Tamil Nadu

South Chennai

CC/132/2017

Suman Das S/o Utpal Kumar das - Complainant(s)

Versus

M/s.Raksha TPA Pvt Ltd., - Opp.Party(s)

K.Ramesh

20 Apr 2022

ORDER

                                                                        Date of Complaint Filed :24.03.2017

                                                                                                                                    Date of Reservation      :04.04.2022

                                                                                                                                    Date of Order               :20.04.2022

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

CHENNAI (SOUTH), CHENNAI-3.

 

PRESENT:  TMT. B JIJAA, M.L.,                                         : PRESIDENT

                     THIRU. T.R. SIVAKUMHAR, B.A., B.L.,        :  MEMBER  I 

                    THIRU. S. NANDAGOPALAN., B.Sc., MBA    : MEMBER II

CONSUMER COMPLAINT No. 132/2017

WEDNESDAY, THE 20^th DAY OF APRIL 2022

 

Suman Das,

S/o. Utpal Kumar Das,

No.L112, Oxygen By Urban Tree,

Pushkin Street, Gandhi Nagar,

Perumbakkam, Chennai – 100.                                                                                    ... Complainant                  

..Versus..

1.Raksha TPA Pvt. Ltd.,

   Rep. by Manager,

   18/4, PLN Complex,

   Conran Smith Road,

   Gopalapuram, Chennai – 86.

 

2.The Oriental Insurance Co. Ltd.,

   Rep by Manager,

   272, Anna Salai III Floor,

   Teynampet, Chennai – 18.                                                                                                       …Opposite Parties

******

Counsel for the Complainant            : M/s. K. Ramesh 

Counsel for the 1^st Opposite Party    : Exparte

Counsel for the 2^nd Opposite Party   :  M/s. Nageswaran & Narichania

 

        On perusal of records and after having heard the oral arguments of both the Counsel for Complainant and the Counsel for 2^nd Opposite Party we delivered the following:

ORDER

1. Pronounced by the President Tmt. B. Jijaa, M.L.,

The complainant has filed this complaint as against the Opposite Parties under Section 12 of the Consumer Protection Act 1986, and prays to pay a sum of Rs.1,00,000/- towards compensation, to pay a sum of Rs.50,000/- towards mental agony, to pay a sum of Rs.54,000/- towards Mediclaim made by the Complainant along with cost.

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

The Complainant took Insurance from the 1^st Opposite Party vide Policy No.411700/48/2017/1169. The Complainant had some problem with his left eye and was admitted in “Sankara Nethralaya” Hospital on 15.12.2016 and was given Intra Vitreal Injection and discharged on 15.12.2016. The Complainant incurred a sum of Rs.28,000/- towards medical expenses.  He immediately submitted his claim form to the 1^st Opposite Party. Again on 16.01.2017 the Complainant was admitted in “Suryodaya Eye Center, The Calcutta Medical Research Institute”  and was given Intra Vitreal Injection and discharged on 16.01.2017. The Complainant incurred a sum of Rs.26,000/- towards medical expenses. He submitted his claim form to the 1^st Opposite Party for a total claim amount of Rs.54,000/-. The Complainant has received a letter from the 1^st Opposite Party on 06.01.2017 rejecting the claim of the Complainant stating that the treatment given to the Complainant is not listed in day care procedures as per clause 2.3(a) and treatment can be done as OPD procedure as per clause 2.3 (note). The Complainant  through his mail dated 10.01.2017 gave a clear explanation that the treatment has been carried out at Operation Theatre  and not as an OPD. But the Opposite Party refused to accept the explanation. Even after necessary clarification and explanation given to the Opposite Party pointing out the clauses 2.3(A)(iv) and 2.3(C) HOSPITALISATION PERIOD. The reason for rejection of the claim of the Complainant showing as if he took treatment as OPD has caused mental agony to the Complainant which cannot be resolved unless he is compensated. Further, the Complainant issued legal notice to the Opposite Parties on 24.02.2017. Even after receipt of the notice there was no reply from the Opposite Party. Hence the complaint.

3.Written Version of the 2^nd Opposite Party in Brief are as follows:

    The 2^ndOpposite Party submits that they had issued a group Mediclaim Policy bearing No.411700/48/2017/1169  and the said policy is strictly governed by the various terms and conditions. The Complainant underwent an operative procedure in his left eye by way of Intra Vitreal Injection for dosage of accentrix drug in the eye on 15.12.2016. The specific process is not covered under section 2.3 of the terms and conditions which contemplates expenses on hospitalization where if hospitalization is only for a minimum period of 24 hours, the admissibility of the claim will be considered. More particularly under section 2.3 (c)  it is clear that the condition of minimum 24 hours hospitalization will also not apply provided, medical treatment and / or surgical procedure is ; (i) undertaken under general or local anesthesia in a hospital / day care center in less than 24 hours because of technological advancement, and (ii) which would have otherwise required a hospitalisation of more than 24 hours. The Complainant was having pre-existing condition of MYOPIA (30 years) and burning sensation for 5 years which would prove that the Complainant had a pre-existing medical problem prior to the inception of the policy. The claim of the Complainant clearly falls under exclusion clause 4.1 where the insurer/ 2^ndOpposite Party is not liable to make any payment under the Policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of pre-existing  health condition or disease or ailment / injuries. The exclusion will apply to any complications arising from pre-existing ailment / disease / injuries. Such complications will be considered as a part of pre-existing health condition / disease. The second treatment taken by the Complainant for the same problem clearly reflects the treatment was not  properly given and a claim for a faulty treatment cannot be indemnified again and again and therefore the claim for the treatment at Calcutta Medical Research Institute is not payable. As the claim did not fall within the ambit of the policy terms and conditions the same was repudiated by the Opposite Parties.  Hence the allegation of the deficiency in service and unfair trade practice is unfounded and untenable. Hence prayed to dismiss the complaint.

4.      The Complainant submitted Proof Affidavit and Written Arguments.

On the side of the Complainant Ex.A1 to Ex.A6 were marked. The 1^st Opposite Party remained Exparte. The 2^ndOppoiste Party has submitted his Version, Proof Affidavit and Written Arguments.

5.      Points for Consideration:-

1.Whether there is any deficiency in service on the part of the Opposite Parties?

2.Whether the Complainant is entitled to get reliefs as claimed in the complaint?

3.To what other reliefs, the Complainant is entitled for?

6.     Point No.1

        On perusal of Ex.A2, the discharge summary issued by the Sankara Nethralaya Hospital it is mentioned that the operative procedure was carried out in the left eye of the Complainant by way of Intra Vitreal Injection of accentrix drug. Further, under the heading Main Complaints it is shown as “Both eyes burning sensation 5 year(s) On set Gradual Progression. Improving and under the heading Past Ocular History it is shown as “Both eyes MYOPIA 30 year(s)”.  In the discharge summary it is mentioned that  the date of admission and discharge of the Complainant was on 15.12.2016.

7.     Ex.A4 the discharge certificate for day care patients  issued by the Suryodaya Eye Center, the Calcutta Medical Research Institute mentions that on 16.01.2017 the nature of procedure done on the Complainant was left eye Intra Vitreal Injenction  ITA and discharged on the same day. It is the case of the 2^nd Opposite Party that the specific procedure in the eye by way of Intra Vitreal Injection for dosage of accentric drug on 15.12.2016 is not covered under section 2.3 of the policy terms and conditions. A further reading of 2.3 would reveal that the minimum time limit of 24 hours will not apply to specific treatments taken in the network hospital / nursing home where the insured is discharged on the same day for various treatments including the  Eye Surgery.

 However clause 4.1 of the Policy reads as follows.

“4.1 pre-existing health condition or disease or ailment / injuries : Any ailment  / disease / injuries / health condition which are pre-existing (treated / untreated, declared / not declared in the proposal form), when the cover incepts for the first time are excluded up to 4 years of this policy being in force continuously”.

      This exclusion will also apply to any complications arising from pre existing ailment / diseases / injuries. Such complication will be considered as  part of the pre-existing health condition or disease.

8.    There are no pleadings or documents to show as to when the policy was taken for the first time. Therefore,  clause 4.1 excludes the liability of the insurer in case of pre-existing health conditions or ailments or injuries.

9.   The counsel for 2^nd Opposite Party relied on the Order dated 25.10.2018 passed by the National Consumer Disputes Redressal Commission in Venkat Reddy  Vs. HDFC Bank Ltd., and another reported in 2018 (4) C.P.R 562: 2019(1) CPJ 396, the relevant portion of order is extracted  hereunder “it is thus, evident that in case of a first heart attack, Non-ST-segment elevation Myocardial Infraction (NSTEMI) was excluded from the purview of the insurance policy. Even Angioplasty was expressly excluded from the purview of the insurance policy. In the present case, since the Complainant had Non-ST-segment elevation Myocardial Infraction (NSTEMI), his claim was not covered under the insurance policy. Even the Angioplasty was expressly excluded from the purview of the said policy” and the Hon’ble National Consumer Disputes Redressal Commission had upheld the dismissal of the complaint.

10.      The claim of the Complainant falls under the exclusion set out in  clause 4.1 of the terms and conditions of the Mediclaim Insurance Policy (Group) Ex.A-3 and the Opposite  Parties  has rightly repudiated the claim of the Complainant. Hence there is no deficiency on the part of the Opposite Parties and the Complainant is not entitled for any compensation as claimed in the complaint. Accordingly, Point No.1 is answered against the Complainant.

11.     Point Nos.2 & 3:-

        We have discussed and decided that there is no deficiency in service on the part of the Opposite Parties. Hence, the Complainant is not entitled to get any reliefs as claimed in the complaint as against the Opposite Parties. Accordingly, Point Nos.2 & 3 are answered against the Complainant.

In the result, this complaint is dismissed. No costs.

Dictated to Steno-Typist, transcribed and typed by her, corrected and pronounced by us in the Open Commission, on this the 20^th day of April 2022.

 

 

S. NANDAGOPALAN                T.R. SIVAKUMHAR                 B.JIJAA

      MEMBER II                        MEMBER I                              PRESIDENT

 

List of documents filed on the side of the complainant:

 

Ex.A1		Policy I.D Card issued by Opp. Party
Ex.A2	15.12.2016	Discharge Summary given by Shankra Nethralaya  Hospital
Ex.A3	06.01.2017	Letter from 1st Opposite Party to the Complainant
Ex.A4	14.01.2017	Discharge Summary given by the Calcutta Medical Research Institute
Ex.A5		Mail Communication between Complainant and the 1st Opposite Party
Ex.A6	24.02.2017	Legal Notice issued by the Complainant

 

 

List of documents filed on the side of the Opposite Parties:   

 

Nil

 

 

 

 

S. NANDAGOPALAN                T.R. SIVAKUMHAR              B.JIJAA

      MEMBER II                        MEMBER I                          PRESIDENT