Tamil Nadu
South Chennai
CC/395/2015
M/s.Kushal Kumar - Complainant(s)
Versus
M/s.Vidal Health TPA Pvt Ltd - Opp.Party(s)
M/s.Sunil Kumar and Others
31 Mar 2022
ORDER
Date of Complaint Filed : 09.09.2015
Date of Reservation : 25.03.2022
Date of Order : 31.03.2022
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
CONSUMER COMPLAINT No.395 /2015
THURSDAY, THE 31stDAY OF MARCH 2022
G. Kushal Kumar,
S/o Ghewar Chand Singhvi,
Residing at No.6, Sami Pillai Street,
First Floor, Choolai,
Chennai – 600 112. .. Complainant
..Versus..
1.Vidal Health TPA Pvt Ltd
Represented by its Branch Manager,
#88, 2nd Floor, AnmolPalani, G.N Chetty Road,
T.Nagar, Chennai – 600 017.
2.The New India Assurance Company Limited
Represented by its Branch Manager,
Periamet City Branch,
1090, Poonamallee High Road,
Periamet, Chennai – 600 084.
3.The New India Assurance Company Ltd,
Rep by its Manager,
Regd. & Head Office : New India Assurance Building,
87, M.G. Road, Fort,
Bombay – 400 001. .. Opposite Parties
******
Counsel for the complainant : M/s. M. Sunilkumar
Counsel for the opposite parties : M/s. S. Radhadevi
On perusal of records and after having heard the oral arguments of both the counsel for complainant and the counsel for the opposite party we delivered the following:
ORDER
Pronounced by the President Tmt. B. Jijaa, M.L.,
The complainant had filed this complaint under section 12 of the Consumer Protection Act, 1986 directing the opposite parties to pay a sum of Rs.57,329/- along with interest @ 12% per annum from the date of filing of the complaint till the date of realization and to a pay a sum of Rs.50,000/- towards the physical pain and a sum of Rs.50,000/- towards the mental agony along with costs.
2.The averments of the complaint in brief are as follows:-
The complainant had accepted the Mediclaim insurance policy of the 2nd opposite party and had paid the premium as called upon by the 2nd opposite party in policy No.71090434142500001326. He submits that the policy was taken in the year 2003 and was in continuous coverage from 29.08.2003.The sum assured under the policy amounted to Rs.1,00,000/-. The complainant was also entitled for a sum of Rs.65,000/- which was added as a cumulative bonus as no claim has been made in the course of the years. The complainant further submitted that he was regularly paying the premium amount right from the inception of the policy without any default. All of sudden he met with an accident on 03.11.2014 and thereby he was admitted in the hospital in M.N. Orthopedic Hospital, Kilpauk and was treated as inpatient till 07.11.2014 in the said hospital.As a Mediclaim policy holder he had claimed for a sum of Rs.90,864/- with the 1st opposite party being authorised person for disbursement of Mediclaim of 2nd and 3rd opposite parties customers. He further states that he was shocked and surprised on receipt of a sum of Rs.30,659/- and Rs.2,876/- against the total claim of Rs.90,864/- .The complainant had immediately objected for the differences not paid. The complainant further states that the opposite parties had settled a similar claim under very similar policy to his elder brother’s wife namely S.Mennabai vide Policy No.710100340811000037 who met with an accident. Whereas though the policy is similar he pleads that there is no justification in disallowing the claim which is within the insured limit of the sum insured. Hence the complainant issued a legal notice dated 05.03.2015 calling upon the opposite parties to pay difference amount as claimed by the complainant. However the 3rd opposite party issued a reply dated 09.03.2015 by refusing to pay the difference amount. The complainant also states that the policy table column clearly reflects sum insured amount and accumulated bonus. He further states that the Insurance Company would have paid or indemnify to pay up to a sum of Rs.1,65,000/- in contra they have paid only a sum of Rs.30,659/- and Rs.2,876/- which is against the policy and thereby put him in a loss / made him to sustain loss. Hence, the complainant filed the complaint directing the opposite parties to pay a sum of Rs.57,329/- being the difference amount towards his total claim and Rs.50,000/- towards physical pain and Rs.50,000/- towards mental agony sustained, as the act of opposite parties amounts to deficiency of service.
3. Written Version of the Opposite parties in brief:-
The opposite parties deny all the allegations and averments contained in the complaint except those that are specifically admitted therein and put the complainant to strict proof of each and every one of the allegations mentioned in the complaint. The opposite parties submit that the complainant has not come to this Hon’ble Commission with clean hands and is guilty of suppression of material facts and the complaint is devoid of merits and filed with a view to harass and cause agony to the opposite parties for no justifiable reasons whatsoever. The complaint has been filed by the complainant with absolutely false and baseless allegations. The opposite parties contended that the complainant ought to prove that the Mediclaim policy was regularly renewed without any break, claims or default. The opposite parties further contended that the complainant had taken Mediclaim valid from 29.08.2014 to 28.08.2015. The Opposite parties further contended that it was clearly mentioned in the said Mediclaim Policy that the complainant is bound by the terms and conditions of New Mediclaim Policy, 2012 and the Mediclaim Policy along with terms and conditions of the policy were handed over to the complainant at the time of taking the Policy. The Opposite Parties further state that the total sum insured for the said Medi Claim Policy was Rs.1,00,000/- only and Cumulative Bonus Buffer was Rs.65,000/-. It is stated that the 1st opposite party is the 3rd party administrator of the 2nd and 3rd opposite parties for settlement of claims and the 2nd & 3rd opposite parties are well reputed Government Insurance Company and they are Custodian of Public Funds. Hence the opposite parties can settle the Mediclaim only as per the terms and conditions of New Medi claim Policy 2012 and after verification of documents submitted by the Complainant. On scrutiny of the Discharge Summary and Bills, the 1st & 3rd opposite Party found that the complainant opted for higher room rent than the entitled category. The complainant is bound by the terms and conditions of the Medi Claim Policy 2012 and referred clauseNo.3.1(a) to 3.1 (d) of the policy in support of their contention, which is stated hereunder
Clause 3.1 of the Medi Claim Policy 2012
Clause 3.1:Our liability for all claims admitted during the Period of Insurance will be only up to sum insured, for which the Insured person is covered as mentioned in the schedule. In respect of those insured person with cumulative Bonus Buffer, our liability for claims admitted under this policy shall not exceed the aggregate of the sum insured and the cumulative bonus buffer. Subject to this we will reimburse the following reasonable, Customary and necessary expenses admissible as per terms and conditions of the Policy.
Clause 3.1 (a) : Room, boarding and nursing expenses as provided by the Hospital not exceeding 1.0% of the sum insured per day.
Clause 3.1 (b):Intensive care unit, Intensive Cardiac Unit expenses not exceeding 2.0% of the sum insured per day.
Clause 3.1 ( c ): Surgeon, Anesthetist, Medical Practitioner, Consultant’s Special fees.
Clause 3.1 (d) : Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical appliances, Medicines &Durgs, Dialysis, Chemotheraphy, Radiotherapy, Artificial Limbs, cost of Prosthetic devices implanted during surgery like pacemaker, relevant laboratory / Diagnostic test, X-ray and other medical expenses related to the treatment.
The opposite party submitted that based on the above said clause the complainant is entitled for claim. The 1st Opposite Party in terms of the clause contained in the Medi Claim Policy assessed the amount payable and amount not payable and the reason for non payment. Accordingly the total amount payable as per the Policy Clause is Rs.30,659/- and Rs.2876/- and the same has been settled, as per the clause 3.1 (a) to 3.1 (d) of the Mediclaim Policy 2012. The opposite parties further contended that they have not rejected or repudiated the claim of the complainant instead they have settled claim as per the referred Policy Clause. Hence there is no deficiency in service on their part. The opposite parties submits that they are well reputed companies and there is no necessity for them to adopt unfair manner and commit deficiency of service and the complainant has been motivated with a view to extract money from the opposite parties, inspite of the claim being settled as per the terms and conditions of the policy. The opposite parties contended that there is no deficiency of service on their part and therefore this complaint is liable to be dismissed. The opposite parties also contended that this complaint is neither maintainable in law nor on facts. The opposite parties contended that the prayer of the complaint is incorrect as the claim amount has already been settled, the amount of Rs.57,329/- sought for towards Medical expenses is not maintainable and a sum of Rs.50,000/- towards physical pain and a sum of Rs.50,000/- towards mental agony and cost of complaint and compensation are unjustifiable and baseless and they are not liable to pay as there was no deficiency in service what so ever on the part of the opposite parties.
4. The complainant submitted his Proof Affidavit and on the side of the Complainant Exs-A1 to Ex-A3 were marked. The opposite parties submitted their Proof Affidavit and on the side of the Opposite Parties Ex-B1 alone was marked.
5. Point for Consideration:-
1. Whether the complainant is entitled for a sum of Rs.57,329/- with interest @12% per annum with compensation of Rs.50,000/- towards physical pain and also for compensation of Rs.50,000/- towards mental agony and cost as prayed for?
6. On Point:-
Heard both sides. Written arguments also filed by both sides. On perusal of records and points put forth by both counsels the following facts are undisputed. The complainant had taken Mediclaim Policy vide No.71090434142500001326 from the 2nd& 3rd opposite parties and the sum assured was Rs.1,00,000/-. The complainant met with an accident on 03.11.2014 and was admitted in MN Orthopedic Hospital, Kilpauk and was treated as inpatient till 07.11.2014. As a Mediclaim Policy holder the complainant had submitted a claim for Rs.90,864/- to the first Opposite party, the authorised person for disbursement of claims of second and third Opposite parties. However, the Opposite parties settled a sum of Rs.30,659/- and Rs.2,876/- as against the total claim of Rs.90,864/-. The complainant on receipt of the above said amount had objected the settlement of claim of Rs.33,535/- as against the total claim of 90,864/- and caused a legal notice dated 05.03.2015 which is Ex.A1 to the opposite parties 1 to 3 claiming difference Mediclaim amount of Rs.57,329/-. On receipt of the said Notice, the Opposite parties sent a reply notice dated 09.03.2015, which is Ex.A2 through Legal Department stating that the settlement of claim to the complainant has been made following the terms and conditions of the Mediclaim Policy and the payment of R.33,535/- was already made to the complainant by the first opposite party after duly processing the medical bills submitted by the complainant and as per annexure 1,2,3 & 4, being the claim processing details attached with the said reply and thereby refused to settle the different amount as claimed by the complainant.
7. The learned Counsel for the complainant contended that the complainant availed Mediclaim Policy in the year 2003 by payment of premium as called up on by the second opposite party, which commenced on 29.08.2003, from which date the complainant had been continuously paying the premium towards the said policy. The said policy was in continuous coverage from 29.08.2003 with the sum assured at Rs.1,00,000/-. Further a sum of Rs.65,000/- was added as cumulative Bonus Buffer, as no claim was made by the complainant in the course of the years.
8. Further, the learned counsel for the complainant contended that the opposite parties neither issued any notice about the change in policy and its terms nor enlightened the complainant relating to the change in policy and its terms and conditions. It was contended that on sole belief that in the event of any happenings of untoward circumstances, the sum assured along with the bonus would be reimbursed and if it was known that only one third of the claim amount would be settled, the complainant would not have continued the Policy with the Opposite parties. The learned counsel for the complainant further contended that the opposite parties failed to intimate the complainant about the claim to be settled as per the change in Policy and its terms and conditions (i.e)., as per New Medi Claim Policy, 2012.Even at the time of receipt of the premium by the opposite parties the complainant was not informed about the change of policy and its terms and conditions.
9. The learned counsel for the complainant further contended that the opposite parties had settled full claim on a similar policy to the complainant’s brother wife, so the opposite parties had clearly committed deficiency of service and hence the complainant is claiming a sum of R.57,329/- towards difference payment as against the total claim of Rs.90,864/- along with interest @ 12% per annum from the date of filing of the complaint till the date of realisation and a sum of Rs.50,000/- towards physical pain and also a sum of Rs.50,000/- towards mental agony from the opposite parties.
10. The learned counsel for the opposite parties contended that the complainant ought to prove that the Mediclaim policy was regularly renewed without any breaks, claims or default. The Mediclaim Policy taken by the complainant was valid from 29.08.2014 to 28.08.2015, wherein it was clearly mentioned that the complainant is bound the terms and conditions of the New Mediclaim Policy, 2012 which is Ex.B1. The learned counsel for the opposite parties further contended that they could settled the Mediclaim only as per the terms and conditions contained in the New Mediclaim Policy 2012 and after verification of documents submitted by the complainant, the claim of the complainant has been settled. The learned counsel for the opposite parties further contended that as per clause 3.1 (a) to 3.1 (d) of the Mediclaim Policy 2012 the first opposite party assessed the amount payable and amount not payable and the reason for the non payment and thereby had settled a sums of Rs.30,659/- and Rs.2,876/- to the complainant, as per Ex.A3.
11. The learned for the opposite parties further contended that they have not rejected or repudiated that claim of the complainant instead had settled the claim of the complainant by following clause 3.1 (a) to 3.1 (d) of the Medi claim Policy 2012. The second and third opposite parties are well reputed companies and the first opposite party is a third party administrator for settlement of their claims. Hence, there is no necessity for them to adopt unfair manner and that they have not committed any deficiency of service and the complaint is neither maintainable in law nor on facts and the same is liable to be dismissed.
12. The learned for the opposite parties further contended that the prayer of the complainant is incorrect as the claim amount had already been settled, hence the complainant is not entitled for any relief as claimed by the complainant.
13. The learned counsel for the complainant in reply to the contentions submitted by the learned counsel for the opposite parties, vehemently submitted that the complainant has not been issued with any notice about the change of the policy and terms and even at the time of payment of the premium amounts the complainant was not informed about the change of Policy and terms by the opposite parties. Only after the written version of the opposite parties, the complainant came to know about the settlement of claim was made as per the terms and conditions of New Mediclaim Policy, 2012 and also contended that the opposite parties had admitted the total sum insured for the said Medical aim Policy at Rs.1,00,000/- and cumulative bonus buffer as Rs.65,000/- and hence the Mediclaim Policy taken by the complainant was in continuous coverage from 29.08.2003.Further replied that the Opposite parties who are custodian of the policy and the related documents, have failed to produce the same before this Commission except the New Mediclaim Policy, 2012. Without notice to the Complainant about the New Mediclaim Policy 2012, the settlement made by the opposite parties in terms of the New Mediclaim Policy, 2012 would clearly amounts to deficiency in service and the complaint is to be allowed as prayed for.
14. On careful perusal of the documents filed by the complainant and the opposite parties, it is clear that the Mediclaim Policy taken by the Complainant was in continuous coverage till the claim was made by the complainant, from the admission made by the opposite parties in paragraph No.3 of their written version and from Ex.A3 with regard to the sum insured and cumulative bonus buffer accrued as no claim was made by the complainant in the course of years. Further, the opposite parties in their reply notice dated 09.03.2015 (Ex.A2) have not refused the averments made in the legal notice dated 05.03.2015(Ex.A1) towards the continuous coverage of the Mediclaim Policy taken by the complainant with effect from 29.08.2003.
15. Considering the facts and circumstances of the case this Commission is of the considered view that the opposite parties are duty bound to put on notice the complainant policy holder about the change of Policy, the limits in regard to the coverage and that the settlement of the claim of the complainant would be made as per the terms and conditions of the Mediclaim Policy, 2012 which would likely to impact the decision of the complainant to seek greater coverage or seek a different kind of policy. As per the principles laid down by the Hon’ble Supreme Court of India vide its order dated 09.12.2021 in Civil Appeal No.6778 of 2013 in Jacob Punnen & Another Vs United India Insurance Co. Ltd, reported in 2021 SCC Online SC 1207, the opposite parties are under a duty to inform the complainant policy holder about the limitations which they imposed in Mediclaim Policy, 2012. The failure of the opposite parties to inform the complainant amounted to deficiency in service. Hence, complainant is entitled for a sum of R.57,329/-, and compensation from the opposite parties and the point is answered accordingly.
In the result, this complaint is allowed in part. Hence, the opposite parties are directed to pay jointly or severally a sum of Rs.57,329/- (Rupees Fifty Seven Thousand Three Hundred and Twenty Nine only) with interest @ 9% per annum from the date of filing of the complaint i.e., 09.09.2015 till the date of payment, with compensation of Rs.10,000/-(Rupees ten thousand only) towards mental agony and cost of Rs.5000/- (Rupees five thousand only) to the complainant, within 6 weeks from the date of receipt of this order, failing which the above amounts shall carry interest at the rate of 9% p.a from the date of this order to till the date of realization.
Dictated to Steno-Typist, transcribed and typed by her, corrected and pronounced by us in the Open Commission, on this the 31stday of March 2022.
T.R. SIVAKUMHAR B.JIJAA
MEMBER PRESIDENT
List of documents filed on the side of the complainant:
Ex.A1 | 05.03.2015 | Legal Notice sent by the complainant |
Ex.A2 | 09.03.2015 | Reply notice for the legal notice sent by the 4th opposite party. |
Ex.A3 | - | Medical consumption sheet |
List of documents filed on the side of the Opposite parties:
Ex.B1 | - |
T.R. SIVAKUMHAR B.JIJAA
MEMBER PRESIDENT
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