Tamil Nadu

South Chennai

CC/271/2018

Mr. P Umasankaran - Complainant(s)

Versus

M/s India Health Insurance TPA Pvt Ltd - Opp.Party(s)

Party in Person

08 Feb 2019

ORDER

                                                                        Date of Filing  : 06.06.2018

                                                                          Date of Order : 08.02.2019

                                                                                  

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

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

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

 

C.C. No.271/2018

DATED THIS FRIDAY THE 08^TH DAY OF FEBRUARY 2019

                                 

Mr. P. Umasankar,

S/o. Mr. V. Poonusamy,

No.5, Tank Bund 2^nd Street,

Sunguvarchathiram,

Kanchipuram District – 602 106.                                  .. Complainant.                                                         

..Versus..

 

M/s. India Health Insurance TPA Private Ltd.,

Prepresented by its Managing director,

Guna Complex,

Door Nos.443 & 445, Old Nos.304 & 305,

Anna Salai,

Teynampet,

Chennai – 600 018.                                                  ..  Opposite party.

          

Counsel for the complainant      :  M/s. N. Uma Sankar

Counsel for the 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 praying to pay a sum of Rs.61,032/- to the complainant towards the insurance dues and to pay a sum of Rs.5,00,000/- towards compensation for professional negligence, deficiency in service and unfair trade practice to the complainant.

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

The complainant submits that he is working as a Shrestadar in Sub-Court, Thiruvallur and paying a subscription amount of Rs.180/- towards every month without interruption for health insurance with opposite party, M/s. India Health Insurance TPA Private Ltd. from July 2016.  The said amount has been recovered from his salary without any default.  But the opposite party even after repeated request has not issued the ID card.  The complainant submits that on 25.07.2017, the complainant was affected by paralytic stroke/ intracerebral haemorrhage and was admitted as inpatient and undergone treatment at Hariharan Diabetic and Heart Care Hospital, Nanganallur.   Due intimation were given through the hospital repeatedly and claim made through the hospital immediately after discharge on 31.07.2017 along with all original bills.  After repeated persuasions, the opposite party has sanctioned only a sum of Rs.17,000/-.  The opposite party has not stated anything about the balance amount and has not come forward to pay the amount. The hospital authorities compelled the complainant to pay the entire amount due for discharging him.  Hence, the complainant paid the balance amount of Rs.61,032/- and he was discharged from the hospital.  Thereafter, the complainant issued demand notice dated:09.10.2017 to the opposite party for the payment of the balance amount.  The opposite party even after receiving the notice has not sent any reply.  The act of the opposite party caused great mental agony.  Hence, the complaint is filed.

2.     In spite of receipt of notice, the opposite party has not appear before this Forum and therefore, the opposite party was set Exparte.  

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

4.     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.A10  are marked.   

5.      The points for consideration is:

1. Whether the complainant is entitled to a sum of Rs.61,032/- towards medical expenses incurred as prayed for?
2. Whether the complainant is entitled to a sum of Rs.5,00,000/- towards negligence, deficiency in service, unfair trade practice and mental agony and cost as prayed for?

6.      On point:-

The opposite party remained exparte.  The complainant filed his written arguments. Heard the complainant’s Counsel also. Perused the records namely the complaint, proof affidavit and documents of the complainant.  The complainant pleaded in the complaint and contended that he is working as a Shrestadar in Sub-Court, Thiruvallur and paid a subscription amount of Rs.180/- towards the opposite party, M/s. India Health Insurance TPA Private Ltd. from July 2016 without interruption for health insurance.  The said amount has been recovered from his salary without any default.  But the opposite party even after repeated requests has not issued the ID card.   Ex.A1 & Ex.A2 is the Certificate issued by the pay drawing officer of the complainant.   Further the complainant contended that on 25.07.2017, the complainant was affected by paralytic stroke / intracerebral haemorrhage was admitted as inpatient and undergone treatment at Hariharan Diabetic and Heart Care Hospital, Nanganallur.   Due intimation were given through the hospital authorities repeatedly and claim made through the hospital immediately after discharge on 31.07.2017 along with all original bills.  Ex.A3 & Ex.A4 is the Discharge Summary and bills showing all detail regarding medical expenses etc to the tune of Rs.78,032/-.  After repeated persuasions, the opposite party has sanctioned only a sum of Rs.17,000/- as per Ex.A6.  The opposite party has not stated anything about the balance amount and has not come forward to pay the amount.  The hospital authorities compelled the complainant to pay the entire amount due for discharging him.  Hence, the complainant was constrained to pay the balance amount of Rs.61,032/- and discharged from the hospital.  Thereafter, the complainant issued demand notice dated:09.10.2017 as per Ex.A7 to the opposite party for due payment of the balance amount.  The opposite party even after receiving the notice has not sent any reply.  Hence, the complainant was constrained to file this case for recovery of a sum of Rs.61,032/- expended towards medical expenses and compensation.  The opposite party remained Exparte.  The health insurance policy issued by the opposite party is still subsisting and the due contribution collected from the salary proves the deficiency in service and unfair trade practice.  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.61,032/- being amount expended towards medical treatment with a compensation of Rs.20,000/- and cost of Rs.10,000/- to the complainant.

  In the result, this complaint is allowed in part.   The opposite party is directed to pay a sum of Rs.61,032/- (Rupees Sixty one thousand and thirty two only) being amount expended towards the medical treatment and to pay a sum of Rs.20,000/- (Rupees Twenty thousand only) towards compensation for mental agony with cost of Rs.10,000/- (Rupees Ten thousand only) to the complainant. 

The aboveamounts shall be payablewithin 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 08^th day of February 2019. 

 

MEMBER-I                           MEMBER-II                     PRESIDENT

 

 

COMPLAINANT SIDE DOCUMENTS:-

		Copy of certificate from the Subordinate Judge, Tiruvallur certifying that the complainant is working as Sheristadar and is covered under New Health Insurance Scheme, 2016
		Copy of details in Annexure VII under the New Health Insurance Scheme, 2016
		Copy of Discharge summary from M/s. Hariharan Diabetic & Heart Care Hospitals (P) Limited, Nanganallur
		Copy of the bill for Rs.78,032/- from M/s. Hariharan Diabetic & Heart Care Hospitals (P) Limited, Nanganallur along with the connected supporting bills
		Copy of letter from Hariharan Diabetic & Heart Care Hospital along with complete case History
		Copy of the Authorisation letter ref MDI 00591241 from the opposite party
		Coy of the Registered Demand notice sent by the complainant to the opposite party
		Copy of the registered notice sent by the complainant to the opposite party
		Copy of acknowledgement card for service of the Registered Demand Notice duly signed by the oppositeparty
		Copy of acknowledgement card for service of the registered Demand Notice duly signed by the opposite party

 

 

 

MEMBER-I                           MEMBER-II                     PRESIDENT