Tamil Nadu

South Chennai

CC/76/2015

A.Chelladurai, S/o.K.Arthaneriswaran - Complainant(s)

Versus

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

P.S.Vasanth Kumar

18 Sep 2019

ORDER

                                                                  Complaint presented on : 06.02.2015

                                                                    Date of Disposal            : 18.09.2019

                                                                                  

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.76/2015

DATED THIS WEDNESDAY THE 18^TH DAY OF SEPTEMBER 2019

                                 

A. Chelladurai,

S/o. Late K. Arthaneriswaran,

No.18/4, Mettu Street,

Nerinjipettai Post,

Erode – 638 311,

Tamil Nadu.                                                                 .. Complainant.                                                

                                                                                         ..Versus..

1. United India Insurance Co. Ltd.,

Regional Office,

Represented by its Regional Manager,

LCB, Auras Corporate Center,

No.98/A, Dr. Radhakrishnan Road,

Chennai – 600 004. 

 

2. M/s. Raksha TPA Pvt. Ltd.,   

Head Office,

Represented by its General Manager,

No.15/5, Mathura Road,

Faridabad – 121 003.

 

3. M/s. Raksha TPA Pvt. Ltd.,   

Regional Office,

Represented by its Regional Manager,

No.18/4, PLN Complex,

Conran Smith Road,

Gopalapuram,

Chennai – 600 086.

 

4. G. Kuppusamy Naidu Memorial Hospital,

Represented by its Medical Director,

No.6327, Nethaji Road,

Pappanaickenpalayam,

Coimbatore – 641 037.                                       ..  Opposite parties.

Counsel for the complainant           : M/s. P.S. Vasanthkumar &

                                                           another

Counsel for the 1^st opposite party  : M/s. M.B. Gopalan & others

For the opposite parties 2 & 3        : Authorized representative,

                                                           Mr. Srihari Kumaran

4^th opposite party                              : Exparte                                   

 

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite parties 1 to 3 under section 12 of the Consumer Protection Act, 1986 prays to reimburse the amount of Rs.84,865/- paid by the complainant to G. Kuppusamy Naidu Memorial Hospital at Coimbatore after the treatment which is covered by the policy No.500200/48/13/41/00000263 issued by the 1^st opposite party and pay interest to the said amount at 12% per annum 19.10.2013 till the date of actual payment to the complainant and to pay a sum of Rs.1,00,000/- towards compensation for mental agony, pain, deficiency and negligence in service with cost of Rs.25,000/- to the complainant.

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

The complainant submits that he employed in M/s. IFMR Rural Channels and Services Private Ltd., Taramani, Chennai.  The complainant company had taken medi-claim insurance policy for the benefits of his employees and their family members including the complainant’s father, K. Arthanarieshwaran vide medi claim policy No.500200/48/13/41/00000263 for the period from 01.08.2013 to 31.07.2014.  The assured sum for the complainant and his family is of Rs.5,00,000/-.  The 2^nd opposite party is the Third Party Administrator (TPA) of the 1^st opposite party and the 3^rd opposite party is the Third Party Administrator of the complainant situated at Chennai.  The 4^th opposite party is the Hospital situated at Coimbatore wherein, the complainant’s father K. Arthanarieshwaran took treatment for Cancer in oropharynx and Oesophagus. The complainant’s father K. Arthanarieshwaran took treatment on various days on 05.09.2013 to 07.09.2013, 26.09.2013 to 28.09.2013, 17.10.2013 to 19.10.2013 and 08.11.2013 to 10.11.2013 and the complainant had filed the discharge summary for the treatment. The complainant’s father also taken chemotherapy treatment in 4^th opposite party hospital on the above mentioned days.  The 4^th opposite party hospital issued a bill for the treatment taken by the complainant’s father for a sum of Rs.84,865/-.  While taking treatment, the complainant requested the opposite parties for cashless treatment for his father.  Since the 4^th opposite party had not tied  up for cashless medical claim with the opposite party, the complainant was asked to pay the medical bill amount.  But the complainant’s father K. Arthanarieshwaran died on 14.05.2014.  The complainant processed the medical claim for Rs.84,865/- with other medical bills for a total sum of Rs.1,24,845/- which was repudiated by the opposite parties on 01.11.2013 stated that using of intoxicating (Tobacco) is not covered under the policy as per clause 4.9 of the G.M.C. Policy condition of the 1^st opposite party.  Thereafter, the complainant sent a letter to the 1^st opposite party through mail on 29.11.2013 and a remainder mail dated:28.12.2013 which was duly acknowledged by the opposite parties.  On 27.03.2014, the grievance officer sent a reply confirming the repudiation of the claim is correct and directed the complainant to approach the Insurance Ombudsman.  On 27.03.2014, the complainant addressed a complaint to the Insurance Ombudsman, Chennai.   

2.     The complainant submits that at page 4 of final award of insurance OMBUDSMAN datedL27.05.2014 as stated as:

It was observed that TPA third party administrative in their claim repudiation letter dated:01.11.2013 has on their own included the ward “Tobacco” under the intoxicating drug under clause 4.9 of the Group mediclaim policy which is  not correct.  Secondly, the letter nowhere states that I (Insurer) has authorized the TPA to repudiate the claim. As per the Medical dictionary the term “intoxication” is defined as

1. A state of impaired mental or physical functioning resulting from ingestion of alcohol; inebriation, simple drunkenness.

2. All organic mental syndrome characterized by the presence in the body of an exogenous psychoactive substance that produces a substance-specific syndrome of effects on the central nervous system (e.g. disturbances of perception, wakefulness, attention, thinking, judgments, emotional control or psychomotor behaviour) that leads to maladaptive behaviour such as belligerence or impaired social or occupational functionin and

3. Poisoning

The insurance OMBUDSMAN accepted the stand of complainant but unfortunately the OMBUDSMAN awarded sum of Rs.25,000/- only as EX-Gratia.

 The complainant with due EX-Gratia and disappointment sent a letter dated:10.06.2014 to the Insurance Ombudsman and the complainant was put to mental stress and pain due to negligence and unfair trade practice of the opposite parties.    Hence, the complaint is filed.

3.      The brief averments in the written version filed by 1^st opposite party is as follows:

The 1^st opposite party specifically denies each and every allegation made in the complaint and put the complainant to strict proof of the same.   The 1^st opposite party states that the complainant availed Group Mediclaim Policy covering the family members which was subsisting.  The employees’ policy is also subsisting.  As per the Exclusion 4.9 of the Policy treatment arising out of use of intoxiacating substances is not covered. The complainant made a claim for the treatment of his father K. Arthanarieshwaran at G. Kuppusamy Naidu Memorial Hospital, Coimbatore for oral cancer.  The medical records and the history of the patient reveals smoking Beedi 10/ day for 10 years which falls within the exclusion of ‘intoxicating’ substance under 4.9 of the Policy. Hence, the 2^nd opposite party, the Third Party Administrator repudiated the claim.   Therefore, there is no deficiency in service on the part of the 2^nd opposite party and hence, the complaint as against the 2^nd opposite party is liable to be dismissed.

4.      The brief averments in the written version filed by opposite parties 2 & 3 is as follows:

The opposite parties 2 & 3 specifically deny each and every allegation made in the complaint and put the complainant to strict proof of the same.   The opposite parties 2 & 3 registered under the Companies Act, 1956 is licensed under IRDA Act, 2001 to act as a facilitator for the processing of the claim.   The insurance contract is between the insured and the insurer i.e. The United India Insurance Co. Ltd.   As per the privity of the contract, the insurance company by itself or its TPA is obliged to process the claim as per the terms and conditions of the policy.   By the virtue of the Memorandum of the Understanding, signed with the United India Insurance Company Ltd. the opposite parties 2 & 3 are nominated as the Third Party Administrator for arranging to process the claims as per the terms and conditions laid by the Insurance Company. The opposite parties 2 & 3 state that the complainant was covered under group mediclaim policy No.500200/48/13/41/00000263 issued by the United India Insurance Co. Ltd., Chennai and the claims in respect of K. Arthanareeswaran were recommended for repudiation as per the policy terms and conditions laid down by the 1^st opposite party and the files were forwarded to the 1^st opposite party for their perusal and further action.  The opposite parties 2 & 3 state that the opposite party has recommended the claim for repudiation in accordance with the terms and conditions of the medi-claim policy entered between the complainant and the 1^st opposite party which was agreed by the complainant.   It is further submitted that the opposite parties 2 & 3 is just a third party administrator who act as a facilitator for the processing of the claims as per the policy terms and conditions laid down by the 1^st opposite party.  It is therefore submitted that the name of the opposite parties 2 & 3 are liable to be deleted as they are not a necessary parties to the present complaint.

5.     In spite of receipt of notice, 4^th opposite party has not appeared before this Forum and hence, the 4^th opposite party was set ex-parte.

6.     To prove the averments in the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A19 are marked.  Proof affidavit of the 1^st opposite party is filed and no document is marked on the side of the 1^st opposite party.   Inspite of sufficient time is given the opposite parties 2 & 3 has not come forward to file proof affidavit to prove the contentions raised in the written version and hence proof affidavit of the opposite parties 2 & 3 were ‘closed’.

7.      The points for consideration is:-

1. Whether the complainant is entitled to get refund of a sum of Rs.84,865/- with interest at the rate of 12% p.a. as prayed for?

 

2. Whether the complainant is entitled to a sum of Rs.1,00,000/- towards compensation for mental agony, pain, deficiency in service, negligence with cost of Rs.25,000/- as prayed for?

 

8.     On point:-                                       

The 4^th opposite party after receiving notice, remained ex-parte.  The opposite parties 2 & 3 has not come forward to file proof affidavit to prove the contentions raised in the written version.  Both complainant and 1^st opposite party filed their respective written arguments.  The complainant pleaded and contended that he employed in M/s. IFMR Rural Channels and Services Private Ltd., Taramani, Chennai.  The complainant company had taken medi claim insurance policy for the benefits of his employees and their family members including the complainant’s father, K. Arthanarieshwaran vide medi claim policy No.500200/48/13/41/00000263 for the period from 01.08.2013 to 31.07.2014 as per Ex.A1 & Ex.A2.  Ex.A3 is the copy of the Member ID card issued by the opposite party.  The sum assured for the complainant and his family is of Rs.5,00,000/-.  The 2^nd opposite party is the Third Party Administrator (TPA) of the 1^st opposite party and the 3^rd opposite party is the Third Party Administrator of the complainant situated at Chennai as per Ex.A2.  The 4^th opposite party is the Hospital situated at Coimbatore wherein, the complainant’s father K. Arthanarieshwaran took treatment for Cancer in oropharynx and Oesophagus. The complainant’s father K. Arthanarieshwaran took treatment on various days on 05.09.2013 to 07.09.2013, 26.09.2013 to 28.09.2013, 17.10.2013 to 19.10.2013 and 08.11.2013 to 10.11.2013 as per Ex.A4 to Ex.A6, copy of Discharge Summaries.  The complainant’s father also taken chemotherapy treatment in 4^th opposite party hospital on the above mentioned days.  The 4^th opposite party hospital issued a bill for the treatment taken by the complainant’s father for a sum of Rs.84,865/- as per Ex.A8.  While taking treatment, the complainant requested the opposite parties for cashless treatment and his father. But the complainant’s father K. Arthanarieshwaran died on 14.05.2014 and Ex.A9 is the copy of Death Certificate.  The complainant processed the medical claim for Rs.84,865/- with other medical bills for a total sum of Rs.1,24,845/- which was repudiated by the opposite parties on 01.11.2013 as per Ex.A10 stating that using of intoxicating (Tobacco) is not covered under the policy as per clause 4.9 of the G.M.C. Policy condition of the 1^st opposite party.  Ex.A11 is the copy of Health Insurance Policy terms and conditions of the 1^st opposite party.  But on a careful perusal of Ex.A11, the Health Insurance Policy - Group, it is very clear in clause 4.9 which reads as follows:

4.9 “Convalescence, general debility; run-down condition or rest cure, Obesity treatment and its complications including morbid obesity, Congenital external disease /defects or anomalies, treatment relating to all psychiatric and psychosomatic disorders, infertility, Sterility, venereal disease, intentional self injury and use of intoxication drugs / alcohol”.

proves that there is iota of any evidence to show the use of tobacco there after the complainant sent a letter to the 1^st opposite party through mail on 29.11.2013 as per Ex.A12 and a remainder mail dated:28.12.2013 as per Ex.A12 which was duly acknowledged by the opposite parties as per Ex.A13.  On 27.03.2014, the grievance officer sent a reply as per Ex.A14 confirming the repudiation of the claim is correct and directed the complainant to approach the Insurance Ombudsman. On 27.03.2014, the complainant addressed a complaint to the Insurance Ombudsman, Chennai as per Ex.A15. After due enquiry, the Insurance Ombudsman passed an award as per Ex.A17 which reads as follows:

It was observed that TPA third party administrative in their claim reputation letter dated:01.11.2013 has on their own included the ward “Tobacco” under the intoxicating drug under clause 4.9 of the Group medi-claim policy which is  not correct.  Secondly, the letter nowhere states that I (Insurer) has authorized the TPA to repudiate the claim. As per the Medical dictionary the term “intoxication” is defined as

1. A state of impaired mental or physical functioning resulting from ingestion of alcohol; inebriation, simple drunkenness.

2. All organic mental syndrome characterized by the presence in the body of an exogenous psychoactive substance that produces a substance-specific syndrome of effects on the central nervous system (e.g. disturbances of perception, wakefulness, attention, thinking, judgments, emotional control or psychomotor behaviour) that leads to maladaptive behaviour such as belligerence or impaired social or occupational functionin and

3. Poisoning

The insurance OMBUDSMAN accepted the stand of complainant but unfortunately the OMBUDSMAN awarded sum of Rs.25,000/- only as EX-Gratia.

 The complainant with due EX-Gratia and disappointment sent a letter dated:10.06.2014 to the Insurance Ombudsman and thereafter filed this complaint claiming reimbursement of medical expenses for a sum of Rs.84,865/- with compensation and cost for the deficiency in service and unfair trade practice.

9.     The learned Counsel for the 1^st opposite party would contend that admittedly, the complainant availed Group Mediclaim Policy covering the family members which was subsisting.  The employees’ policy is also subsisting.  As per the Exclusion 4.9 of the Policy treatment arising out of use of intoxiacating substances is not covered.  The complainant made a claim for the treatment of his father K. Arthanarieshwaran at G. Kuppusamy Naidu Memorial Hospital, Coimbatore for oral cancer.  The medical records and the history of the patient reveals smoking Beedi 10/ day for 10 years which falls within the exclusion of ‘intoxicating’ substance under 4.9 of the Policy. Hence, the 2^nd opposite party; the Third Party Administrator repudiated the claim.  But on careful perusal of the Exclusion clause 4.9, there is nothing about the tobacco included as an ‘intoxicating’ substances proves the deficiency in service and unfair trade practice.  Considering the facts and circumstances of the case, this Forum is of the considered view that the opposite parties 1 to 3 are jointly and severally shall refund a sum of Rs.84,865/- with a compensation of Rs.25,000/- and cost Rs.10,000/- to the complainant.

In the result, this complaint is allowed in part.   The opposite parties 1 to 3 are jointly and severally liable to refund a sum of Rs.84,865/- (Rupees Eighty four thousand eight hundred and sixty five only) and to pay a sum of Rs.25,000/- (Rupees Twenty five thousand only) towards compensation for mental agony with cost of Rs.10,000/- (Rupees Ten thousand only) to the complainant.   There is “No claim” made against the 4^th opposite party.

The aboveamounts shall be payablewithin 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 18^th day of September2019. 

 

MEMBER                                                                                PRESIDENT

 

COMPLAINANT SIDE DOCUMENTS:-

Ex.A1		Copy of policy documents of the complainant issued by the 1st opposite party for 01.08.2013 to 31.07.2014
Ex.A2		Copy of Policy document from 01.08.2012 to 31.07.2013
Ex.A3		Copy of Member ID card issued by the opposite parties
Ex.A4		Copy of Discharge summary for 05.07.2013 to 07.09.2013 issued by G. Kuppusamy Naidu Memorial Hospital, Coimbatore
Ex.A5		Copy of Discharge summary for 26.09.2013 to 28.09.2013 issued by G. Kuppusamy Naidu Memorial Hospital, Coimbatore
Ex.A6		Copy of Discharge summary for 17.10.2013 to 19.10.2013 issued by G. Kuppusamy Naidu Memorial Hospital, Coimbatore
Ex.A7	14.03.2014	Copy of Doctors Certificate
Ex.A8		Copy of payment medical bills
Ex.A9	14.05.2014	Copy of Death Certificate
Ex.A10	01.11.2013	Copy of repudiation letters issued by the 3rd opposite party to complainant
Ex.A11		Copy of Health Insurance Policy terms and conditions of 1st opposite party
Ex.A12	29.11.2013 & 28.12.2013	Copy of complainant’s mail letter to grievance redressal officer of the 1st opposite party along with reminder mail
Ex.A13	11.12.2013	Copy of acknowledge letter for registering grievances of complaint
Ex.A14	27.03.2014	Copy of final reply mail letter from grievance cell of the 1st opposite party to complainant
Ex.A15	27.03.2014	Copy of complaint filed by the complainant before insurance OMBUDSMAN, Chennai
Ex.A16	22.05.2014	Copy of minutes of hearing (Insurance Ombudsman)
Ex.A17	27.05.2014	Copy of final award passed by the insurance Ombudsman, Chennai
Ex.A18	10.06.2014	Copy of the complainant’s dissatisfaction letter to insurance OMBUDSMAN with regard to award
Ex.A19	08.12.2010	Copy of medi claim settlements details (2010-11) by ICICI Lombard

 

1^ST OPPOSITE PARTY SIDE DOCUMENTS:-  NIL

OPPOSITE PARTIES 2 & 3 SIDE DOCUMENTS:-  ‘Closed as no Proof Affidavit’

                              

 

MEMBER                                                                                PRESIDENT