Date of Filling      :  04.12.2013.

                                                                                            Date of Disposal  :  27.07.2016.

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.67/2013

(Dated this Wednesday the 27^th day of July 2016)

Mrs. A. Lavanya Satheesh,

W/o. Mr. A. Satheesh,

No.214, Bazaar Street,

Palavakkam Village and Post,

Uthukottai Taluk,

Thiruvallur District.                                                                      … Complainant.

/ Versus /

1.  The Manager,

     Heritage Health Services Ltd.,

     G C Towers, Flat No.5,

     Old No.17, New No.31,

     Duraisamy Road,

     T. Nagar,

     Chennai - 600 017.

2.  The Branch Manager,

     United India Insurance Company Limited,

     No.53, North Raja Street,

     Thiruvallur - 600 001.                                                       … Opposite parties.

This complaint is coming upon before us finally on 19.07.2016 in the presence of M/s. V. Murali, Counsel for the complainant and Mr. L. Thanigaivel, Counsel for the 2^nd opposite party and  the 1^st opposite party was set Ex-parte for non appearance and having perused the documents and evidences on the side of the complainant and the 2^nd opposite party, 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^st & 2^nd opposite parties for seeking the balance claim of Rs.27,514/- along with 12% interest p.a. from 18.10.2013 and to pay Rs.50,000/- towards compensation for causing mental agony with cost Rs.5,000/-.

The brief averments of the complaint is briefly as follows:-

The complainant has taken an individual Health Insurance Policy from the 2^nd  opposite party on 26.03.2007.   From that onwards, she is renewing the policy periodically. The latest policy No.012002/48/12/97/00001164 for the period covering from 26.03.2013 to 25.03.2014 for the sum insured Rs.2,00,000/-.  That due to severe abdomen pain she was admitted in M/s. Vijaya Health Centre, Vadapalani, Chennai – 600 026 on 15.10.2013 as inpatient and operated on 16.10.2013 by Laparoscopic Surgery for a removal of Pedunclated lipoma measuring 2.05 cm x 1.5 cm, and the removal of Filmsy omental adhesions to the anterial abdomen wall.  After that she was discharged from the hospital on 18.10.2013.

2.       At the time of admission itself, she submitted the Insurance details to the Hospital authorities, they informed her that the same was informed to the 1^st opposite party, who is the official TPA of the 2^nd opposite party, the 1^st opposite party processed the claim.  At the time of discharge, the hospital authorities informed her that Heritage Health Services Pvt. Ltd. has only approved for Rs.40,167.00 out of final bill of Rs.67,681.00, which was billed by M/s. Vijaya Health Centre.  Then, the husband of the complainant telephoned to the 1^st opposite party, who in turn informed that as per the policy conditions the complainant is only eligible for that amount only.  Since there is no other alternative left to the complainant she paid the balance amount of Rs.27,514.00 in cash and got discharged from the hospital.

3.       Since, she has taken a policy for Rs.2,00,000/- she want to know the reasons for the reduced claim, she made a representation to both the opposite parties to the addresses mentioned  in the policy bond on 04.11.2013 through Registered post asking them to furnish reasons for non-settling the claim amount of Rs.67,681/-.  The letter sent to the 1^st opposite party was returned as “Left without instruction” and the notice sent to the 2^nd opposite party was returned as “refused”.  Being the public sector organization, the 2^nd opposite party refused to receive the letter and the act of him is purely abuse of law.  Both the opposite parties were bound to settle her claim amount of Rs.67,681/-.  But they settled a sum of Rs.40,167/- only for which they have not assigned any reason.  But both the opposite parties not even received her representation, that itself shows the deficiency of service of both the opposite parties which caused lot of mental agony, hardship and monetary loss.  Hence, the complainant is filed.

4.       The contention of written version of the 2^nd opposite party is  briefly as follows:-

The complaint is not maintainable in law and on facts.  The 2^nd opposite party admits that the complainant had taken a policy for a period from 26.03.2013 to 25.03.2014 for a sum assured of Rs.2,00,000/- and other allegations are not true and are denied.

5.       It is submitted that the complainant underwent a surgery in her abdomen on 16.10.2013.  If the complainant had the pre-history any major aliments like as stated above, she will have to disclose the particular ailment to the insurance company.  Then the insurance company will continue the policy by not covering the known ailment but also the company will cover for the other ailments as per their terms and conditions available in the policy.  This was known to the complainant through the 1^st opposite party when the policy was taken by her. The insurance company will have to follow the rules and regulations as in the policies and that too New Rule 6 of the said policy and not as alleged in the complaint.

6.       The 1^st opposite party is the authorized agent of the insurance company for giving easy and speedy disposal for the claimants and the 1^st opposite party will act according to the rules and regulation of the policies.  Infact, the 2^nd opposite party has approved the calculations given by the 1^st opposite party and the 2^nd opposite party can pay only 70% of the claim amount to the complainant as per the rules and regulations of the Insurance Company which was paid to the complainant and the complaint itself is unnecessary one.  It is further submitted that the room rent charged by the hospital authorities in the final bill is highly excessive and the doctor’s fees as charged in the final bill is also excessive.  The complaint is a premature one and the Hon’ble Forum has no jurisdiction to try this complaint.  Hence, the complaint is liable to be dismissed with cost.

7.       In order to prove the case, on the side of the complainant, the proof affidavit submitted for his evidence and Ex.A1 to Ex.A9 were marked.  While so, on the side of the 2^nd opposite party, the proof affidavit is filed  and Ex.B1 is marked on his side for his evidence.

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

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

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

9.     Written arguments filed by the complainant.   Inspite of sufficient time given for filing of written arguments and for adducing oral arguments, the 2^nd opposite party has not come forward neither to file the written arguments nor for oral arguments.  Hence written arguments and oral arguments on the side of the 2^nd opposite party is closed.  

10.     Point no.1:-      

On perusal of the averments of the complaint, as well as the evidences on the side of the complainant, it is learnt that the complainant has taken Health Insurance Policy from the 2^nd opposite party on 26.03.2007 through the 1^st opposite party for a sum assured Rs.2,00,000/- for the period covering from 26.03.2013 to 25.03.2014, for which, the copy of the policy is marked as Ex.A1.  It is further learnt that the complainant was admitted in M/s. Vijaya Health Centre, Vadapalani, Chennai on 15.10.2013 as in patient and undergone Laparoscopic Surgery for the removal of pedunclated lipoma and omental adhesions to the anterial abdomen wall and discharged from the hospital on 18.10.2013 and the discharge summary is marked as Ex.A2 and the medical bills are marked from Ex.A3 to Ex.A6 respectively and thereafter, the 1^st opposite party process the calculation, the 2^nd opposite party had approved for Rs.40,167/- out of the final bill of Rs.67,681/- though the complainant insured for Rs.2,00,000/- and therefore, the complainant had paid the balance amount of Rs.27,514/- in cash and got discharged from the hospital and thereby, the opposite parties caused mental agony and hardship which leads to deficiency in service.  Then, the complainant sent Ex.A7, letter to the opposite parties and the same were returned which are marked as Ex.A8 & Ex.A9 respectively. 

11.     On the other hand, on going through the written version and the evidence adduced on the side of the 2^nd opposite party, it is learnt that the only contention by the 2^nd opposite party is that “the insurance company will have to follow the rules and regulations in the policies and that too New Rule 6 of the said policy” and as per the rules and regulations and the calculations given by the 1^st opposite party, the 2^nd opposite party can pay only 70% of the claim amount to the complainant and the same was paid to the complainant and therefore, there is no deficiency in service on the part of the 2^nd opposite party and in order to establish their contention Ex.B1, the rules and regulations of the said policy is marked.

12.     At the outset, on careful perusal of the rival submissions put forth on either side, it is crystal clear that except the contention about the claim amount and other materials facts narrated in the complaint are all admitted one.  In such circumstances, the duty cast upon this Forum to decide whether the contention raised by the 2^nd opposite party has been established and as per the rules and regulations mentioned in rule 6 of the Ex.B1 policy that the claim amount have been settled.  First of all, on seeing the Ex.A3 & Ex.A5, the final bills issued  by M/s. Vijaya Health Centre the total bill amount is Rs.67,681/- and the claim amount awarded by the 2^nd opposite party is Rs.40,167/- was deducted and the remaining amount comes out Rs.22,644/-.  If it is so, as narrated by the complainant the said amount Rs.22,644/- was paid by the complainant for which Ex.A6 is marked.  From these documents, it is crystal clear that the 2^nd opposite party has settled a sum of Rs.40,167/- out of the total bill amount of Rs.67,681/-.  These facts are admitted by both parties. 

13.     Such being so, as per the evidence of the 2^nd opposite party, it is stated that as per Ex.B1, the rules and regulations and the calculation submitted by the 1^st opposite party, the 2^nd opposite party was awarded the claim amount of Rs.40,167/- and further it is admitted by the 2^nd opposite party that as per the rules and regulations they can pay only 70% of the claim amount of the complainant.  If it is so, whether to that extent of 70% was fulfilled by the 2^nd opposite party is in question.  At this point of time, this Forum has to calculate the 70% of the claim amount is just and necessary as already pointed out in the total bill amount as per Ex.A3 & Ex.A5 are of Rs.67,681/-.  So, 70% of the said amount is calculated as Rs.47,376.70.  The amount already settled by the 2^nd opposite party is of Rs.40,167/- and the balance of amount of Rs.7,209.70 is rounded off as Rs.7,210/- which has to be paid by the  2^nd opposite party as per rules and regulation of the 2^nd opposite party’s insurance company.

14.     The next point to be decided is how the amount of Rs.40,167/- has been arrived by the 2^nd opposite party?.  In this regard, it is learnt from the evidence of the 2^nd opposite party that as per the calculation submitted by the 1^st opposite party only, the 2^nd opposite party has arrived the amount of Rs.40,167/-  But such calculation statement has not been filed before this Forum by the 2^nd opposite party   in order to substantiate the same.   Moreover, the 1^st opposite party who has submitted the said calculation statement to the 2^nd opposite party is remained Ex-parte.   Moreso, such alleged calculation statement has not been filed  by the 2^nd opposite party before this Forum.  Therefore, in what basis the said calculation statement have been prepared or calculated by whom and in what aspect it has been arrived as Rs.40,167/- are all in dark.  From the above facts and circumstances, the 2^nd opposite party has not established that the calculation statement for Rs.40,167/- was arrived as per the rules and regulations under rule 6 of the policy and 70% of the claim amount.  Therefore, this Forum can easily to arrive that the calculation of Rs.40,167/- is not a full pledged one and thereby, there is a deficiency of service on the part of the opposite parties to that extent and failing to pay the correct claim amount to the complainant.  Thus, point no.1 is answered accordingly.

15.     Point no.2:-

As per the decision arrived in point no.1, it is crystal clear that the claim amount paid by the 2^nd opposite party to the complainant  is not correct as per rule 6 of the Ex.B1, policy and also not up to 70% of the claim and therefore, the complainant is entitled for the balance claim amount to the extent of 70% of the total claim of the complainant with reasonable compensation and cost.  Thus, point no.2 is answered accordingly.

16.     In the result, this complaint is allowed in part.  Accordingly, the 1 & 2^nd opposite parties are jointly or severally directed to pay a sum of Rs.7,210/- towards the balance claim amount as per the terms and conditions of the policy and to pay a sum of Rs.5,000/- towards compensation for causing mental agony and hardship due to the deficiency of service on the part of the 1 & 2^nd opposite parties and Rs.5,000/- towards cost totally of Rs.17,210/- (Rupees seventeen thousand two hundred and ten only).  In respect of other reliefs, this complaint is dismissed.

 The above amount shall be payable within one month from the date of receipt of the copy of the order, failing which, the said amounts shall carry interest at the rate of 9.5% 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 27^th   July 2016.

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MEMBER - I                                                                            PRESIDENT

List of documents filed by the complainant:-

List of documents filed by the 2^nd opposite party:-

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MEMBER - I                                                                            PRESIDENT