Date of Filling     :  28.04.2016.

                                                                                           Date of Disposal :  09.12.2016.

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.19/2016

(Dated this Friday the 09^th day of December 2016)

N.C. Ravichandran,

S/o. Mr. N.C. Sadagopan,

No.161, Jawaharlal Nehru Road,

Thiruvallur District and Taluk - 602 001.                              … Complainant.

/ Versus /

1.  The Manager,

     United India Insurance Company Limited,

     Represented by its Branch Manager,

     No.153, Jawaharlal Nehru Road,

     Thiruvallur Taluk & Town,

     Thiruvallur - 602 001.     

2.  Heritage Health T.P.A. Private Limited,

     Prince Centre,

     S.206, 2^nd  Floor,

     Thousand lights,

     Chennai - 600 006.                                                   … Opposite parties.

This complaint is coming upon before us finally on 28.11.2016 in the presence of M/s. N. Madhavi, Counsel for the Complainant and the  1 & 2^nd opposite parties are set Exparte for non appearance and upon hearing the oral arguments, having perused the documents, evidences and written arguments of the Complainant, 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 1 & 2^nd opposite parties for claiming Rs.12,866/- towards medical expenses, Rs.5,00,000/- towards compensation for mental agony caused to the complainant with cost.

2.       The brief averments of the complaint as follows:-

          The complainant is practicing as an Advocate at Thiruvallur for the past 35 years.  The complainant took a Health Insurance Policy with the 1^st opposite party for Rs.3,25,000/-.  The complainant at frequent intervals got fever from 2013 onwards and consulted many doctors, the problem did not cease.  Finally, Dr. Sudhakar attached to the Ramachandra Medical College and Hospital gave treatment.  Dr. Sudhakar advised the complainant to be inpatient for observation.  During that period, all the tests were taken, the complainant was inpatient on 25.03.2014 and spent Rs.35,885/-.  The complainant submitted the policy and all the medical records were submitted to the 1^st opposite party.  But the 2^nd opposite party, on 22.04.2014 repudiated the claim.  Reply was sent on 08.05.2014.  On 11.06.2014, the 1^st opposite party asked the complainant to furnish certain documents.  On 18.06.2014, the complainant submitted the papers.  The 1^st opposite party agreed and gave reply dated 17.07.2014 that they are prepared to pay the amount.  On 01.11.2014, the 2^nd opposite party informed that Rs.23,019/- was paid.  The complainant was not consulted and the payment made by the 2^nd opposite party is wrong.  The sum of Rs.12,866/- is due to the complainant.  On 19.11.2014 and 29.01.2015, the complainant gave a complaint and no action was taken.  Hence the complaint.

3.       In spite of sufficient time and opportunities given, the opposite parties did not turn up before this Forum and therefore, the opposite parties were set Exparte. 

4.       In order to prove the case of the complainant, the complainant has filed the proof affidavit as his evidence Ex.A1 to Ex.A8 are marked.

5.    At this juncture, the point for consideration before this Forum is:-

1. Whether there is any deficiency of service on the part of the 1 & 2^nd opposite parties as alleged in the complaint?

     2. To what other reliefs, the complainant is entitled to?

6.       Written arguments filed and also oral arguments adduced on the side of the complainant.  Though the 1 & 2^nd opposite parties remained       Ex-parte, this Forum wants to dispose the case fully on merits.

7.       Point no.1:-

According to the case of the complainant is that, the opposite party failed to pay the claim amount of Rs.12,866/- in full as per the terms and condition of the policy even the complainant is fully eligible for the said claim which leads to the deficiency of service on the part of the opposite parties.  In such circumstances, this Forum has to consider as to whether the complainant has proved the averments made in the complaint by means of relevant and consistent evidence. 

8.       First of all, on going through the evidence adduced on the side of the complainant, the complainant took Health Insurance Policy with the 1^st opposite party for Rs.3,25,000/-, which is an admitted fact.  It is further learnt that the complainant got fever and in connection with that he was admitted as inpatient on 25.03.2014 in the Ramachandra Medical College and Hospital as advised by the Dr. Sudhakar and spent Rs.35,885/-.   In continuance, when the complainant claimed the medical expenses, the 2^nd opposite party repudiated his claim on 22.04.2014 which is marked as Ex.A1 and for which, the complainant has sent Ex.A2, reply dated:08.05.2014 to the 1^st opposite party.  On receipt of the Ex.A2, the 1^st opposite party to reconsider the matter and requests for certain documents for further levy of the said claim which is marked as Ex.A3 and the reply sent by the complainant is marked as Ex.A4.  It is further learnt that after receipt of the Ex.A4, the 1^st opposite party has agreed and prepared to pay the amount and sent Ex.A5 and Ex.A6, communications.  On 01.11.2014, the 2^nd opposite party has informed that they would pay Rs.23,019/-.   But the complainant is not agreeing for the said amount which is wrong calculation and the sum of Rs.12,866/- was due to the complainant.

9.       In this connection, the complainant gave a complaint by means of letters dated 19.11.2014 and 29.01.2015 respectively which are marked as Ex.A7 & Ex.A8. But no action was taken by the opposite parties.  Though the complainant has been paying the policy right from 2014 onwards, the contention of the opposite party is not proper.  The complainant further deposed that the action of the opposite parties is against law and amount for deficiency of service and thereby, he has been put to mental hardship and agony.

10.     In the light of above facts, circumstances and the evidence adduced by the complainant, it is crystal clear that the complainant has proved the allegations made in the complaint in a proper manner by means of cogent and consistent evidence.  If it is so, in order to disprove the allegations made by the complainant, the opposite parties have neither appeared before this Forum nor to produce any kind of evidence.  In such circumstances, it goes without saying that there is no contra evidence to the case of the complainant.  Therefore, this Forum can easily to draw an adverse inference against the opposite parties.  Therefore, this Forum without any hesitation comes to the conclusion that there is deficiency of service on the part of the opposite parties which would certainly caused mental agony and hardship to the complainant.  Thus the point no.1 is answered accordingly.

11.     Point no.2:-

Regarding this point, it is seen from the written arguments submitted by the complainant that, though the complainant claimed Rs.12,866/- he has restricted the due amount to the tune of Rs.9,948/- only instead of Rs.12,866/- and the same has to be taken into consideration.  Further regarding the compensation, as per the conclusion arrived in point no.1 the attitude of the opposite parties have certainly caused mental agony and hardship to the complainant cannot be disputed.  Therefore, the complainant is entitled for reasonable compensation with cost.  Thus point. No.2 is answered accordingly.

In the result, this complaint is allowed in part.  Accordingly, the 1^st opposite party is only directed to pay a sum of Rs.9,948/- (Rupees nine thousand nine hundred and forty eight only) towards claim amount and to pay a sum of Rs.5,000/- (Rupees five thousand only) towards compensation for the deficiency of service on the part of the 1^st opposite party along with the cost of Rs.3,000/- (Rupees three thousand only) totally of Rs.17,948/- (Rupees seventeen thousand nine hundred and forty eight only) to the complainant.   Regarding the 2^nd opposite party, this complaint is dismissed.

 The above amounts shall be payable within one month from the date of receipt of the copy of the order, failing which the said amount shall carry interest at the rate of 9.5% p.a.  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 09^th  December 2016.

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MEMBER - I                                                                             PRESIDENT

List of documents filed by the complainant:-

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MEMBER - I                                                                             PRESIDENT