Date of filing:      29.01.2019

                                                                                                                                 Date of disposal : 15.11.2022

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

THIRUVALLUR

 

 BEFORE  TMT. Dr.S.M. LATHA MAHESWARI, M.A.,M.L, Ph.D (Law)                 .…. PRESIDENT

                 THIRU.P.MURUGAN,M.Com.ICWA(Inter),B.L.,                                        ....MEMBER-II

 

RBT/CC. No.64/2022

THIS TUESDAY, THE 15th DAY OF NOVEMBER 2022

(CC.No.46/2019 sent from DCDRC, Chennai North)

 

Mr.N.Chandrasekaran, S/o.Nataraj,

No.9/12, Gandhi Street,

Sri Venkateshwara Nagar,

Kolathur, Chennai -600 099.                                                           ……Complainant.     

                                                                          //Vs//

1.M/s.The New India Assurance Company Limited,

    Mint Micro Office,

    Rep. by its Manager,

    No.84-85, Arihant plaza, 2nd Floor, 

    S.B.I. Building, Park Town,

   Wall Tax Road, Chennai 600 003.

 

2.M/s.Medi Assist Insurance TPA Private Limited,

    Rep. by its Manager,

    2nd Floor, R.W.D.Atlantis Building,

    No.24, Nelson Manickam Road,

    Chennai – 600 029.                                                              .......Opposite parties. 

 

Counsel for the complainant                               :   Mr.S.Mahendran, Advocate.

Counsel for the opposite parties                        :   M/s.S.Radhadevi, Advocate.

                         

This complaint has been filed before DCDRC, Chennai (North) as CC.No.46/2019 and transferred to this commission by the order of the Hon’ble State Consumer Disputes Redressal Commission, Chennai and taken on file as CC.No.64/2022 and this complaint coming before us on various dates and finally on 03.10.2022 in the presence of M/s.S.Radhadevi Advocate, counsel for oppostie parties and upon perusing the documents and evidences of both parties, this Commission delivered the following: 

ORDER

PRONOUNCED BY TMT. Dr.S.M. LATHA MAHESWARI,   PRESIDENT.

 

This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act, 1986 alleging deficiency in service in repudiating the medical insurance claim along with a prayer to direct the opposite parties to settle the claim amount of Rs.1,10,000/- with 24% interest per annum and to pay a sum of Rs.50,000/- compensation for the mental agony and hardship caused to the complainant and to pay a sum  of Rs.20,000/- towards cost of the proceedings to the complainant. 

Summary of facts culminating into complaint:-

 

It was the case of the complaint that he obtained medical insurance policy for himself and for his family for a total sum of Rs.3,00,000/- from the 1st opposite party vide policy No.71020634162500000065 which is valid from 20.09.2016 to 09.09.2019.  Complainant took treatment for Coronary Artery disease at Neomed Hospital where he underwent enhanced EECP and spent around Rs.1,10,000/-.  When the said amount was claimed from the 1st opposite party through 2nd opposite party the said claim was rejected. Thus aggrieved the present complaint was filed against both the opposite parties alleging deficiency in service and to settle the claim amount of Rs.1,20,000/- with 24% interest along with Rs,50,000/- compensation and Rs.20,000/- cost.

Crux of the defence put forth by the opposite parties:-

Both the opposite parties jointly filed version disputing the complaint allegations contending inter alia that the claim could not be honoured for the reason that the treatment undergone for Coronary Artery disease i.e. EECP to restore the blood flow in the Coronary Vessels to enhance myocardial perfusion comes under the exclusion clause of the policy.  Thus both the opposite parties stated that there is no deficiency in service on their side and sought for the dismissal of the claim.

On the side of complainant proof affidavit was filed and submitted documents marked as Ex.A1 to A3. On the side of opposite parties proof affidavit was filed and submitted document Ex.B1 was marked on their side. 

Points for consideration:

Whether the out of repudiation of Medi claim by the opposite parties citing the exclusion clause under the policy amounts to deficiency in service?

If so to what reliefs the complainant is entitled?

Point No.1;-

The following documents were filed on the side of complainant in support of his contentions;

Insurance policy issued by the 1st opposite party dated 20.09.2016 was marked as Ex.A1;

Discharge Summary of the complainant dated 11.03.2017 was marked as Ex.A2;

Claim repudiation letter dated 07.04.2017 was marked as Ex.A3;

On the side of opposite parties the following document was filed in support of their defence;

Policy Terms and conditions was marked as Ex.B1;

Inspite of sufficient opportunities and proper notice the complainant did not appear to adduce any oral arguments.  Hence after hearing the oral arguments of the opposite parties this commission decided to consider the written arguments filed by the complainant to dispose of the complaint on merits.

It is stated by the complainant that he had taken the policy for himself and for his family.  However, when he underwent EECP the 2nd opposite party did not settle the claim of Rs.1,10,000/- and thus the irresponsible attitude of both opposite parties caused mental agony and monetary loss to the complainant.  

The crux of the arguments made by the learned counsel for the opposite parties is that as the treatment underwent by the complainant comes under exclusion clause of the policy, the claim of the complainant could not be entertained.

On perusal of the terms and conditions appended to the policy produced by opposite parties as Ex.B1 we are of the view that the complaint is liable to be dismissed for the reason that under clause 4 of the policy certain treatments are excluded from the perview of the claim and under clause 4.4.22 it has been specifically provided as follows “Treatment for Age Related Macular Degeneration (ARMD), treatment such as Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ESP), Enhanced External Counter Pulsation (EESP), Hyperbaric Oxygen Therapy“. Thus when the discharge summary Ex.A2 clearly provides that the complainant underwent treatment for Coronary Artery disease i.e.EECP which treatment was clearly excluded under the said clause, the act of opposite parties in rejecting the medical claim of the complainant could not be found fault with.  As the medi claim is a pure contract of insurance both parties are bound by the terms and conditions of the policy. Thus we hold that there is no deficiency in service in the rejection of the medical claim made by the complainant.  The point is answered accordingly in favour of the opposite parties and as against the complainant.

In the result, the complaint is dismissed.  No order as to cost. 

Dictated by the President to the steno-typist, transcribed and computerized by him, corrected by the President and pronounced by us in the open Commission on this the 15th day of November 2022.

 

  Sd/-                                                                                                                   Sd/-

MEMBER-II                                                                                                    PRESIDENT

 

List of document filed by the complainant:-

 

Ex.A1 20.09.2016 Insurance policy issued by the 1st opposite party. Xerox

Ex.A2 11.03.2017 Discharge Summary of the complainant. Xerox

Ex.A3 07.04.2017 Claim repudiation letter. Xerox

 

List of documents filed by the opposite parties:-

 

Ex.B1 ............... Terms and conditions. Xerox

 

 

Nil

 

 

    Sd/-                                                                                                                Sd/-

MEMBER-II                                                                                                  PRESIDENT