Tamil Nadu

South Chennai

28/2008

R.Dharmachand Jain - Complainant(s)

Versus

M/s TPA Services (I) Pvt Ltd and another - Opp.Party(s)

M/s. Ashok Menon

14 Feb 2018

ORDER

                                                                                                                           Date of Filing  : 09.08.2007

                                                                          Date of Order : 14.02.2018

DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, CHENNA (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                                                                  

CC. NO.28 /2008

WEDNESDAY THE 14^TH DAY OF FEBRUARY 2018

R. Dharamchand Jain,

2/1, Manali Road,

M.K.B. Nagar,

Chennai 600 039.                                                                   .. Complainant

                                                         ..Vs..

 

1. M/s. TPA Services (1) Pvt. Ltd.,

Rep. by its Manager,

1, Circular Road,

United India Colony,

Kodambakkam,

Chennai 600 024.

 

2.  The Divisional Manager,

D07, National Insurance Co.,

35, North Usman Road,

T.Nagar, Chennai 600 017...Opposite parties.

 

Counsel for complainant         :  M/s. Ashok Menon  

Counsel for opposite party-1  :  M/s.Elveera Ravindran

Counsel for opposite party-2  :  M/s.N.Vijayaraghavan & another      

 

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite parties under section  12 of the Consumer Protection Act 1986 seeking direction to pay a sum of Rs.1,51,075.36 with interest and to pay a sum of Rs.50,000/- as damages and to pay cost of the complaint.  

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

          The complainant submit that  he had taken six policies in respect of his wife Mrs. Susiladevi Jain for the period commencing from 22.12.1999.    The complainant’s wife Susiladevi Jain fell ill and after prolonged treatment during which at certain times the check up conducted on her revealed that she had recovered and after she expired on 12.8.2005.   Subsequently to the demise of the complainant’s wife he had filed the necessary claim with the 1^st opposite party for payment under the policies.    The opposite parties  stating that the complainant had claimed a sum of Rs.1,52,500/- while he was entitled to Rs.50,000/- only and also stating that as the complainant had already received excess payment of Rs.1,05,000/- the 3^rd claim amount of Rs.50,000/- could be adjusted in the excess payment and thereafter the complainant was to refund a sum of Rs.50,000/- to the 1^st opposite party.   The complainant state that he booked the policy for Rs.50,000/- in the year 1999 which was enhanced to Rs.1,60,000/- on 22.12.2001 vide policy No.501700/48/2001/8501828 and the second claim was received for carcinoma under policy No.501700/48/038501605 under claim No.0804799 was settled on 18.11.2004.    Under policy No.501700/48/04/8501358 and claim No.03052051 the complainant had claimed Rs.1.52,000/- but opposite party stated that  he was entitled Rs.50,000/- and that the complainant had already received an extra payment of Rs.1,05,000/- the 3^rd claim amount would be adjusted from the excess payment and that the complainant has to refund to the 1^st opposite party a sum of Rs.55,000/- which was received by the complainant as excess payment.      As such the act of the opposite parties amounts to deficiency in service which caused mental agony and hardship to the complainant.  Hence this complaint is filed.  

2. The brief averments in the written version filed by the  1^st opposite party is as follows:

The  1^st opposite party deny each and every allegations except those that are specifically admitted herein.  The 1^st opposite party state that  it is only a third party administrator for the speedy and effective processing and disposal of the claims and hence there is no privity of contract between the complainant and the 1^st opposite party.   Hence there is no deficiency in service on the part of the 1^st opposite  party and the complaint is liable to be dismissed.

3. The brief averments in the written version filed by the  2^nd  opposite party is as follows:

The 2^nd opposite party deny each and every allegations except those that are specifically admitted herein.  The  2^nd opposite party state that  the complainant had availed a medi claim policy on and from 1.12.1999 and continuous thereafter, covering his now deceased wife Sushila Devi also.  She was detected to suffer from Carcinoma in the vagina for which treatment she lodged a claim in June 2001.   The said claim was settled for Rs.52,500/-.   In the policy commencing thereafter the sum insured for the now deceased person could only have been the already existing Rs.50,000/- plus of Rs.5,000/- in all amounting to Rs.55,000/-.   Further the 2^nd opposite party state that  the insurer settled the said claim for Rs.1,60,000/- on 18.11.2004.  This settlement was a mistaken one.  Fundamentally the sum insured in respect of the disease already suffered and claim paid could only be for Rs.55,000/- as adverted to above.  While so the settlement was made for Rs.1,60,000/- which was wrong being in excess by Rs.1,05,000/-.   Hence it is submitted that the insurer is not liable to pay any sum much less the sum of Rs.1,52,000/-.  On the other hand the complainant liable to refund Rs.50,000/- lying in excess with them.    Hence there is no deficiency in service on the part of the 2^nd  opposite  party and the complaint is liable to be dismissed.

4.      In order to prove the averments of the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A20 marked.  Proof affidavit of the opposite parties filed and Ex.B1 to Ex.B4  marked on the side of the  opposite parties.

 

5.      The points for consideration is :

1. Whether the complainant is entitled to a sum of Rs.1,51,075.36 with interest as prayed for?

2. Whether the complainant is entitled to a sum of Rs.50,000/- towards compensation for mental agony with cost as prayed for?

6.      POINTS 1 & 2:

        The complainant has not filed written arguments and has not turned up to advance any oral arguments also. Heard the opposite party.  Perused the records (viz) complaint, written version, proof affidavits and documents.  The complainant pleaded and stated in the proof affidavit  that he has availed mediclaim policies dated 22.12.1999 bearing No.501700/48/1999/8501405, dated 20.12.2000 policy No.501700/48/2000/8506636, dated 21.12.2001 policy No.501700/48/2001/8501828, dated 26.12.2002 policy No.501700/48/02/8502872, dated 19.12.2003 policy No.501700/48/03/8501605, dated 20.12.2004 policy No.501700/48/04/8501358 as per Ex.A1 to Ex.A6.  The complainant’s wife Mrs. Susiladevi Jain fell ill and after prolonged treatment she expired on 12.8.2005.  The complainant informed the 2^nd opposite party and explained the treatment undergoing by his wife.    On 13.8.2004 the 2^nd opposite party also called for the particulars regarding the policy as per Ex.A8.   Immediately after the demise  of the complainant’s wife the complainant submitted a claim related to medical expenses on 16.2.2005 and again on 20.1.2006 as per Ex.A18 & Ex.A19.  Since the opposite party has not come forward to settle the medical expenses.  The complainant issued legal notice dated 10.4.2006 for which the opposite party sent a reply dated 29.5.2006 vide Ex.A20.   The opposite party without settling the amount raised untenable contention and claiming a sum of Rs.1,05,000/- as excess paid.  Since the complainant suppressed the material facts is against true facts.  Further the complainant pleaded and contended  in the proof affidavit that he has taken the policy for Rs.50,000/- in the year 1999 which was enhanced to Rs.1,60,000/- on 22.12.2001 vide policy No.501700/48/2001/8501828 and the second claim was received for carcinoma under policy No.501700/48/038501605 and the  claim No.0804799 was settled on 18.11.2004.  After the demise of the complainant’s wife claim for a sum of Rs.1,52,000/- was made as per the enhanced insurance policy.   But the opposite parties repudiated the claim with untenable grounds.  Hence the complainant was constrained to file this case.

7.     The contention of the 1^st opposite party is that the 1^st opposite party is a 3^rd party administrator for the speedy and effective processing and disposal of the claims and hence there is no privity of contract between the complainant and the 1^st opposite party.  The 1^st opposite party is an unnecessary party to this case.   Furthermore there is no customer relation with the 1^st opposite party and the case against the 1^st opposite party may be dismissed.

8.     The contention of the 2^nd opposite party is that admittedly the complainant availed a mediclaim policy on 1.12.2009 and continued thereafter coving his deceased wife Sushila Devi also.  The complainant’s wife was detected to suffer from carcinoma in the vagina for which treatment she lodged a claim in June 2001.   The said claim was settled for Rs.52,500/- in the said policy the sum insured is for rs.50,000/- plus bonus of Rs.5000/- totally Rs.55,000/-.  It is the practice and rule of insurers not to agree for enhancement in respect of diseases already suffered for any more than the existing limit in respect of renewal policies.   But the opposite party has not produced any such rules or provision of law for  such practice.  In this case admittedly the complainant availed mediclaim policy on 1.12.1999 for a sum of Rs.50,000/-  and thereafter  he has availed mediclaim policies dated 22.12.1999 bearing No.501700/48/1999/8501405, dated 20.12.2000 policy No.501700/48/2000/0506636, dated 21.12.2001 policy No.501700/48/2001/8501828, dated 19.12.2003 policy No.501700/48/03/8501605 as per Ex.A1 to Ex.A6. While continuing the treatment of the complainant’s wife Sushila Devi suffering from carcinoma.   Further the learned counsel for the opposite party contended that while so Sushila Devi suffered from relapse of the said disease for which a claim was made in 2004 and was settle for Rs.1,60,000/- on 18.11.2004 mistakenly against the sum assured for Rs.55,000/-.  But no document filed.  Further the contention of the 2^nd opposite party is that since the claim for Rs.1,60,000/- was settled against the policy amount of Rs.55,000/- there was an excess Rs.1,05,000/-.   Hence the claim related to Rs.1,52,000/- after the demise of Sushila Devi was repudiated and due letter addressed to the complainant for re payment of Rs.1,05,000/-.  But on 18.11.2004 the complainant had six mediclaim policies namely dated 22.12.1999 bearing No.501700/48/1999/8501405, dated 20.12.2000 policy No.501700/48/2000/8506636, dated 21.12.2001 policy No.501700/48/2001/8501828, dated 26.12.2002 policy No.501700/48/02/8502872, dated 19.12.2003 policy No.501700/48/03/8501605, dated 20.12.2004 policy No.501700/48/04/8501358 as per Ex.A1 to Ex.A6.   The opposite party has taken into consideration of only one policy taken on 1.2.1999 for Rs.50,000/- alone without  taking  into the consideration of the policies without any basis proves the deficiency  of service and unfair trade practice.  Considering the facts and circumstances of the case this forum is of the considered view that the opposite parties 1 & 2 are jointly and severally liable to pay a sum of Rs.1,51,075.36 with interest at the rate of 9% p.a. from the date of complaint i.e. 9.8.2007 to till the date of this order i.e. 14.2.2018  and also shall pay compensation of Rs.15,000/- for mental agony with cost of Rs.5000/- and the points are answered accordingly.

In the result the complaint is allowed in part.   The opposite parties 1 & 2 are jointly and severally liable to pay a sum of Rs.1,51,075.36 (Rupees one lakh fifty one thousand and seventy five and thirty six paisa   only ) with interest at the rate of 9% p.a. from the date of complaint i.e. 9.8.2007 to till the date of this order i.e. 14.2.2018  and also shall pay compensation of Rs.15,000/- (Rupees fifteen thousand only)  for mental agony with cost of Rs.5000/- (Rupees five 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 Assistant, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 14^th  day of February 2018. 

MEMBER –I                       MEMBER-II                              PRESIDNET.

COMPLAINANT SIDE DOCUMENTS:

Ex.A1- 22.12.1999 - Copy of Insurance policy.

Ex.A2- 20.12.1999 - Copy of Insurance policy.

Ex.A3- 21.12.2001           - Copy of Insurance Policy.

Ex.A4- 26.12.2002   - Copy of Insurance Policy.

Ex.A5-19.12.2002 - Copy of Insurance policy.

Ex.A6- 20.12.2004         - Copy of insurance policy.

Ex.A7- 2.6.2004    - Copy of letter from the complainant.

Ex.A8- 13.8.2014  - Copy of letter from the 2^nd opp. party.

Ex.A9-  23.8.2004 - Copy of letter from the complainant.

Ex.A10- 10.3.2005         - Copy of letter from the complainant.

Ex.A11- 19.4.2005         - Copy of Ack. Of claim.

Ex.A12- 12.9.2005         - Copy of letter from the complainant.

Ex.A13- 12.10.2005 – Copy of letter from the complainant.

Ex.A14- 9.11.2005           - Copy of letter from the 2^nd opposite  party.

Ex.A15- 14.11.2005 – Copy of letter from the complainant.

Ex.A16- 24.11.2005 – Copy of letter from the 1^st opposite party.

Ex.A17- 28.11.2005 – Copy of letter from the 1^st opposite party.

Ex.A18- 16.12.2005  - Copy of letter from the complainant.

Ex.A19- 20.1.2006           - Copy of letter from the complainant.

Ex.A20- 29.5.2006           - Copy of reply notice. 

OPPOSITE  PARTY SIDE DOCUMENTS:

Ex.B1- 3.4.2009  -  copy of claim repudiation letter.  

Ex.B2- 14.9.2006 - Copy of letter sent by the 1^st opposite party.

Ex.B3- 10.3.2006 - Copy of letter sent by the 1^st opposite party.

Ex.B4- 29.5.2006 - Copy of reply letter.

 

MEMBER –I                       MEMBER-II                              PRESIDNET.