Tamil Nadu

South Chennai

112/2011

Nirmal Kumar - Complainant(s)

Versus

National Insurance Co. Ltd - Opp.Party(s)

G.Munendran

11 Jan 2018

ORDER

                                                                                                                           Date of Filing  : 04.05.2011

                                                                          Date of Order : 11.01.2018

DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, CHENNA (SOUTH)

2^ND Floor, Frazer Bridge Road, V.O.C. Nagar, Park Town, Chennai-3

PRESENT: THIRU. M. MONY, B.Sc., L.L.B, M.L,                    : PRESIDENT

                 TMT. K. AMALA, M.A. L.L.B.                                :  MEMBER-I

CC. NO.112/2011

THURSDAY THE 11^th DAY OF JANUARY 2018

Nirmal Kumar,

S/o. Moolchand Maheswari,

No.18, Crescent Park Street,

T.Nagar, Chennai 600 017.                              .. Complainant.

 

                                      ..Vs..

 

1. The Branch Manager,

National Insurance Co.  Ltd.,

C-32, II Avenue,

Anna Nagar,

Chennai 600 040.    

 

2. The Regional Manager (Grievances Cell),

National Insurance Co Ltd.,

190, Anna Salai,

Chennai 600 002.                                           .. Opposite parties.

 

 

Counsel for complainant         :  M/s. G.Munendran   

Counsel for opposite parties  :   M/s. Elveera Ravindran

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite parties under section  12 of the Consumer Protection Act 1986 seeking direction to reimburse the medical expense of Rs.11,713/- with interest and also to pay a sum of Rs.50,000/- towards compensation for mental agony and to pay cost of the complaint.

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

          The complainant submit that  he  availed mediclaim policy from the year 2004.   During the month of July 2008 the complainant was bitten by a poisonous insect  resulting vomiting, infection and swelling in his left leg.    Immediately the complainant consulted his family doctor who referred him  to Apollo Hospital for complete health check up besides advising him to consult a Neurologist for recurring head ache.   Accordingly the complainant went to the Apollo Hospital and had the check up.  Thereafter the complainant  got admitted himself in the hospital run by his family doctor for three days from 9.7.2008 to 11.7.2008 and continued treatment as outpatient till 15.7.2008.   The complainant incurred a total expenditure of Rs.11,773/-.  The complainant submitted the medical reimbursement amount of Rs.11,773/- with the 1^st opposite party  on 11.11.2008 which was rejected by the opposite parties.    As such the act of the opposite parties amounts to deficiency in service which caused mental agony and hardship to the complainant. 

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

The  opposite parties deny each and every allegations except those that are specifically admitted herein.   The opposite party submit that on receipt of the intimation of the  claim through their TPA on the basis of the documents submitted by the complainant and the facts and circumstances of the case it was seen that the complainant had violated clause No.2.4 and 4.23 the opposite paries had vide their letter dated 11.11.2008 clearly informed the complainant that the hospital  in which the complainant had undergone treatment  is only an outpatient clinic with only beds.    Moreover the treatment taken on OPD basis.   As per policy condition 2.4. the hospital shall comply with minimum criteria as under:

        15 Inpatient beds.

          Fully equipped operation theatre of its own wherever surgical operations are carried out. 

Fully qualified nursing staff under its employment round the clock; Fully qualified doctors, etc.

Since the  hospital in which the complainant  had taken treatment did not comply with the above condition.   Therefore the rejection of the claim by the insurer as per policy conditions 4.23 and 2.4 is justified and the Ombudsman is not inclined to interfere with the decision of the insurer.   Hence there is no deficiency in service on the part of the opposite  parties and the complaint is liable to be dismissed.

3.     In order to prove the averments of the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A.8 marked.  Proof affidavit of the opposite parties filed and Ex.B1 to Ex.B6  marked on the side of the  opposite parties.

4.   The points for consideration is :

1. Whether the complainant is entitled to reimburse the medical expense amount of  Rs.11,713/- with interest as prayed for ?

2.  Whether the complainant is entitled to a sum of Rs.50,000/- as compensation for mental agony with cost as prayed for ?

5.  POINTS 1 & 2:

            Heard both sides.   Perused the records (viz) complaint, written version, proof affidavits and documents.    Admittedly the complainant  availed mediclaim policy from the year 2004 and its subsisting.   The contention of the complainant is that during the month of July 2008 the complainant was bitten by a poisonous insect  resulting vomiting, infection and swelling in his left leg.    Immediately the complainant consulted his family doctor who referred him  to Apollo Hospital for complete health check up besides advising him to consult a Neurologist for recurring head ache.   Accordingly the complainant went to the Apollo Hospital and had the check up.   Ex.A3 is the bill for Rs.7000/- incurred towards the said check up.  Thereafter the complainant  got admitted himself in the hospital run by his family doctor for three days from 9.7.2008 to 11.7.2008 and continued treatment as outpatient till 15.7.2008 as per Ex.A1 & Ex.A2.   The complainant incurred a total expenditure of Rs.11,773/-.   Since the complainant mediclaim policy No.500505/48/078500000573 was subsisting.  The complainant submitted the medical reimbursement amount of Rs.11,773/- with the 1^st opposite party which was rejected by the opposite parties  on the flimsy ground of dealt which amounts to deficiency in service and unfair trade practice.   Hence the complainant was constrained to file this case.   The complainant is claiming a sum of Rs.11,773/- towards expenditure incurred for medical treatment and a sum of Rs.50,000/- towards mental agony. 

6.     Further the contention of the complainant is that as per Ex.B1 terms and conditions  of the mediclaim  policy;  the opposite parties chosen to rely on only two clauses namely 2.4 sub clause 4.23  is as follows:

2.4  Hospital / Nursing Home means  any institution in India established for indoor care and treatment of sickness and injuries and which

EITHER

(a)  has been registered either as a hospital or Nursing Home with the local authorities and is under the supervision of the registered and qualified medical practitioner;

                                                           OR

(b) should comply with minimum criteria as under

i)  it should have at least  15 inpatient beds, in Class “C” towns conditions of number of beds may be reduced to 10

ii) Fully equipped operation Theatre of its own wherever surgical operations are carried out.

iii) Fully qualified nursing staff under its employment  round the clock.

iv) Fully qualified Doctor(s) should be in  charge round the clock.

The hospital selected by the complainant is having a Family Physician Centre at T.Nagar.   Hence the repudiation of the claim of the opposite parties is unlawful as per Clause 4.23.   The opposite parties is grossly unjustified in view of the fact  whatever medical expenses incurred by the complainant  from 3.7.2008 to 15.7.2008 was only in the aftermath of the poisonous insect bite suffered by the complainant  is proved from Ex.A1 to Ex.A3 and Clause 4.23 is not applicable.

7.     The contention of the opposite parties is that on the receipt of the intimation of the claim through their TPA on the basis of the documents  submitted  by the complainant  and the facts and circumstances of the case it is very clear that the complainant had violated Clause 4.2 and 4.23  of Ex.B3 and letter dated 11.11.2008 repudiating the claim by informing that the hospital in which undergone treatment an outpatient clinic with only 2 beds.    Moreover the treatment taken on OPD basis.  As per policy condition 2.4 the hospital shall comply with minimum criteria as under : -

        15 Inpatient beds.

          Fully equipped operation theatre of its own wherever surgical operations are carried out.  

          Fully qualified nursing staff under its employment round the clock; Fully qualified doctors, etc.    But on a careful perusal of Ex.B1 there is no such criteria given in detail.  Further the contention of the opposite parties that the contract of insurance is a contract of uberrimae Fidei Utmost Good Faith and both the contracting parties are bound by the terms and conditions of the policy.    On scrutiny of the policy terms, it is observed that  under the definition  Hospital the minimum requirements have been laid down by the policy.    Insurance policies are contracts and to enjoy  the benefits of the policy it is necessary to adhere to the terms and conditions stated in the contract.  But the complainant opted to undergo treatment at the nursing home of his own choice which does not meet the policy  requirement.   Further the contention of the opposite parties is that the complainant has expended a sum of Rs.3400/- towards inpatient charges and a sum of Rs.7,000/- claimed for master health check up which cannot be reimbursed under the policy.   But on a careful perusal of the entire records and consequence with the reason  for treatment due to insect bite resulted such tests reports and treatment. Further the emergency treatment   can be taken nearby hospital also.  Further the contention of the opposite party is that the claim of compensation is exorbitant.   Considering the facts and circumstance of the case this Forum is of the considered view that  opposite parties 1 & 2 are jointly and severally liable to refund a sum of Rs.11,773/- and shall pay compensation of Rs.5,000/- towards mental agony with cost of Rs.5,000/- and the points are answered accordingly.

In the result the complaint is allowed in part.  The opposite parties 1 & 2 are jointly and severally liable to refund a sum of Rs.11,773/-  (Rupees Eleven thousand seven hundred and seventy three only) and shall pay compensation of Rs.5,000/- (Rupees Five thousand only) towards mental agony with cost of Rs.5,000/-  (Rupees five 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 Assistant, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 11^th day of January 2018. 

 

MEMBER –I                                                                           PRESIDNET.

COMPLAINANT’S SIDE DOCUMENTS:

Ex.A1- 3.7.2008  - Copy of Family Physician Centre Hospital Report.

Ex.A2- 11.7.2008 - Copy of discharge summary.

Ex.A3- 15.7.2008 - Copy of medical bill

Ex.A4- 11.8.2008 - Copy of claim form.

Ex.A5- 11.11.2008- Copy of rejection letter.

Ex.A6- 3.8.2009  - Copy of representation made to the 2^nd opp. party.

Ex.A7- 22.9.2008 - Copy of petition made to Insurance Ombudsman.

Ex.A8- 8.2.2010  - Copy of letter enclosing award of Ombudsman.

 

OPPOSITE  PARTIES SIDE DOCUMENTS:  

Ex.B1-                - Copy of Policy of Insurance.

Ex.B2-                - Copy of Terms and conditions.

Ex.B3- 30.8.2008  - Copy of letter given by S.R.Niranjan.

Ex.B4-                - Copy of Self contained note.

Ex.B5- 11.11.2008         - Copy of letter given by opposite parties to complainant.

Ex.B6-                - Copy of Award No.10 (CHN) (G) 83/2009-10.

 

 

MEMBER –I                                                                           PRESIDNET.