Tamil Nadu

South Chennai

CC/424/2014

M/s.M.C.Jemina Nalathem - Complainant(s)

Versus

M/s. Royal Sundharam Alliance Insurance Company Ltd - Opp.Party(s)

M/s. R.Sivaprakasam

04 Jul 2017

ORDER

                                                                        Date of Filing :   27.10.2014

                                                                        Date of Order :   04.07.2017

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, CHENNAI (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

C.C.NO. 424/2014

TUESDAY THIS  4^TH   DAY OF JULY 2017

 

1.  Mrs. M.C. Jemina Nalathem,

W/o. S. Julin Joseph Cross,

45/18, Lakshmi Narayana Street,

Duraisamy Subway 2^nd Right

West Mambalam,

Chennai 600 033.

 

2. Mr. S. Julin Joseph Cross,

S/o. R.Saving Cross,

45/18, Lakshmi Narayana Street,

Duraisamy Subway 2^nd Right

West Mambalam,

Chennai 600 033.                                              .. Complainants

                                        ..Vs..

 

1.  Royal Sundaram Alliance Insurance Co. Ltd.,

Rep. by its Managing Director,

Ground Floor, Desh Bandhu Plaza,

47, Whites Road, Royapettah,

Chennai 600 014.

 

2. The Ombudsman,

Office of the Insurance Ombudsman,

Fatima Akthar Court, IV Floor,

459, Anna Salai, Teynampet,

Chennai 600 018.

 

3. Consumer Affairs Department,

IRDA, Rep. its Authorized Signatory,

3^rd Floor, Parishram Bhavan,

Bsheerbagh,

Hyderabad 500 004.                                        ..  Opposite parties.

 

 

Counsel for Complainant           :    M/s. R.Sivaprakasam & another   

Counsel for opposite party-1     :    M/s. M.B.Gopalan & others.

For the opposite parties 2 & 3   :    Exparte.  

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 Rs.1,40,396.93 with interest  and also to pay a sum of Rs.1,00,000/- towards mental agony and Rs.1,50,000/- towards deficiency in service and Rs.50,000/- towards litigation expenses to the complainant.

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

         The complainants submit that  the first complainant is the wife of the second complainant.     Believing the representation made by the first opposite party, the 2^nd complainant subscribed to the Family Medical Insurance Plan of the first opposite party and paid the necessary amount to the first opposite party and took a Family Health Insurance Policy for an assured sum of Rs.2,00,000/- for himself, the first complainant, his son, and daughter.  As per the policy schedule issued by the first opposite party under Policy NO.GL00005173000100, the said Medical Insurance Policy was valid from 8.6.2012 to 7.6.2013.   The complainants did not made any claim during the said period.    The said Insurance policy was duly renewed by the 2^nd complainant in July 2013 after paying the necessary amount by cheque  and the above said policy was renewed by the 1^st opposite party for the period from 22.7.2013 to 21.7.2014.   

2.     Further the complainants states that  on 15.6.2014 the first complainant fell ill suddenly with swelling in the neck.   As per the doctor’s advice, the first complainant was admitted to Christan Medical College and Hospital, Vellore as in patient on 15.6.2014 for treatment.  After conducting the necessary medical tests, as the first complainant was diagnosed with “Multifocal Papillary Carcinoma Thyroid with Left Cervical Lympth Nodal Metastases”, the first complainant underwent the necessary surgery on 17.6.2014 and after the post operative treatment the first complainant was discharged on 21.6.2014.   The complainants also paid a total sum of Rs.1,15,731.93 towards medical expenses.   After the first complainant discharged from the hospital, the second complainant submitted the necessary claim to the first opposite party on 18.7.2014 through email.     Thereafter the complainants were shocked to receive a letter dated 23.7.2014 from the first opposite party stating that the complainant’s claim was repudiated on some untenable and arbitrary grounds and in violation of the terms of the Insurance Policy.   Despite of several demands made by the complainants but the opposite party did not sanction the complainants’ claim.    The complainant further renewed their medical insurance policy with the 1^st opposite party in  June 2014.

3.     In continuation of the medical treatment, the first complainant visited the above said Christian Medical College Hospital, Vellore on 11.9.2014 for taking scan and other tests and incurred medical expenses to the tune of Rs.2850/-.  Again the first complainant was admitted in the said hospital on 15.9.2014 for further treatment and discharged on 16.9.2014 and the first complainant incurred medical expense to the tune of Rs.21,815/-. Inspite of proper claim dated 18.7.2014  and the reminder dated 5.8.2014 made by the complainants to the first opposite party, they have deliberately failed and neglected to pay the claim amount of Rs.1,40,396.93 to the complainants.  Immediately  the complainant filed a complaint before the 2^nd opposite party Ombudsman and sent a copy to 3^rd opposite party; since there is no proper response.    As such the act of the opposite parties clearly amounts  to gross deficiency in service and thereby caused deficiency in service and mental agony to the complainant.  Hence the complaint is filed.

4. The brief averments in the Written Version of  the 1^st  opposite party   are as follows:

        The 1^st  opposite party state that the opposite party denies all the allegations contained in the complaint except those which are specifically admitted herein and this opposite party puts the complainant to strict proof of each and every allegation.    Admittedly the complainants availed Health Insurance Policy from 8.6.2012 to 7.6.2013 and belatedly renewed from 22.6.2013to 21.6.2014.   The policy is subject to specific exclusion of certain diseases for initial period of 1-2 years as petitioner Exclusion Nos.3(a), 3 (b) of the policy.    The 1^st opposite party also state that the 1^st complainant was treated for Carcinoma in June 2014. It has occurred during the second policy which was a fresh policy or at the most running in the second year of insurance.    In view of the Exclusion of Carcinoma during first two years of insurance, the claim of treatment in June 2014 was not admissible under the policy held by the complainants.    The 1^st opposite party state that they have issued the Policies for the period 8.6.2012 to 7.6.2013 based on proposal of the complainants and further policy on 22.6.2013 to 21.6.2014 subject to the terms and conditions stipulated in the policy which have been accepted by the complainants and binding upon them.  Any claim has to be considered subject the terms of the said policies.     Merely because of Hospital being “listed Hospital” any treatment cannot be claimed.  When the illness suffered is excluded for the first two years, the claim is not payable and expenses of treatment have to be borne by the complainants.    The 2^nd and 3^rd opposite parties are not relevant parties to the complaint.       Hence there is no deficiency in service on the part of the 1^st opposite party and therefore this complaint is liable to be dismissed.

5.     Inspite of service of notice the 2^nd and 3^rd opposite parties are called absent and set exparte.

6.        In order to prove the averments of the complaint, the complainants have filed proof affidavit as their evidence and documents Ex.A1 to Ex.A22 marked.  Proof affidavit of 1^st opposite party filed and Ex.B1 marked on the side of the 1^st  opposite party.

7.   The point for the consideration is:  

1) Whether the complainants are entitled to a sum of

    Rs.1,40,396.93 towards medical expenses with interest as

    prayed for ?

 

2  Whether the complainants are entitled to a sum of Rs.1,00,000/

     towards mental agony and a sum of Rs.1,50,000/- towards

     deficiency of service with cost of Rs.50,000/- as prayed for ?

 

 

8.   POINTS 1 & 2

        Admittedly the complainants availed the medical insurance policy under the scheme Family Health Insurance Policy from the 1^st opposite party.   Ex.A1 is the  Health Shield Card.   Ex.A2 is the policy schedule for 2012 - 2013.  Ex.A3, Ex.A4 & Ex.A8 are the receipts for payment of premium towards renewal of the policy.    As per the policy condition that there shall be no break in policy for two years and the insured was below the age of 40 years.   The learned counsel for the complainant contended that suddenly on 15.6.2014 the complainant was fell ill with swelling in the neck and was taken to Christen Medical College and Hospital, Vellore and admitted as inpatient.  After necessary medical tests the complainant was diagnosed with “Multifocal Papillary Carcinoma” Thyroid with Left Cervical Lympth Nodal Metastases”.   Hence the complainant was constrained to undergo surgery as per direction of the medical practitioner on 17.6.2014 and was discharged on 21.6.2014.   Ex.A9 is the discharge summary.   Thereafter the complainant undergone medical treatment in the same Christen Medical College and Hospital, Vellore on 21.6.2014, 11.8.2014, & 16.9.2014 also.  Ex.A10, Ex.A20, & Ex.A21 are the medical bills and discharge summary.  Further the learned counsel for the complainant contended that immediately after discharged from the hospital on 21.6.2014 due claim form with all the medical report sent to the opposite parties including by email and was duly acknowledged by the opposite parties as per Ex.A11, Ex.A12 and Ex.A13.   On 23.7.2014 the 1^st opposite party sent a letter rejecting the claim as per Ex.A14.   Immediately  the complainant filed a complaint before the 2^nd opposite party Ombudsman and sent a copy to 3^rd opposite party; since there is no proper response.  Hence the complainant was constrained to file this case for claiming compensation.

9.     Further the learned counsel for the complainant contended that the only contention of the opposite parties is that after availing the policy Ex.A2 the complainant has not renewed the policy within the prescribed period and there is no break of 45 days in renewing the policy.  Hence the complainant is not entitled any compensation; is not acceptable because the complainant availed policy continuously for three periods till 2014-2015.  After payment of 3^rd premium on 12.6.2014 the complainant was admitted as inpatient before Christen Medical College and Hospital, Vellore on 15.6.2014 and surgery was  conducted only on 17.6.2014 and discharged on 21.6.2014.   Thereby the complainants fully satisfied the two year Exclusion is as follows:

“Treatment of Spondylosis /  Spondilitis – any type.  Inter vertebral Disc Prolapse and such other Degenerative Disoders.  Cataract, Benign Prostatic Hypertrohy, Hysterectomy, Fistula, Fissure in Anus, Piles, Hernia, Hydrocele, Sinusitis, Knee / Hip joint replacement, Chronic Renal Failure or end stage Renal Failure.  Heart diseases, any type of Carcinoma / Sarcoma / Blood Cancer, Osteoarthritis of any joint for all Insured Persons for two years from the Commencement Date of the cover with U under this Family Good Health Policy.  These exclusions will not be applicable if caused directly due to an accident during period of insurance.  

However if these diseases are Pre-Existing as defined at the time of proposal then they will be considered as falling under Exclusion. “

          Note:

For Insured Persons up to the age of 40 years holding an Individual Health Indemnity Insurance Policy.

1.  For a period of one year and renewed with Us without any break,  First Year Exclusions shall be waived and Two year Exclusion shall become the First Year Exclusions, provided it is not a Pre Existing Disease.
2. For a period of two continuous years and above and renewed with us without any break.  First Year Exclusion and Two Year Exclusions shall be waived provided it is not a Pre Existing Disease.  

Further as per Ex.A22 the opposite party agreed to consider the payment of medical expenses.  The learned counsel for the 1^st opposite party contended that as per Ex.A6 the policy and its conditions commencement date is 8.6.2012  for claiming medical expenses the insured was proved the above said conditions much less there shall be no violation in that.   In this case admittedly the complainant availed the medical insurance policy as per Ex.A2 while renewing the policy there is break of 45 days happened; thereby the renewal policy shall not be treated as continuous policy but it should be treated as a new policy.   As per the said policy condition the new policy of the complainant shall not covered such medical claim.   But on a careful perusal of the document Ex.A2 , Ex.A3, Ex.A4, Ex.A5, Ex.A8, Ex.A9 it is apparently clear that the complainant availed the policy for the period 8.6.2012 to 7.6.2013  thereafter renewed from 22.7.2013 to 21.7.2014 and further paid premium on 12.6.2014 for the period 22.7.2014 to 21.7.2015 and the complainant suddenly  fell ill on 15.6.2014 and was admitted in the hospital undergone surgery on 17.6.2014 and discharged on 21.6.2014 proves that there is a continuous of policy for two years even though there is a break of 45 days.    The opposite party cannot say or plea for ignorance of receiving 3^rd premium Ex.A8.  The condition of the policy also strictly says that the two continuous consequent premium without any break.   Further it is also seen from Ex.A22 that even after repudiation of the claim of the opposite parties they have been considered the claim of the complainant and the claim was approved by the own Medical Panel.   Considering the facts and circumstances of the case, this forum is of the considered view that the 1^st opposite party is liable to pay a sum of Rs.1,40,397/- towards the medical expenses with interest at the rate of 9% p.a. from the date of this complaint (i.e)  27.10.2014  to till the date of this order i.e. 04.07.2017 and compensation of Rs.25,000/- towards mental agony and cost of Rs.5,000/- and point is answered accordingly.

In the result, the complaint is allowed in part.   The 1^st opposite party is liable to pay a sum of Rs.1,40,397/- (Rupees one lakh forty thousand three hundred and ninty seven only) towards the medical expenses with interest at the rate of 9% p.a. from the date of this complaint (i.e)  27.10.2014  to till the date of this order i.e. 04.07.2017 and compensation of Rs.25,000/- (Rupees Twenty five thousand only) towards mental agony and cost of Rs.5,000/- (Rupees Five thousand only) to the complainant.  No order as against the 2^nd and 3^rd opposite parties.   

The above  amount shall be payable within six weeks from the date of receipt of the copy of the 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  4^th  day  of  July 2017.  

 

MEMBER-I                        MEMBER-II                             PRESIDENT.

 

Complainants” side documents:

Ex.A1- 8.6.2012    - Copy of Health Shield Card issued to the 2^nd complainant.

Ex.A2- 14.6.2012  - Copy of Insurance Policy Schedule.

Ex.A3- 22.7.2013  - Copy of Receipt issued by the 1^st opposite party.

Ex.A4- 24.7.2013  - Copy of Insurance policy schedule.

Ex.A5- 25.7.2013  - Copy of letter issued by 1^st opposite party for renewal.

Ex.A6-         -       - Copy of Family Good Health Insurance Key Features.

Ex.A7-         -       - Copy of List of Hospitals.

Ex.A8- 12.6.2014  - Copy of receipt for renewal for 2014-2015.

Ex.A9-20.6.2014   - Copy of Discharge summary.

Ex.A10- 20.6.2014 – Copy of Inpatient discharge bill.

Ex.A11- 20.6.2014         - Copy of Claim Form sent to the 1^st opposite party.

Ex.A12- 18.7.2014         - Copy of letter sent to the 1^st opposite party with claim form.

Ex.A13- 19.7.2014         - Copy of Ack. from the 1^st opposite party.

Ex.A14- 23.7.2014         - Copy of letter from 1^st opposite party rejecting the claim.

Ex.A15- 30.7.2014         - Copy of letter from the 1^st opposite party rejecting claim.

Ex.A16- 5.8.2014  - Copy of reminder sent to the 1^st opposite party.

Ex.A17- 14.8.2014         - Copy of complaint sent to the 3^rd opposite party.

Ex.A18- 19.8.2014         - Copy of complaint sent to the 2^nd opposite party.

Ex.A19- 21.8.2014         - Copy of Ack. from the 2^nd opposite party.

Ex.A20- 11.9.2014         - Copy of Medical bill for Rs.2,850/-

Ex.A21- 16.9.2014         - Copy of Discharge summary with medical bill for Rs.1815/-

Ex.A22- 17.2.2015         - Copy of Approval letter issued through email by the

                              1^st opposite party to the complainant.

 

 

Opposite parties’ side document: -   

 

Ex.B1- 14.6.2012 }  Copy of Insurance policy with terms and conditions       

            20.7.2013}

 

 

 

 

MEMBER-I                        MEMBER-II                             PRESIDENT.