Date of Filling : 28.01.2015.
Date of Disposal : 27.07.2016.
DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, THIRUVALLUR - 1.
PRESENT: THIRU. S. PANDIAN, B.Sc., L.L.M., … PRESIDENT
TMT. S. SUJATHA, B.Sc., … MEMBER - I
Consumer Complaint No.14/2015
(Dated this Wednesday the 27th day of July 2016)
Mrs. A. Lavanya,
W/o. Mr. A. Satheesh,
No.214, Bazaar Street,
Palavakkam Village and Post,
Uthukottai Taluk,
Thiruvallur District. … Complainant.
/ Versus /
1. The Branch Manager,
Heritage Health Services Ltd.,
Prince Centre, S-206, 2nd Floor,
No.709-710, Mount Road,
Thousand Lights,
Chennai - 600 006.
2. The Branch Manager,
United India Insurance Company Limited,
No.153, J N Road,
Thiruvallur - 602 001. … Opposite parties.
This complaint is coming upon before us finally on 19.07.2016 in the presence of M/s. V. Murali, Counsel for the complainant and Mr. L. Thanigaivel, Counsel for the 2nd opposite party and the 1st opposite party was set Ex-parte for non appearance and having perused the documents and evidences on the side of the complainant and the 2nd opposite party, this Forum delivered the following,
ORDER
PRONOUNCED BY THIRU. S. PANDIAN, PRESIDENT
This complaint is filed by the complainant U/S 12 of Consumer Protection Act, 1986 against the 1st & 2nd opposite parties for seeking the balance claim of Rs.25,579.50 along with 12% interest p.a. from 04.12.2014, to settle the pre-hospitalizaiton bills of Rs.8,163.90 and to pay Rs.50,000/- towards compensation for causing mental agony with cost Rs.5,000/-.
The brief averments of the complaint is briefly as follows:-
The complainant has taken for herself, for her two sons and for her from the 2nd opposite party on 26.03.2007. From that day onwards, she is renewing the policy periodically. The latest policy No.012002/48/13/97/00000911 for the period covering from 26.03.2014 to 25.03.2015 for the sum insured Rs.2,00,000/-on herself and Rs.1,00,000/- on her both sons namely A. Keethivardhan and A. Harshavardhan respectively.
2. That her elder son A. Keethivardhan was fainted in his school in the last week of Nov-2014. Subsequently, he was developed a swelling around the right ear. Immediately he was taken to Vijaya Hospital, Vadapalani, Chennai on 02.12.2014 and consulted ENT Specialist Dr. N.S. Reddy. There the Doctor advised him to take Blood test and CT scan immediately On perusing the reports and CT Scan Doctor advised the complainant that to admit her son A. Keethivardhan. Immediately on 03.12.2014 at 9:00 AM, A. Keethivardhan was operated in the Right ear. After the operation he was shifted to ICU and after to the ward. The next day on 04.12.2014 at about 6:00 PM the Doctor advised the complainant to discharge her son from the hospital.
3. At the time of admission itself, she submitted the Insurance particulars to the Hospital authorities they in turn informed the complainant that the same was forwarded to the 1st opposite party, who is the official TPA of the 2nd opposite party, the 1st opposite party processed the claim. At the time of discharge hospital authorities informed the complainant that the 1st opposite party has approved for Rs.28,000/- out of the final bill of Rs.53,579.50, which was billed by Vijaya Hospital, Vadapalani. Then, the complainant had approached the 1st opposite party, who in turn informed the complainant that as per the policy conditions the complainant is only eligible for that amount otherwise approach the 2nd opposite party. Since, there is no other option left to the complainant, she paid the balance amount of Rs.25,579.50 by cash and discharged the complainant’s son from the hospital. Further, pre-hospitalization bills of the Doctor fees, Blood test bill and the CT Scan bills to the tune of Rs.8,163.90 was also not included in the final bill.
4. To know the reason for reduced claim the complainant made representation to both the opposite parties to the address mentioned in the policy bond on 12.12.2014 through Registered post seeking the opposite parties to furnish the reasons for not settling the claim amount of Rs.53,579.50 fully. The letter sent to the 1st opposite party is yet to be returned and the letter sent to the 2nd opposite party is duly served on him on 16.12.2014, but till date both the opposite parties were not replied to the complainant’s letter and thereby, not doing their statuary obligation giving particulars to the policy holders. Both the opposite parties were failed to discharge their duties, that itself shows the deficiency in their services. The irresponsible acts of the opposite parties caused lot of mental agony, hardship and monetary loss to the complainant. Hence, the complainant filed this complaint.
5. The contention of written version of the 2nd opposite party is briefly as follows:-
The complaint is not maintainable in law and on facts. The opposite party admits that the complaint had taken a policy for her son for a period from 26.03.2014 to 25.03.2015 for a sum of Rs.2,00,000/- and other allegation are not true and are denied. The complainant’s son had underwent ENT surgery on November 2014. If the complainant’s son had the pre-history any major ailments as stated above, she will have to disclose the particular ailment to the Insurance company. Then the insurance company will continue the policy by not covering the known ailment as per their terms and conditions available in the policy. This was known to the complainant through the 1st opposite party when the policy was taken by her. The insurance company will have to follow the rules and regulations as in the policies and that too New Rule 6 of the said policy and not as alleged in the complaint.
6. The 1st opposite party is the authorized agent of the insurance company for giving easy and speedy disposal for the claimants and the 1st opposite party will act according to the rules and regulation of the policies. Infact, the 2nd opposite party has approved the calculations given by the 1st opposite party and the 2nd opposite party can pay only 70% of the claim amount to the complainant as per the rules and regulations of the Insurance Company which was paid to the complainant and the complaint itself is unnecessary one It is further submitted that the room rent charged by the hospital authorities in the final bill is highly excessive and the doctor’s fees as charged in the final bill is also excessive. The Hon’ble Forum has no jurisdiction to try this complaint. The damage sought for by the complainant is an imaginary one and the cause of action alleged is incorrect and the documents filed along with the complaint are all not related to the claim of complainant. Hence, the complaint is liable to be dismissed with cost.
7. In order to prove the case, on the side of the complainant, the proof affidavit submitted for his evidence and Ex.A1 to Ex.A11 were marked. While so, on the side of the 2nd opposite party, the proof affidavit is filed and no document is filed on his side.
8. At this juncture, the point for consideration before this Forum is:-
- Whether there is any deficiency of service on the part of the opposite parties as alleged in the complaint?
- To what other reliefs, the complainant is entitled to?
9. Written arguments filed by the complainant. Inspite of sufficient time given for filing of written arguments and for adducing oral arguments the 2nd opposite party has not come forward neither to file the written arguments nor for oral arguments. Hence written arguments and oral arguments on the side of the 2nd opposite party is closed.
10. Point no.1:-
On perusal of the averments of the complaint, as well as the evidences on the side of the complainant, it is learnt that the complainant has taken Health Insurance Policy to her son from the 2nd opposite party on 26.03.2007 through the 1st opposite party for a sum assured Rs.2,00,000/- for the period covering from 26.03.2014 to 25.03.2015, for which, the copy of the policy is marked as Ex.A1. It is further learnt that the complainant’s son was developed a swelling around his right ear and was admitted in M/s. Vijaya Health Centre, Vadapalani, Chennai on 02.12.2014 as in patient and undergone an operation in his right ear on 03.12.2014 and discharged from the hospital on 04.12.2014 and the discharge summary is marked as Ex.A2 and the medical bills are marked from Ex.A3 to Ex.A7 & Ex.A9 respectively and thereafter, the 1st opposite party process the calculation, the 2nd opposite party had approved for Rs.28,000/- out of the final bill of Rs.53,579.50/- though the complainant insured for Rs.2,00,000/- and therefore, the complainant had paid the balance amount of Rs.25,579.50 in cash and got discharged from the hospital and thereby, the opposite parties caused mental agony and hardship which leads to deficiency in service. Then, the complainant sent Ex.A10, letter to the opposite parties and the acknowledgement card of the 2nd opposite party is are marked as Ex.A11.
11. On the other hand, on going through the written version and the evidence adduced on the side of the 2nd opposite party, it is learnt that the only contention by the 2nd opposite party is that “the insurance company will have to follow the rules and regulations in the policies and that too New Rule 6 of the said policy” and as per the rules and regulations and the calculations given by the 1st opposite party, the 2nd opposite party can pay only 70% of the claim amount to the complainant and the same was paid to the complainant and therefore, there is no deficiency in service on the part of the 2nd opposite party.
12. At the outset, on careful perusal of the rival submissions put forth on either side, it is crystal clear that except the contention about the claim amount and other materials facts narrated in the complaint are all admitted one. In such circumstances, the duty cast upon this Forum to decide whether the contention raised by the 2nd opposite party has been established and as per the rules and regulations mentioned in rule 6 of the claim amount have been settled. First of all, on seeing the Ex.A9 Series, the final bill issued by M/s. Vijaya Health Centre the total bill amount is Rs.53,579.50 and the claim amount awarded by the 2nd opposite party is Rs.28,000/- was deducted and the remaining amount comes out Rs.25,579.50 and the said amount was paid by the complainant for which Ex.A9 Series is marked. From these documents, it is crystal clear that the 2nd opposite party has settled a sum of Rs.28,000/- out of the total bill amount of Rs.53,579.50. These facts are admitted by both parties.
13. Such being so, as per the evidence of the 2nd opposite party, it is stated that as per the rules and regulations of the policy, the calculation has been submitted by the 1st opposite party, the 2nd opposite party was awarded the claim amount of Rs.28,000/- and further it is admitted by the 2nd opposite party that as per the rules and regulations they can pay only 70% of the claim amount of the complainant. If it is so, whether to that extent of 70% was fulfilled by the 2nd opposite party is in question. At this point of time, this Forum has to calculate the 70% of the claim amount is just and necessary as already pointed out in the total bill amount as per Ex.A9 Series is of Rs.53,579.50. So, 70% of the said amount is calculated as Rs.37,505/-. The amount already settled by the 2nd opposite party is of Rs.28,000/- and the balance of amount of Rs.9,505/- which has to be paid by the 2nd opposite party as per rules and regulation of the 2nd opposite party’s insurance company.
14. The next point to be decided is how the amount of Rs.28,000/- has been arrived by the 2nd opposite party?. In this regard, it is learnt from the evidence of the 2nd opposite party that as per the calculation submitted by the 1st opposite party only, the 2nd opposite party has arrived the amount of Rs.28,000/- But such calculation statement has not been filed before this Forum by the 2nd opposite party in order to substantiate the same. Moreover, the 1st opposite party who has submitted the said calculation statement to the 2nd opposite party is remained Ex-parte. Moreso, such alleged calculation statement has not been filed by the 2nd opposite party before this Forum. Therefore, in what basis the said calculation statement have been prepared or calculated by whom and in what aspect it has been arrived as Rs.28,000/- are all in dark. From the above facts and circumstances, the 2nd opposite party has not established that the calculation statement for Rs.28,000/- was arrived as per the rules and regulations under rule 6 of the policy and 70% of the claim amount. Therefore, this Forum can easily to arrive that the calculation of Rs.28,000/- is not a full pledged one and thereby, there is a deficiency of service on the part of the opposite parties to that extent and failing to pay the correct claim amount to the complainant.
15. Regarding, the separate claim of Rs.8163.90, it is pertinent to note that as per the averments of the complainant itself, it is a pre-hospitalization bill. Moreover, the said amount has not been claimed before the opposite party through the Medi-claim policy as mentioned in the complaint. Therefore, such amount of bill has not been considered by the opposite party and hence no question of deficiency of service arose. At this point of time, the said amount cannot be taken into consideration in this complaint by this Forum. Thus, point no.1 is answered accordingly.
16. Point no.2:-
As per the decision arrived in point no.1, it is crystal clear that the claim amount paid by the 2nd opposite party to the complainant is not correct as per Rule 6 of the policy and also not up to 70% of the claim and therefore, the complainant is only entitled for the balance claim amount to the extent of 70% of the total claim of the complainant with reasonable compensation and cost and not entitled for other reliefs as prayed in the complaint. Thus, point no.2 is answered accordingly.
17. In the result, this complaint is allowed in part. Accordingly, the 1 & 2nd opposite parties are jointly or severally directed to pay a sum of Rs.9,505/- towards the balance claim amount as per the terms and conditions of the policy and to pay a sum of Rs.5,000/- towards compensation for causing mental agony and hardship due to the deficiency of service on the part of the 1 & 2nd opposite parties and Rs.5,000/- towards cost totally of Rs.19,505/- (Rupees nineteen thousand five hundred and five only). In respect of other reliefs, this complaint is dismissed.
The above amount shall be payable within one month from the date of receipt of the copy of the order, failing which, the said amounts shall carry interest at the rate of 9.5% till the date of payment.
Dictated by the president to the steno-typist, transcribed and computerized by him, corrected by the President and pronounced by us in the open Forum on this 27th July 2016.
Sd/-**** Sd/-****
MEMBER - I PRESIDENT
List of documents filed by the complainant:-
Ex.A1 | 26.03.2014 | Policy issued by the 2nd complainant | Xerox copy |
Ex.A2 | 04.12.2014 | Discharge summary of the complainant’s son | Xerox copy |
Ex.A3 | 02.12.2014 | Doctor consultation fees bill for Rs.500/- | Original |
Ex.A4 | 02.12.2014 | Medical bill | Original |
Ex.A5 | 02.12.2014 | CT Scan bill | Original |
Ex.A6 | 02.12.2014 | Laboratory bill | Original |
Ex.A7 | 03.12.2014 | Vijaya Hospital Advance bill | Original |
Ex.A8 | 04.12.2014 | Authorization letter of Heritage Health Services | Xerox copy |
Ex.A9 | 04.12.2014 | Vijaya Hospital Final bill | Original |
Ex.A10 | 12.12.2014 | Letter sent by the complainant to the opposite parties with postal receipts | Xerox copy |
Ex.A11 | 16.12.2014 | Acknowledgement card of the 2nd opposite party | Original |
List of documents filed by the 2nd opposite party:-
Nil.
Sd/-**** Sd/-****
MEMBER - I PRESIDENT
