Tamil Nadu

South Chennai

CC/340/2018

Mr. Guruviah - Complainant(s)

Versus

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

M/s M Anbarasu

13 Jul 2022

ORDER

Date of Complaint Filed : 09.07.2018

Date of Reservation      : 28.06.2022

Date of Order               : 13.07.2022

 

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.340/2018

WEDNESDAY, THE 13^th DAY OF JULY 2022

Mr. Guruvaiah,

S/o Subburayalu,

Residing at No.82/41,

Nambi Street,

Poonamalli,

Thiruvallur District – 600 056.                                                                                                                           ... Complainant                          

 

..Vs..

The Manager,

India Health Insurance TPA PVT Ltd,

Guna Complex, No-443 & 445,

Anna Salai,

Teynampet,

Chennai – 600 018.                                                                                                                                           ...  Opposite Party

 

******

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

Counsel for the Opposite Party       : Exparte

 

        On perusal of records and after having treated the Written Arguments of the Complainant as Oral Arguments, we delivered the following:

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 direct the Opposite Party to pay a sum of Rs.80,921/- towards insurance claim amount with interest and to pay a sum of Rs.25,000/- towards litigation charges and to pay a sum of Rs.1,00,000/- towards mental agony caused to the Complainant and all the above compensation has to pay at the interest of 18% p.a.

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

          The Complainant was working as a Vocational teacher in Tamil Nadu Government. He booked a policy in policy No.010600/48/16/41/00000001 with Opposite Party company, the above policy dealing with medical claim. Subsequent to that the Complainant's son Mr. G. Suresh suffered with stomach pain. Hence, on 23.11.2017 the Complainant's son was taken into hospital at "Be Well Hospital" for emergency treatment and admitted him in that hospital. The above hospital was situated near by the Complainant's house. Further the Complainant had spent a sum of Rs. 80,921/- for said treatment. Thereafter the Complainant had taken his son to Ramchandra Hospital at Porur, Chennai for further treatment. Later his son discharged from the hospital. The Opposite Party denied to compensate a sum of Rs. 80,921/- to the Complainant which was spent by him at "Be Well hospital" at Poonamalli for treatment expenses, it is illegal and against of natural justice. The Complainant submits that there is a clear judgment passed by the Hon'ble High Court in similar case where the policy holder takes an emergent treatment  anywhere, the policy company cannot deny the claim. The Opposite Party company had violated the rules and principles laid by the Hon'ble High Court and Supreme Court. The Complainant has taken sincere efforts to receive said claim from the Opposite Party company. But the Opposite Party company playing fraudulent manner and demanding, threatening and harassing the Complainant. Due to the Opposite Party company's activities the Complainant got mental agony. Further the Complainant submits that he made a representation to the Opposite Party company for claim but the Opposite Party company has not considered such representation till date. The Complainant submits that on 24.03.2018 the Complainant sent a legal notice to the Opposite Party claiming a sum of Rs 80,921/- along with compensation of sum of Rs. 1,00,000/-, the notice was received by the Opposite Party on 26.03.2018 and thereafter the Opposite Party not replied. Hence the complaint.

3.      The Complainant submitted his Proof Affidavit and Written Arguments. On the side of the Complainant, documents Ex.A-1 to Ex.A-5 were marked.    

4.    The Opposite Party did not appear  before this Commission even after sufficient notice served on them. Hence the Opposite Party was set exparte .

5.     Points for Consideration

1. Whether the complaint is maintainable?

2. Whether there is deficiency in service on the part of the Opposite Party?

3. Whether the Complainant is entitled for reliefs claimed?

4. To what other reliefs the Complainant is entitled to?

 

Point No.1 :-

          The case of the Complainant is that he had taken Medi Claim Policy No. 010600/48/16/41/00000001 from the Opposite Party on 23.11.2017. The Complainant’s son Mr. G.Suresh  was admitted in “Be Well Hospital” for emergency treatment and had spent Rs.80,921/- for treatment. Thereafter the Complainant’s son had taken treatment at Ramachandra Hospital. The Opposite Party had denied compensation for the sum of Rs.80,921/- spent at Be Well Hospital, which has caused mental agony. Even after receipt of the legal notice dated 24.03.2018, the Opposite Party did not reply.

        The Complainant has not made any averment as to when he had made claim to the Opposite Party for the treatment at the Be Well Hospital and when the claim was repudiated by the Opposite Party. No document is also produced to support the contention of the Complainant that of Rs.80,921/- spent at “Be Well” Hospital has been repudiated by the Opposite Party. There is no averments on what ground that the Opposite Party denied compensation to the Complainant neither any document to support his contention of denial of compensation. The Complainant has not made the United India Insurance Company Ltd a party to the Complainant from whom he has taken Medi Claim Policy. The Complainant having filed the Complainant without impleading the insurance company, namely United India Insurance Company Ltd clearly affects the complaint on the ground of non joinder of necessary parties and had made only the third Party administrator as a party to the Complaint who is not directly involved in deciding such claims as made by the Complainant and only assists in the administrative aspect of the services mentioned in the contract.

        In view of the above discussions we hold that the complaint filed against the Opposite Party alone is not maintainable, as the Opposite Party is in no way liable to pay or compensate the Complainant and hence the complaint is not maintainable.

Point Nos.2 to 4:-

        As discussed the Complainant has not availed any services from the Opposite Party who is only an agent of United India Insurance Co., Ltd, from whom the Complainant had availed Mediclaim Policy. Hence there is no deficiency of service on the part of the Opposite Party. The Complainant is not entitled to any reliefs claimed in the complaint or for any other reliefs.

In the result this complaint is dismissed. No cost.

Dictated to Steno-Typist, transcribed and typed by her, corrected and pronounced by us in the Open Commission, on  13^th of July 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	-	Copy of ID Card
Ex.A2	-	Copy of insurance detail
Ex.A3	-	Medical record
Ex.A4	24.03.2018	Copy of Legal Notice
Ex.A5	26.03.2018	Acknowledgment card

 

 

List of documents filed on the side of the Opposite Party:-

 

NIL

 

 

 

S. NANDAGOPALAN                                                       T.R. SIVAKUMHAR                                                          B.JIJAA

         MEMBER II                                                                      MEMBER I                                                            PRESIDENT