Tamil Nadu

South Chennai

CC/71/2016

M.Subramaniyam - Complainant(s)

Versus

M/s.Health Claims Team, Royal Sundaram Alliance Insurance Company Ltd - Opp.Party(s)

Party in Persion

23 Jan 2020

ORDER

                                                                             Date of filing      : 07.03.2016

                                                                               Date of Disposal : 23.01.2020

                                                                                  

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.71/2016

DATED THIS THURSDAY THE 23^RD DAY OF JANUARY 2020

                                 

M. Subramanyam,

Plot No.61, Door No.66,

T.V.K. IInd Link Road,

Thiruvalluvar Nagar,

Erukkencherry,

Chennai – 600 118.                                                        .. Complainant.   

                                                                                                ..Versus..

 

M/s. Royal Sundaram Alliance Insurance Company Limited,

Represented by its Manager / Health Claims Team,

Register Office at:-

No.21, Pattullos Road,

Chennai – 600 002.                                                    ..  Opposite party.

 

For the complainant                  : Party in person

Counsel for the opposite party : M/s. M.B. Gopalan Associates &  

                                                     others

 

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 pay a sum of Rs.17,623/- being Genuine Health Claims of the complainant and to pay a sum of Rs.10,000/- towards compensation for mental agony and deficiency in service with cost of Rs.3,000/- to the complainant.

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

The complainant submits that he has availed Health Shield Gold Insurance Policy vide Policy No.HJ00000996000111 with the opposite party.   The complainant submits that he was suffering from breathing difficulty, giddiness on 17.02.2015.  The complainant consulted a doctor at Dr. Ramachandran’s Diabetic Hospital, Egmore, Chennai on the same day.   The doctor examined him and advised the complainant to admit in the hospital to do necessary investigations and treatment pertaining to the health condition of the complainant.  The complainant submits that after treatment when his condition became stable; the doctor who was treated him discharged the complainant on 18.02.2015 and advised to come for review on 18.05.2015.  Subsequent to his discharge, the complainant submitted medical bills for a sum of Rs.14,292/- and a sum of Rs.3,331/- dated:11.03.2015 & 16.04.2015 respectively to the opposite party. The opposite party rejected the complainant’s claim through their letter dated:28.04.2015 & 20.05.2015.  In response to the insurance letter dated:28.04.2015, the complainant sent a letter dated:07.05.2015 that he was admitted into Ramachandran’s Diabetic Hospital on 17.02.2015 as per the advice of the Doctor alone.  The complainant submits that the opposite party once again in their letter dated:13.07.2015 rejected the claim.  The opposite party has not come forward to settle the claim of the complainant.  The act of the opposite party amounts to deficiency in service and unfair trade practice which caused great mental agony.  Hence, the complaint is filed.

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

The opposite party specifically denies each and every allegation made in the complaint and put the complainant to strict proof of the same.    The opposite party states that the complainant was holding Health Shield Gold Insurance Policy for the period from 21.01.2015 to 20.01.2016.  The opposite party submits that the coverage under the Policy is subject to terms and conditions stipulated therein.   Essentially, the Health Policy is intended to cover in patient hospitalisation expenses incurred for diagnosis and treatment of any sickness that requires such hospitalization. The complainant has merely produced the Policy Schedule but not the terms and conditions of the policy.   Such conduct is to be deprecated.   The opposite party carves leave to produce the policy terms and refer to and rely upon the same.  The opposite party states that the policy does not cover hospitalisation primarily for the purpose of diagnostic study, investigation or laboratory examinations (vide Exclusion No.9) which are not consistent with the diagnosis and treatment of any ailment, sickness or injury.   The complainant reported a claim for hospitalisation on 17.02.2015 as stated in the complaint.   On examination of the medical records, it was found that the complainant was subject to various investigations and discharged.   There was no treatment for any specific ailment that required hospitalization.  It is pertinent that even in the present complaint, there is no mention of any ailment that was diagnosed and the admission was essentially for investigations.  Such expenses are not admissible under the policy and hence, the opposite party denied the claim for valid reasons.  The opposite party states that the complainant submitted the claim for purchase of medicines which were not related to any hospitalisation.  Such claim for purpose of medicines is not within the scope of coverage.  The opposite party states that when the hospitalisation claim itself is not admissible, the question of treating the purchase of medicines as Post Hospitalization does not arise.   The claim appears to be borne out of complete misunderstanding of the policy.   Hence, the same was declined.   Therefore, the rejection of the claims by the complainant are on the valid grounds based on proper appreciation of facts and the terms of the policy and the same is liable to be dismissed.

3.     To prove the averments in the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A16 are marked.  Proof affidavit of the opposite party is filed and documents Ex.B1 alone is marked on the side of the opposite party.

4.      The points for consideration is:-

1. Whether the complainant is entitled to get the Health Claim Amount of Rs.17,623/- as prayed for?
2. Whether the complainant is entitled to get a sum of Rs.10,000/- as compensation for mental agony and deficiency in service with cost of Rs.3,000/- as prayed for?

 

 

5.      On point:-

Both parties filed their respective written arguments.   Heard their Counsels also.   Perused the records namely; the complaint, written version, proof affidavits and documents.   The complainant pleaded and contended that he has availed Health Shield Gold Insurance Policy No.HJ00000996000111 with the opposite party as per Ex.A1 & Ex.A2.   Further, the contention of the complainant is that he had breathing difficulty and giddiness on 17.02.2015 consulted a doctor at Dr. Ramachandran’s Diabetic Hospital, Egmore, Chennai on the same day.   The doctor examined him and advised the complainant to admit in the hospital to do necessary investigations and treatment pertaining to the health condition of the complainant as per Ex.A5 & Ex.A11 a certificate issued in favour of the complainant by a doctor who consulted him and issued Discharge summary proves that he was an inpatient, undergone treatment to his health problem.   Further the complainant contended that after treatment and his condition became stable the doctor who has treated him discharged the complainant on 18.02.2015 as per Ex.A11(S). Subsequent to his discharge, the complainant submitted medical bills for a sum of Rs.14,292/- and a sum of Rs.3,331/- dated:11.03.2015 & 16.04.2015 respectively to the opposite party as per Ex.A7, Ex.A13, Ex.A14 & Ex.A15.  But the opposite party rejected the complainant’s claim through their letter dated:28.04.2015, 20.05.2015 & 16.07.2015 as per Ex.A3 stated that the complainant was admitted only for investigation purpose.  But on a careful perusal of Ex.A11(S), Discharge Summary shows that the complainant was treated with administration of medicine for his health problems by the Doctors proves that he stayed in the hospital for one day for diagnose and treatment.  Therefore, he has every right to claim the amount expended for his treatment under the Health Insurance policy availed from the opposite party.   Therefore, the lawful claim of the complainant was rejected by the opposite party amounts to deficiency in service and unfair trade practice.  Hence, the complainant is constrained to file this case.  

6.     The learned Counsel for the opposite party would contend that the policy does not cover by invoking the exclusion clause 9 stipulated the terms and conditions of policy.   But it will not applicable to the complainant’s case, as per Ex.B1, terms and conditions of the policy under the following heads:-

Hospitalization

Hospitalization means admission in a Hospital for a minimum period of 24 In patient Care consecutive hours except for specified procedures/ treatments, where such admission could be for a period of less than 24 consecutive hours.

Illness

Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function which manifests itself during the Policy Period and requires medical treatment.  

1. Acute condition – Acute condition is a disease, illness or injury that is likely to respond quickly to treatment which aims to return the person to his or her state of health immediately before suffering the disease / illness / injury which leads to full recovery.
2. Chronic condition – A chronic condition is defined as a disease, illness or injury that has one or more of the following characteristics:

• it needs ongoing or long-term monitoring through consultations, examinations, check-ups and / or tests
• it needs ongoing or long-term control or relief of symptoms
• it requires your rehabilitation or for you to be specially trained to cope with it
• it continues indefinitely
• it comes back or is likely to come back

Post-hospitalization Medical Expenses

Medical Expenses incurred immediately after the insured person is discharged from the hospital provided that:

1. Such Medical Expenses are incurred for the same condition for which the insured person’s hospitalization was required and
2. The impatient hospitalization claim for such hospitalization is admissible by the insurance company.

The complainant’s claim is proved to be right full claim under the policy (Health Shield Gold Insurance) availed by him.   Therefore, the repudiation of the complainant claim by the opposite party amounts to deficiency in service and unfair trade practice.  Moreover, in corroboration with Ex.A11(S) evidence produced by the complainant did not reveal any violation of policy terms and conditions.  Considering the facts and circumstances of the case, this Forum is of the considered view that the opposite party shall pay the Genuine Health Claim amount of Rs.17,623/- and shall pay a compensation of Rs.10,000/- for mental agony and deficiency in service with cost of Rs.3,000/- to the complainant.

In the result, this complaint is allowed in part.   The opposite party is directed to pay a sum of Rs.17,623/- (Rupees Seventeen thousand six hundred and twenty three only) being medical bill and hospitalisation expenses incurred by the complainant and to pay a sum of Rs.10,000/- (Rupees Ten thousand only) towards compensation for mental agony and deficiency in service with cost of Rs.3,000/- (Rupees Three 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 23^rd day of January 2020. 

 

MEMBER                                                                                PRESIDENT

COMPLAINANT SIDE DOCUMENTS:-

Ex.A1	11.03.2015 & 16.04.2015	Copy of acknowledgement issued  for receiving Medi-claim by Royal Sundaram Alliance Insurance Company Limited
Ex.A2	09.01.2015	Copy of Royal Sundaram Alliance Insurance Company Limited Health Insurance Policy No.HJ00000996000111-J004
Ex.A3	28.04.2015, 20.05.2015 & 16.07.2015	Copy of letters of the opposite party to the complainant
Ex.A4	07.05.2015 & 13.07.2015	Copy of letters of the complainant to the opposite party
Ex.A5	11.07.2015	Copy of Certificate issued by Dr. Santhosh Jeyaraj Consultant Diabetalogist Dr. Ramachandran’s Diabetic Hospital, Egmore
Ex.A6	27.01.2015	Copy of letter of Royal Sundaram Alliance Insurance Company Limited, (Return of Documents)
Ex.A7	18.02.2015	Copy of bill No.15/24919 issued by Dr. A. Ramachandran’s Diabetes Hospital, Egmore
Ex.A8	17.02.2015	Copy of CBG Report, Echocardiogram
Ex.A9	17.02.2015	Copy of Carotid and Vertebral Artery, Doppler
Ex.A10	17.02.2015	Copy of ABI Main Screen Report
Ex.A11	15.02.2015	Copy of Discharge Summary & Prescription
Ex.A12	17.02.2015 & 22.01.2015	Copy of LAB Investigation Report & ECG Dr. Prescription
Ex.A13	22.01.2015, 23.01.2015, 27.02.2015, (2 nos.), 31.05.2015, 12.01.2015, 01.02.2015, 25.01.2015, 16.02.2015, 25.02.2015, 04.03.2015, 06.03.2015, 22.03.2015 (2 nos.), 27.03.2015, 31.03.2015 (2 nos.), 01.04.2015 & 02.04.2015	Copy of consulting fees of the Doctor, Prescriptions of Doctor & Pharmacy bills -
Ex.A14	08.04.2015, 08.04.2015, 08.04.2015 & 13.04.2015	Copy of Dr. Prescription Copy of Dr. Consulting bill Copy of Physiotherapy Treatment bill Copy of Physiotherapy Treatment bill
Ex.A15	16.04.2015	Copy of bill issued by Dr. A. Ramachandran’s Diabetes Hospital, Egmore
Ex.A16	16.04.2015	Copy of Doctor Prescriptions & Lab Investigation Report

 

OPPOSITE PARTY SIDE DOCUMENTS:-  

Ex.B1

Copy of Insurance Policy with terms and conditions

 

 

 

MEMBER                                                                                                                                                                                    PRESIDENT