Tamil Nadu

South Chennai

229/2011

.Vijaya Raghavan - Complainant(s)

Versus

HFC ERGO Genral insurance Company Ltd - Opp.Party(s)

V.Balaji

14 Feb 2018

ORDER

                                                                        Date of Filing :   09.08.2011

                                                                        Date of Order :   14.02.2018

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, CHENNAI (SOUTH)

     2^nd Floor, Frazer Bridge Road, V.O.C. Nagar, Park Town, Chennai-3

PRESENT: THIRU. M.MONY, B.Sc., L.L.B. M.L.,                     : PRESIDENT            

                  TMT. K.AMALA, M.A. L.L.B.,                                 : MEMBER I

             DR. T.PAUL RAJASEKARAN, M.A ,D.Min.PGDHRDI, AIII,BCS : MEMBER II

C.C.NO.229/2011

   WEDNESDAY THIS 14^TH DAY OF FEBRUARY 2018

 

Mr. S.Vijaya Raghavan,

S/o. N.Srinivasan,

Old No.11/12, New No.25,

Second Floor,

Canal Bank Road,

CIT Nagar East,

Nandanam, Chennai 600 035.                 .. Complainant

                                                  ..Vs..

 

HDFC ERCO General Insurance Co. Ltd.,

Rep. by its Manager,

Old No.559, New No.528,

Second Floor,

Anna Salai, Thenampet,

Chennai 600 018.                                      .. Opposite parties.

Counsel for Complainant          :   M/s.V.Balaji & another         

Counsel for opposite party       :   M/s.M.B.Gopalan & others.   

ORDER

THIRU. T.PAUL RAJASEKARAN ::    MEMBER-II

This complaint has been filed by the complainant against the opposite party under section 12 of the Consumer Protection Act 1986 seeking direction to pay a sum of Rs.90,722/- towards the hospitalization charges and to pay a sum of Rs.25,000/- towards compensation for mental agony and Rs.5000/- as cost of the compliant.

 1. The averment of the complaint in brief are as follows:

 The complainant submit that he is a savings bank account holder and credit card holder  of the opposite party.  On 25.03.2010 he took health Suraksha  Policy for Rs.2,00,000/- under policy No.50190019  which is a mediclaim policy and Sarv Suraksha Policy for Rs.10,00,000/- on 25.03.2010 under policy No.50190020  which is a “life cover policy” with personal accident benefit.  Further the complainant also state that due to stomach pain complainant under the direction of Dr. Bharadwaj, Dr. R. Vijayakumar asked the complainant  to take scan and other tests. Based on the test complainant was admitted in RG Urology and Laparoscopy Hospital on  18-08-2010 and undergone surgery on 19-08-2010  Left Open Pyeloplasty and JJ stenting   was performed with  General Anaesthesia and got discharged on 25-08-2010.   Further the complainant state that before admitting for surgery the complainant claimed cashless service which was denied by the opposite party.  The reason for denial is claim falls under the first two years exclusion clause of the policy”.   The repudiation was directly sent to the hospital itself.   After the discharge the complainant met the opposite party and requested them to issue the claim.   The opposite party states that already they have repudiated the claim and issuing claim form does not arise.   As such the act of  the opposite party amounts to deficiency in service which caused mental agony and hardship to the complainant.  Hence this complaint is filed.

2.    The brief averments in Written Version of  the  opposite parties is  as follows:

The  opposite party deny each and every allegations except those that are specifically admitted herein.  The opposite party submit that the policy covers expense of hospitalization for treatment of ailments, subject to specific exclusions.  In particular vide clause 4 (c ) (ii) of the policy, there is specific exclusion of certain ailments during the first two years of insurance, especially surgery of genitor urinary system unless & Laparascopy Hospital from 18.8.2010 to 25.8.2010 which was intimated to the third party administrator M/s. Family Health Plan Limited by the hospital with request for cashless facility.    In view of the fact that the policy was in its first year and the ailment was clearly excluded, the third party administrator had rejected the cashless service.  No further claim was made by the complainant admittedly.  The denial of cashless service cannot be considered to be deficiency in service as the “Health Suraksha Policy” is a reimbursement policy under which Cashless facility” is given as an add on benefit to the customer subject to the terms and conditions of the policy.   The insured is always open to raise a reimbursement claim at the later stage even after the denial of the cashless facility.   This  has been mentioned in the letter sent by the TPA.   It is required to be noted that the denial of cashless facility does  not tantamount to repudiation of the claim, especially when the complainant made no formal claim after treatment or submitted any medical records or bills to the opposite party.   Hence there is no deficiency in service on the part of the  opposite party and the complaint is liable to be dismissed.

3.     In order to prove the averments of the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A4 marked.  Proof affidavit of opposite party filed and Ex.B1 to Ex.B4 marked  on the side of the  opposite party.

4.   The points for the consideration is: 

1. Whether the complainant is entitled to get Rs.90,722-  towards   hospitalization charges as prayed for?.

 

2. Whether the complainant is entitled to get Rs.25,000- for mental agony and deficiency of services with cost of Rs.5000/-  as prayed for?

 

5.   POINTS 1 & 2:

Heard both sides and Perused the records (viz)complaint, written version, proof affidavit and documents.   The Complainant is a savings bank account holder and credit card holder  of the opposite party.  On 25.03.2010 he took health Suraksha  Policy for Rs.2,00,000/- under policy No.50190019  which is a mediclaim policy Ex.A1 and Sarv Suraksha Policy for Rs.10,00,000- on 25.03.2010 under policy No.50190020  which is a life cover policy with personal accident benefit as per Ex.A2.

6.     The learned counsel for the complainant contended that due to stomach pain complainant under the direction of Dr. Bharadwaj, Dr. R. Vijayakumar asked the complainant  to take scan and other tests. Based on the test complainant was admitted in RG Urology and Laparoscopy Hospital on  18-08-2010 and undergone surgery on 19-08-2010  left open Pyeloplasty and JJ stetting   was performed with  General Anaesthesia and got discharged on 25-08-2010 as per Ex.A4. 

7.   The learned counsel for the complainant contended that before admitting for surgery the complainant claimed cash less service which was denied by the opposite parties.  After surgery the opposite party repudiated the claim stating that the surgery was conducted within two years and as per the exclusion clause the complainant is not entitled  for  Rs.90,722/- reimbursement towards pre hospitalization charges.   Surgery charges and post hospitalization charges.  Ex.A4 is the discharge summary.   The learned counsel for the complainant contended that as per the medical literature prostate cancer is as follows:

The prostate gland is located in a man’s pelvis underneath the bladder.  Where it supports the reproductive process.  The prostate cells that can become cancerous cells that produce many of the components of a man’s ejaculate or semen.

Because of its highly variable behavior most men found with the disease must be carefully assessed for exactly how aggressive the cancer is.  This assessment can best be accomplished in a multidisciplinary clinic staffed by urologists, pathologist, radiation oncologists and medical oncologists who can provide the best possible estimate as to how aggressive his cancer is and what all of his management options are.

8.     The learned counsel as per decision reported in

III (2007) CPJ 34 (NC)

NATIONAL INSURANCE CO. LTD.

..Vs..

D.P. JAIN

 

The  learned counsel for the opposite party contended that the complainant has not submitted any claim form any record except the request made for the cashless treatment at the very inception, without submitting the claim form with records filing this case for compensation as deficiency in service is untenable and premature.  But the opposite party admitted both policies  of health Suraksha policy and Sarva Suraksha policy and the complainant was emergently admitted in the hospital and undergone surgery.  Further the contention of the opposite party is that as per the policy it covers expense towards hospitalization for treatment subject to the exclusions in clause 4 (c ) (ii) of the policy (i.e) ailments during the first two years of insurance related to surgery of genitor urinary system unless necessitated by malignancy for which the complainant underwent treatment at R.G. Urology and Laparscopy Hospital from 18.8.2010 to 25.8.2010 was intimated to the 3^rd party administrator M/s. Family Health Plan Limited by the Hospital since the operation was conducted within the first year of the policy, the 3^rd party administrator rejected the service.   But on a careful perusal of the medical literature the exclusion clause is not applicable in this case.  Further the contention of the opposite party is that the allegation of the deficiency in service is imaginary.  The treatment for Geneto urinary system unless necessitated by malignancy is excluded during the first two years.   As per the medical literature 

The prostate gland is located in a man’s pelvis underneath the bladder,  Where it supports the reproductive process.  The prostate cells that can become cancerous are cells that produce many of the components of a man’s ejaculate or semen.

Because of its highly variable behavior most men found with the disease must be carefully assessed for exactly how aggressive the cancer is.  This assessment can best be accomplished in a multidisciplinary clinic staffed by urologists, pathologist, radiation oncologists and medical oncologists who can provide the best possible estimate as to how aggressive his cancer is and what all of his management options are.

9.  The learned counsel as per decision reported in

I (2000) CPJ 1 (SC)

SUPREME COURT OF INDIA

M/S. MODERN INSULTAORS LTD.,

..Vs..

ORIENTAL INSURANCE CO. LTD.,

Considering the facts and circumstances of the case,  this forum is of the considered  view that the opposite party shall pay a sum of Rs.90,722/- towards hospitalization charges and compensation of Rs.10,000/- for mental agony and cost of Rs.5,000/- to the complainant and the points are answered accordingly.

In the result the complaint is allowed in part.   The opposite party shall pay a sum of Rs.90,722/-  (Rupees Ninety thousand seven hundred and twenty two only)  and also shall pay compensation of Rs.10,000/- (Rupees ten thousand only)  for mental agony with cost of Rs.5000/- (Rupees five thousand only) to the complainant. 

The aboveamounts shall be payable within six weeks from the date of receipt of the copy of this order, failing which, the said amounts shall carry interest at the rate of 9% p.a to till the date of payment.

 

          Dictated by the President to the Assistant, taken down, transcribed and computerized by her, corrected by the Member-II and pronounced by us in the open Forum on this the 14^th day  of  February 2018.  

 

 MEMBER-I                        MEMBER-II                             PRESIDENT.

Complainant’s side documents:

Ex.A1- 25.3.2010  - Copy of Health Suraksha Policy.

Ex.A2- 25.3.201    - Copy of Sarv Suraksha Policy.

Ex.A3- 17.8.2010  - Copy of Repudiation letter.

Ex.A4- 25.8.2010  - Copy of Discharge summary.

Opposite party’s side document: -  

 

Ex.B1-              - Copy of policy.

 

Ex.B2-               - Copy of tests reports.

 

Ex.B3-              - Copy of cashless application.

 

Ex.B4-            - Copy of denial of cashless facility.

 

 

MEMBER-I                        MEMBER-II                             PRESIDENT.