot be decided in a proceeding under Article 226 of the Constitution of India. 20. A perusal of the impugned notice would reveal that the same was preceded by various correspondences and discussions in between NIC with the petitioner. From the audit conducted prior to issuance of the said notice, numerous irregularities and fraud in claims management by the petitioner were noticed and upon being apprised of such facts, the petitioner itself on the basis of a finding that some of its employees had colluded to perform illegal acts, lodged police complaints against the said employees. It is in the said backdrop of facts, the impugned notice of suspension was issued and there is no infirmity in the decision making process. 21. It is in the said backdrop of facts, the impugned notice of suspension was issued and there is no infirmity in the decision making process. 21. A cumulative reading of all the clauses of the SLA would reveal that the said contract confers specific authority upon NIC to terminate the contract coupled with the authority to maintain strict surveillance upon the TPA and to ensure that the policy holders remain protected. Even after arriving at a finding in an unambiguous manner that there was an element of fraud in claims management by the petitioner, it would be an absurdity to suggest that NIC, having the authority to cancel the contract itself, cannot take steps to close the breach of the terms and conditions of the agreement even after ascertaining that the interest of the policy holders is at stake. In such circumstances, it is not acceptable to this Court that NIC had no authority to issue the impugned notice. The judgment delivered in the case of Management of Hotel Imperial, New Delhi & Ors (supra) pertaining to the ordinary law of master and servant is distinguishable on facts. 22. For the above reasons, this Court is unable to grant the reliefs as prayed for in the writ petition. 23. Accordingly, the writ petition is dismissed. There shall, however, be no order as to costs. Urgent Photostat certified copy of this judgment, if applied for, be given to the parties, as expeditiously as possible, upon compliance with the necessary formalities in this regard.