Tamil Nadu

South Chennai

CC/64/2020

Mr.M.G. Mathivanan - Complainant(s)

Versus

Heritage Health Insurance TPA (P) Ltd., Insurance Claim Division, Rep. By Manager and 2 others - Opp.Party(s)

M/s Selvaraju

26 Sep 2022

ORDER

Date of Complaint Filed :16.07.2020

Date of Reservation       :19.09.2022

Date of Order                :26.09.2022

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

CHENNAI (SOUTH), CHENNAI-3.

 

PRESENT:    TMT. B. JIJAA, M.L.,                                            : PRESIDENT

                        THIRU. T.R. SIVAKUMHAR, B.A., B.L.,           :  MEMBER  I 

                       THIRU. S. NANDAGOPALAN., B.Sc., MBA.,     : MEMBER II

 

CONSUMER COMPLAINT No.64/2020

MONDAY, THE 26^th DAY OF SEPTEMBER2022

Mr.M.G.Mathivanan,

2/4, 1^st Lane, V.G.P Salai,

Hospital Road,

Saidapet,

Chennai - 600 015.                                                             ... Complainant

..Vs..

1.Heritage Health Insurance TPA (P) Ltd,

   Insurance Claim Division,

   Rep. by Manager,

   Prince Centre, S-206, II Floor,

   700-710 Mount Road,

   Thousand Lights,

   Chennai - 600 006.

 

2.National Insurance Company Limited,

   Rep. by Manager,

   II Floor, No.46, Moore Street,

   Regina Mansion,

   Chennai - 600 002.

 

3.The Chairman and Managing Director,

   National Insurance Company Limited,

   3,Middleton Street,

   Kolkatta - 700 071.                                                  …Opposite Parties

******

Counsel for the Complainant                    : M/s. M.Selvaraju

Counsel for the 1^st Opposite Party            : Exparte

Counsel for the 2^nd & 3^rdOpposite Parties   : M/s. Vadivel

 

ORDER

Pronounced by the President Tmt. B. Jijaa, M.L.,

1.      The Complainant has filed this complaint as against the Opposite Party under section 12 of the Consumer Protection Act, 1986 and prays to reimburse the claim of surgery cost of Rs.90,000/- together with interest @18% p.a from the date of discharge and to pay a sum of Rs.2,00,000/- for the mental agony suffered and loss due to illegal withholding of amount along with cost of Rs.5,000/-.     

2.     The averments of Complaint in brief are as follows:-

The Complainant availed BOI National Swasthya Bima Policy (Health Insurance Policy) for himself and his family members from the 2^nd Opposite Party since 17.04.2017 vide Policy No.500200501810000227. On 23.04.2018 the Complainant had paid premium amount of Rs.6202/- to the 2^ndOpposite Party and the insurance was valid till 22.04.2019. The Complainant’s wife Mrs.Jayanthy was diagnosed with Gall Bladder stones and underwent Laparoscopic Cholecystectomy surgery on 25.06.2018 and got discharged on 30.06.2018. on 01.09.2018 the Complainant made a claim for a sum or Rs.90,000/- with the 1^st and 2^nd Opposite Parties. The 2^nd Opposite Party abruptly rejected the claim of the Complainant vide letter dated 04.09.2018 stating that as per clause 4.5 the waiting period for Cholecystitis is 2 years , the date of inception of policy is 17.04.2017, since it was the 2^nd year, the cashless cannot be extended. There is no waiting period in the terms of the policy for the treatment of “Cholecystitis” (Removal of stone in the GallBladder) as  claimed by the 2^nd Opposite Party in their letter dated 04.09.2018. The Complainant caused a legal notice on 30.06.2020 to the Opposite Parties claiming the sum of Rs.90,000/- and for compensation. The Opposite Parties in spite of receipt of notice have not come forward to settle the claim of the Complainant. Hence the complaint.

3.  Written Version filed by the 3^rd Opposite Party, adopted by the 2^nd Opposite Party in brief is as follows:-

The Complainant had availed BOI National Swasthya Bima Policy (Health Insurance Policy) No.500200501810000227 for himself and his family members, i.e. (1) M.G.Mathivaanan, (2) Mrs. Jayanthi - wife (3) G.M.Mukundan - son and (4) G.M.Parthiban - son issued by the 2^nd Opposite Party herein for the period 23.04.2018 to 22.04.2019. The 2^ndOpposite Party is the Divisional office and the 3^rd Opposite Party is the Head office. As per the policy the cover was for a sum of Rs.4,00,000/- only and the Complainant paid a premium of Rs.6.202/- to the 2^nd Opposite Party inclusive of GST. Further the averment that while admitting to the hospital the Complainant had made an attempt through the said hospital to do cashless surgery, however the 1^st and 2^ndOpposite Party have denied the same without assigning any reason. The said averment is not correct and true. The opposite parties are bound by the terms and conditions of the policy. They cannot go beyond the terms and conditions of the policy to honour each and every claim of the Complainant simply because there was a policy on the date of incident. It is the duty of the Complainant to pay the hospital bills for the services rendered by the concerned hospital. The rejection of the claim made by the Complainant is not wanton or routine without application of mind, but as per the terms and conditions of the policy. It is submitted that the averments contained in paragraph nos.8 and 9 of the complaint have to be verified and judged in accordance with the terms and conditions of the policy. Hence prayed to dismiss the complaint.

At the stage of filing Proof Affidavit the 2^nd and 3^rd Opposite Parties filed a joint memo stating that they have arrived at the settlement.

4.  Joint Memo Filed by the Complainant and 2^nd and 3^rd Opposite Parties are as follows:-

It is most respectfully submitted that the Complainant and the 2^nd and 3^rd Opposite Parties arrived at a settlement in this matter.  By virtue of the settlement, a consent award may be passed in the following terms:-

By consent there shall be an award for a sum of Rs.75,000/- in full quit of the entire claim in C.C.No.64/2020 in favour of the Complainant and the award shall be payable by the 2^nd and 3^rd Opposite Parties within four weeks from the date of receipt of the copy of the order.

Hence it is prayed that this Hon’ble Commission may be pleased to pass suitable and others as this Hon’ble Commission may deem fit and proper in the circumstances of the case and thus render justice.

The joint memo filed by the Complainant and 2^nd and 3^rd Opposite Parties shall form part and parcel of this order.

5. By virtue of the settlement arrived between the Complainant and Opposite Parties 2 and 3 a consent award is passed in the following terms:

The 2^nd and 3^rdOpposite Parties is liable to pay a sum of Rs.75,000/- towards full and final settlement of the entire claim in C.C. No.64/2020 to the Complainant, within 4 weeks from the date of receipt of this order.

In the result the Complaint is allowed in part. The 2^nd and 3^rd Opposite Parties are directed to pay a sum of Rs.75,000/- (Rupees Seventy Five Thousand Only) towards full and final settlement of the entire claim in C.C. No.64/2020 to the Complainant, within 4 weeks from the date of receipt of this order failing which the above amounts shall carry interest at the rate of 9% p.a from the date of this order till the date of realization.

In the result the Complaint is allowed.

Dictated to Steno-Typist, transcribed and typed by her, corrected and pronounced by us in the Open Commission, on 26^th of September 2022.

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                    B.JIJAA

         MEMBER II                       MEMBER I                         PRESIDENT

 

 

List of documents filed on the side of the Complainant:-

 

 

Ex.A1	23.04.2018	Copy of Policy of Insurance No.500200501810000227
Ex.A2	23.04.2018	Copy of Collection receipt, vide No.500200811810000533
Ex.A3	01.09.2018	Copy of Claim letter
Ex.A4	04.09.2018	Copy of Rejection letter
Ex.A5	-	Copy of BOI National Swasthya Bima Policy terms and conditions
Ex.A6	30.06.2020	Copy of Legal notice
Ex.A7	03.07.2020 & 09.07.2020	Copy of acknowledgements

 

 

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                 B.JIJAA

         MEMBER II                       MEMBER I                        PRESIDENT