Tamil Nadu

South Chennai

CC/203/2019

P Kamalammal - Complainant(s)

Versus

M/s United India Insurance Co Ltd. - Opp.Party(s)

M/s A P Surya Prakasam

05 Mar 2020

ORDER

                                                                                 Date of filing  : 08.08.2019

                                                                                   Date of Order : 05.03.2020

                                                                                  

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.203/2019

DATED THIS THURSDAY THE 05^TH DAY OF MARCH 2020

                                 

P. Kamalammal,

W/o. Mr. Perumal,

No.13/40, Bheemanna 2^nd Street,

Chennai – 600 018.                                                                                                                                                                     .. Complainant.                                           

..Versus..

 

United India Insurance Company Limited,

Represented by its Manager,

Lakshmi Tower, 3^rd Floor,

Dr. Radhakrishna Salai,

Chennai – 600 004.                                                                                                                                                                  ..  Opposite party.

 

Counsel for the complainant  :  M/s. A.P. Surya Prakasam & others

Opposite party                        :  Ex-parte

 

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 refund a sum of Rs.2,40,000/- being medical expenses incurred by the complainant with interest at the rate of 18% p.a. from 10.12.2018 till the date of repayment and to pay a sum of Rs.2,50,000/- towards compensation for mental agony and financial hardship suffered by the complainant with cost of Rs.10,000/- to the complainant.

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

The complainant submits that she is a Senior Citizen aged about 86 years, a retired Government employee having medical insurance, met with an accidental fall at her residence on 05.12.2018 at about 11.58 p.m. and sustained pain and inability to move her right upper hand and other injuries.   Immediately, the complainant was taken to the nearest hospital namely; Kaveri Hospital, Alwarpet, Chennai – 600 018.   After due investigation, the Doctors advised the complainant to undergo an operation and internal fixation of proximal humerus on 08.12.2018.  The complainant was admitted into the emergency ward on 05.12.2018 and surgery was done.   The complainant submits that immediately after admitting the complainant in the hospital, the complainant’s son A.P. Babu met the representative of the opposite party available in the hospital and claimed cashless treatment as per the health card.   But the opposite party’s representatives advised the complainant’s son to pay the hospital expenses initially and after discharge and completion of treatment, the complainant can claim reimbursement from the opposite party.   The complainant submits that even after repeated requests and demands, the opposite party refused to reimburse the medical expenses.   Hence, the complainant issued legal notice dated:19.03.2019 for claiming reimbursement of medical expenses.    The opposite party has not paid the said claim.  The act of the opposite party caused great mental agony and inconvenience to the complainant.   Hence, the complaint is filed.

2.     In spite of receipt of notice, the opposite party has not appeared before this Forum and hence, the opposite party was set ex-parte. 

3.     Though the opposite party was remained Ex-parte, this Forum is to dispose of this compliant fully on merits with available materials evidences 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 her evidence and also documents Ex.A1 to Ex.A5 are marked.  

5.      The points for consideration is:-

1. Whether the complainant is entitled to refund a sum of Rs.2,40,000/- being expenses incurred for medical treatment with interest at the rate of 18% p.a. as prayed for?
2. Whether the complainant is entitled to a sum of Rs.2,50,000/- towards compensation for mental agony, unfair trade practice etc as prayed for?

6.      On point:-

The opposite party after receipt of notice has not entered appearance in this Forum and remained ex-parte.   The complainant filed proof affidavit, documents and written arguments.  Perused the records.  The complainant pleaded and contended that the complainant is a Senior Citizen aged about 86 years, a retired Government employee having medical insurance, met with an accidental fall at her residence on 05.12.2018 at about 11.58 p.m. and sustained pain and inability to move her right upper hand and other injuries.   Immediately, the complainant was taken to the nearest hospital namely; Kaveri Hospital, Alwarpet, Chennai – 600 018.   After due investigation, the Doctors advised the complainant to undergo an operation and internal fixation of proximal humerus on 08.12.2018.  The complainant was admitted into the emergency ward on 05.12.2018 and due surgery was done.  Ex.A3 is the copy of Discharge Summary.   Further the contention of the complainant is that immediately after admitting the complainant in the hospital as per the due advice of the hospital administration the complainant’s son A.P. Babu met the representative of the opposite party available in the hospital and claimed cashless treatment as per the health card.   Ex.A1 is the copy of cashless treatment card.  But the opposite party’s representatives advised the complainant’s son to pay the hospital expenses initially and after discharge, the complainant can claim reimbursement of medical expenses from the opposite party.   The denial of cashless treatment by the opposite party amounts to deficiency in service and unfair trade practice since the cashless treatment is provided in Ex.A1, Health Insurance Card.  

7.     Further the contention of the complainant is that even after repeated requests and demands the opposite party refused to reimburse the medical expenses.   Hence, the complainant was constrained to issue legal notice dated:19.03.2019 as per Ex.A4 claiming reimbursement of medical expenses.  The complainant has expended a sum of Rs.2,40,000/- towards medical expenses as per Ex.A2, copy of hospital bills and Ex.A3, copy of Discharge Summary.   The opposite party has not paid the said claim.  Hence, the complainant is compelled to file this case claiming the medical expenses of Rs.2,40,000/- with a compensation of Rs.2,50,000/- and cost. 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.2,40,000/- being medical expenses incurred by the complainant and to pay a sum of Rs.30,000/- towards compensation for 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 pay a sum of Rs.2,40,000/- (Rupees Two lakhs forty thousand only) being medical expenses incurred by the complainant and to pay a sum of Rs.30,000/- (Rupees Thirty thousand only) towards compensation for mental agony and 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 05^th day of March 2020. 

 

MEMBER                                                                                                                                                                                                PRESIDENT

 

COMPLAINANT SIDE DOCUMENTS:-

Ex.A1		Copy of cashless treatment card
Ex.A2	10.12.2018	Copy of hospital bills
Ex.A3	19.12.2018	Copy of discharge summary
Ex.A4	19.03.2019	Copy of legal notice of the complainant through her Counsel to the opposite party
Ex.A5		Copy of the returned postal cover

 

 

 

MEMBER                                                                                                                                                                                               PRESIDENT