Tamil Nadu

South Chennai

CC/14/2019

Dr. Suresh Prabhakar Kumar - Complainant(s)

Versus

India Health Insurance Ltd., - Opp.Party(s)

M/s. R Karhikeyan

13 Aug 2019

ORDER

                                                                        Date of Filing  : 19.11.2018

                                                                          Date of Order : 13.08.2019

                                                                                  

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (SOUTH)

@ 2^ND Floor, T.N.P.S.C. Road, V.O.C. Nagar, Park Town, Chennai – 3.

 

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

TR. R. BASKARKUMARAVEL, B.Sc., L.L.M., BPT., PGDCLP.  : MEMBER

 

C.C. No.14/2019

DATED THIS TUESDAY THE 13^TH DAY OF AUGUST 2019

                                 

Dr. K. Suresh Prabakara Kumar,

S/o. Late M. Kumaradas,

No.100-A, Redhills Road,

Lakshmipuram,

Perambur,

Chennai – 600 099.                                                         .. Complainant.                                               

 

                                                                                                 ..Versus..

 

MD India Health Insurance TPA Private Limited,

Rep. by its Managing Director,

New Door No.443 & 445, Old Door No.304 & 305,

Guna Complex,

Anna Salai,

Teynampet,

Chennai – 600 018.                                                    ..  Opposite party.

          

Counsel for the complainant  :  M/s. R. Karthikeyan & others

Opposite party                        :  Exparte

 

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite party under section 12 of the Consumer Protection Act, 1986 prays to reimburse the amount of Rs.2,31,461/- with interest at the rate of 18% p.a. and to pay a sum of Rs.2,00,000/- towards compensation for mental agony and financial loss and expenses suffered by the complainant with cost.

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

The complainant submits that he is the nominee and caretaker of his mother namely; Mrs. D. Prathavathi (Late) she has retired from the Government service on attainment of the age of superannuation as a teacher on April 1990.  The complainant submits that his mother availed medical insurance policy vide policy No.A304218 with the opposite party.   The complainant submits that on 06.11.2016, the complainant’s mother fell down and suffered injury on the head and face immediately Brain CT scan was taken and diagnosed as Acute (L) fronto tempero parietal subdural heamatoma causing midline shift with extensive intraventricular hemorrhage along with septicemia and Acute renal shut down.   Then, the complainant’s mother was admitted in the Lake View Hospital on 06.11.2016 at 06.00 A.M. and was treated as an ICU patient.  The complainant submits that on 11.11.2016, the complainant’s mother had developed Oliguria and treatment was given by the Doctors of Lake View Hospital since her Creatinine Level increased the Doctors recommended for emergency hemodialysis and she was immediately referred to Sundaram Medical Foundation, Anna Nagar on 12.11.2016 for dialysis and once her general condition stabilized, she was shifted to Lake View Hospital.  The complainant submits that his mother was admitted at Sundaram Medical Foundation on 12.11.2016 and has been paid registration fee. The complainant submits that while his mother was inpatient at Sundaram Medical Foundation Hospital from 12.11.2016 till 17.11.2016 he has paid medical charges to the above hospital for the period of his mother stay in that hospital.

2.     The complainant submits that on 17.11.2016, his mother developed hypertension while undergoing hemodialysis and she was declared dead by the hospital management at 09.18 A.M. on the same day.  The complainant submits that soon after the death of his mother, he intimated to the opposite party through email and claimed for reimbursement of medical expenses.  The complainant submits that he made several oral requests with the opposite party to disburse the medical expenses incurred for his mother’s treatment.  But the opposite party turned deaf ears to the complainant’s requests.  The complainant submits that his mother was paying her policy premium through her salary towards insurance with the opposite party when she was in Government service with the fond hope that the policy may render protection against uncertainties which may arise in future. The complainant submits that though he is a nominee and beneficiary of his mother, the opposite party has failed to disburse the medical expense incurred for the complainant’s mother.  The complainant submits that on 05.11.2018 issued a legal notice to the opposite party demanding his claim but no reply from the opposite party.  The act of the opposite party amounts to deficiency in service and unfair trade practice which caused great mental agony.  Hence, the complaint is filed.

3.     In spite of receipt of notice, the opposite party has not been appeared before this Forum and hence, the opposite party was set exparte.

4.     Though the opposite party remained Exparte, this Forum is to dispose this compliant fully on merits with available materials before this Forum. 

5.     In such circumstances, in order to prove the allegations made in the complaint the proof affidavit is filed by the complainant as his evidence, and also documents Ex.A1 to Ex.A16 are marked.

6.      The points for consideration is:-

1. Whether the complainant is entitled to reimburse the medical expenses of Rs.2,31,461/- incurred with interest at the rate of 24% p.a. as prayed for?

2. Whether the complainant is entitled to a sum of Rs.2,00,000/- towards compensation for mental agony and financial loss and expenses suffered by the complainant with cost as prayed for?

7.      On point:-

The opposite party after receipt of notice has not entered appearance before this Forum and remained exparte.  The complainant has filed his proof affidavit and written argument.  Heard the complainant’s Counsel also.  Perused the records namely; the complaint, proof affidavit and documents of the complainant.  The complainant pleaded and contended that he is the nominee and caretaker of his mother namely; Mrs. D. Prathavathi (Late); she has retired from the Government service on attainment of the age of superannuation as a teacher on April 1990 as per Ex.A1.  further the contention of the complainant is that his mother has given/ availed Govt. medical insurance policy vide policy No.A304218 with the opposite party as per Ex.A1.   Due contribution also collected from his pension.  Further the contention of the complainant is that on 06.11.2016, the complainant’s mother fell down and suffered injury on the head and face.  Immediately Brain CT scan was taken and diagnosed as Acute (L) fronts tempero parietal subdural heamatoma causing midline shift with extensive intraventricular hemorrhage as per Ex.A8 (S). Then, the complainant’s mother was admitted in the Lake View Hospital on 06.11.2016 at 06.00 A.M. and was treated as an ICU patient. Due information also given to the opposite party for cashless treatment.  Further the contention of the complainant is that on 11.11.2016, the complainant’s mother had developed Oliguria and treatment was given by the Doctors of Lake View Hospital; since her Creatinine Level increased the Doctors recommended for emergency hemodialysis and she was immediately referred to Sundaram Medical Foundation, Anna Nagar on 12.11.2016 for dialysis as per Ex.A6. The said Sundaram Medical Foundation is an authorised Hospital of the opposite party.

8.     Further the contention of the complainant is that his mother was admitted at Sundaram Medical Foundation on 12.11.2016 and has been paid registration fee as per Ex.A13.   Further the contention of the complainant is that while his mother was inpatient at Sundaram Medical Foundation Hospitalfrom 12.11.2016 till 17.11.2016 he has been paid medical charges to the above hospital for the period of his mother stay in that hospital as per Ex.A10 and a copy of test report, copy of CT Scan Report and Sonogram produced as evidence before this Forum as Ex.A11 & Ex.A12 respectively.  Further the contention of the complainant is that on 17.11.2016 his mother developed hyper tension while undergoing hemodialysis and she was declared dead by the hospital management at 09.18 A.M. on the same day.  The complainant has produced Death Certificate of his mother, Ex.A15.  Ex.A19 is blood charges bill issued by Madras Medical Mission and a copy of in-patient Death Summary of his mother ExA11 is also filed by the complainant as evident to substantiate his claim this case.   Further the contention of the complainant is that soon after the death of his mother initiated to the opposite party and due claim made through Sundaram Medical Foundation through email and claimed for reimbursement of medical expenses.  Further, the contention of the complainant is that he made several oral requests with the opposite party to disburse the medical expenses incurred for his mother’s  treatment but the opposite party turned deaf ears to the complainant’s requests. 

9.     Further the contention of the complainant is that his mother was paying her policy premium through her salary towards insurance with the opposite party when she was in Government service and thereafter from her pension with the fond hope that the policy may render protection against uncertainties which may arise in future and was admitted in the authorised Hospital under critical condition.  Further the contention of the complainant is that though he is a nominee and beneficiary of his mother, the opposite party has failed to disburse the medical expense incurred for the complainant’s mother.  In this case, the complainant raised the claim through the authorised Hospital wherein the treatment availed and thereafter made the claim for the opposite party directly.  Further the contention of the complainant is that on 05.11.2018 issued a legal notice to the opposite party as per Ex.A16 demanding his claim but no reply from the opposite party.   Hence, the complainant is constrained to file this case for reimbursement of medical expenses incurred for his mother’s treatment.  The opposite party remained exparte and has not come forward to file any written version and proof affidavit.  Considering the facts and circumstances of the case, this Forum is of the considered view that the opposite party shall refund a sum of Rs.2,31,461/- with interest at the rate of 9% p.a. from the date of presentation of this complaint to till the date of this order and a compensation of Rs.10,000/- towards mental agony with cost of Rs.10,000/- to the complainant. 

In the result, this complaint is allowed in part.  The opposite party is directed to reimburse a sum of Rs.2,31,461/- (Rupees Two lakhs thirty one thousand four hundred and sixty one only) being medical expenses incurred for his mother’s treatment along with interest at the rate of 9% p.a. from the date of presentation of this complaint (i.e.) 19.11.2018 till the date of this order (i.e.) 13.08.2019 and to pay a sum of Rs.10,000/- (Rupees Ten thousand only) towards compensation for mental agony with cost of Rs.10,000/- (Rupees Ten thousand only) to the complainant.

The above amounts 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 Steno-typist, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 13^th day of August 2019. 

 

MEMBER                                                                               PRESIDENT

 

COMPLAINANT SIDE DOCUMENTS:-

Exhibits	Date	Description of documents
Ex.A1		Copy of pension payment order
Ex.A2	06.11.2016 to 12.11.2016	Copy of inpatient bill at Lake View Hospital
Ex.A3	06.11.2016 to 12.11.2016	Copy of drug charges at Lake View Hospital
Ex.A4	07.11.2016	Copy of investigation amount at Lake View Hospital
Ex.A5	07.11.2016 to 12.11.2016	Copy of lab charges at Hitech Diagnositc Centre
Ex.A6	12.11.2016	Copy of Discharge Summary at Lake View Hospital
Ex.A7	10.11.2016	Copy of Blood Bank receipt at Indian Red Cross Society
Ex.A8	06.11.2016 to 12.11.2016	Copy of CT Scan at Gemini Scan
Ex.A9	17.11.2016	Copy of Blood charges at MMM
Ex.A10	12.11.2016 to 17.11.2016	Copy of inpatient bill at Sundaram Medical Foundation
Ex.A11	17.11.2016	Copy of inpatient Death Summary
Ex.A12	12.11.2016 to 16.11.2016	Copy of inpatient test report at Sundaram Medical Foundation
Ex.A13	12.11.2016	Copy of registration charges at Sundaram Medical Foundation
Ex.A14	12.11.2016	Copy of expenditure statement by Lake View Hospital
Ex.A15	17.11.2016	Copy of Death Certificate
Ex.A16	05.11.2018	Copy of legal notice issued by the complainant

 

 

MEMBER                                                                                PRESIDENT