Date of Filing : 03.07. 2014
Date of Order : 11.02.2016.
DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, CHENNAI(SOUTH)
2nd Floor, Frazer Bridge Road, V.O.C.Nagar, Park Town, Chennai-3
PRESENT: THIRU. B. RAMALINGAM M.A.M.L., : PRESIDENT
TMT. K.AMALA, M.A. L.L.B., : MEMBER I
DR. T.PAUL RAJASEKARAN, M.A ,D.Min.PGDHRDI, AIII,BCS : MEMBER II
C.C.NO.283/2014
THURSDAY THIS 11TH DAY OF FEBRUARY 2016
R.Krishnakumar,
S/o. R. Narayanaswamy,
27/3, I Cross East Street,
Shenoy Nagar,
Chennai 600 030. ..Complainant
..Vs..
The Branch Manager,
National Insurance Company Ltd.,
II Floor, Khivraj Mansion,
738 Anna Salai,
Chennai 600 002. ..Opposite party.
For the Complainant : M/s. C. Krishnamoorthy
For the Opposite party : M/s. N. Vijayaraghavan & another
Complaint under section 12 of the Consumer Protection Act 1986. Complaint is filed seeking direction against the opposite party for awarding a sum of Rs.16,65,805/ together with cost of the complaint to the complainant.
ORDER
THIRU. T.PAUL RAJASEKARAN :: MEMBER-II
1.The case of the complainant is briefly as follows
The complainant submits that he holds a Medi-claim policy with the opposite party for his family right from 2000 onwards and that the same has been continuously and uninterruptedly renewed periodically. The complainant further submit that he has paid 6% additional premium as required by the opposite party to avail cashless treatment in the network hospitals, which include M/s. Billroth Hospital, Chennai. The complainant’s mother suffered chest pain on 28.2.2014. She had been taken to M/s. Billroth Hospitals, Chennai on the same day, which is a network hospital as per policy conditions. The complainant’s mother underwent treatment for her chest pain as an in-patient at M/s. Billroth hospital from 28.2.2014 to 4.3.2014 and was discharged on 4.3.2014 itself. Again the complainants mother had to undergo implant of Pace-maker and she was admitted as an inpatient from 5.3.2014 to 10.3.2014. After both the treatment periods, he had submitted the bills issued by M/s Billroth Hospitals, for Rs.94,492/- and Rs.1,78,734/ respectively. These amounts have been paid by the complainant though he holds cashless service facility, direct to the Hospital and that the complainant sought for reimbursement of the same. However the opposite party failed to reimburse the entire sum of money claimed, though there is no upper limit for award of the claim as per the 6% enhanced premium collected from him, which includes cashless facility. The opposite party had reimbursed a sum of Rs.52435/ in the claim for Rs.94492/ and a sum of Rs.54985 in the claim for Rs.1,78,732.
2. Accordingly the complainant had issued a notice to the opposite party on 25.4.2014 enlightening the facts and demanding payment of unpaid claim amount and also compensation. As per the reply letter dated 12.5.2014 issued by the opposite party that the condition in 4.1.4.2, 4.3, in the schedule attached to the policy under the caption “ For increasing sum insured the waiting periods as in exclusion under 4.1, 4.2, 4.3. This clause relates to waiting period for any undisclosed disease, at the time of taking policy. The complainant states that conditions 4.1.4.2, 4.3, read together would not unsuit his claim. Hence the opposite party had committed deficiency in service. As such the complainant sought for claims awarding a sum of Rs.16,65,805/ together with cost of the complaint to the complainant. Hence the complaint.
Written version opposite party is as follows:
3. It denies all the averments and allegation contained in the complaint except those that are specifically admitted herein. The complainant has availed Mediclaim policy with the opposite party covering himself, his wife, two children and his mother respectively since 2000 onwards and the same has been renewed periodically. The complainant has availed medi claim policy initially for sum insured of Rs.1 lakh and later on increased the sum insured under the policy periodically. As far as the claim of complainant is concerned the patient was found suffering from diabetes Mellitus since 2010 and the same disease suffered by the patient has been treated as pre-existing only to the extent of “increasing sum insured”. Hence the claim was settled on the basis of sum insured i.e Rs.1 lakh insured under the policy for the period 21.3.2010 to 20.3.2011 for Rs.52,435/ and Rs.54,985/ in accordance with the policy terms and conditions. The complainant also received the said sum of Rs.52,435/ and Rs.54,985 in full and final satisfaction as against the claim lodged by him for 94,492/ and Rs.1,78,734/ respectively.
The opposite party specifically submits that the clause in the schedule attached to the policy clearly states as follows:
For increasing SI (Sum Insured) the waiting period as in exclusion clauses 4.1/4.2/4.3 of the policy shall apply on the enhanced sum insured as if it is a new policy. The benefit shall accrue for PED (preexisting diseases) or waiting period diseases once the policy with enhanced SI completes waiting period noted in the policy for these diseases”.
Therefore as per the policy condition the complainant is not entitled to claim for the remaining sum which is not payable under the policy. Hence there is no deficiency in service and the complaint is liable to be dismissed.
4. Complainant has filed his Proof affidavit and Ex.A1 to Ex.A10 were marked on the side of the complainant. Proof affidavit of Opposite party filed and Ex.B1 to Ex.B9 were marked on the side of the opposite party.
5. The points that arise for consideration are as follows:-
1) Whether there is any deficiency in service on the part of the opposite parties?
- Whether the complainant is entitled to the reliefs asked for?.
6. POINT 1 & 2 :
Perused the complaint filed by the complainant and his proof affidavit and documents Ex.A1 to Ex.A10 were marked on the side of the complainant. Written version filed by the opposite party and document Ex.B1 to Ex.B9 marked on the side of the opposite party and also considered the both side arguments.
7. The complainant had taken a Mediclaim policy with the opposite party covering five members of the family since 29.2.2002 to 20.3.3004 with the opposite parties Direct Agent Branch-I of opposite party-1 for a sum of Rs.1,00,000/- for self, spouse, dependent mother and Rs.50,000/- each for dependent children. Again he renewed the policy with the opposite party’s branch at Mylapore from 21.3.2004 to 20.3.2005 then again the complainant renewed the policy with their Division No.2 situated at Moore Street, Chennai from 21.3.2005 to 20.3.2010 (Ex.A1) after that the complainant renewed his policy at the opposite party’s Direct Agent Branch-I at Mount Road from 21.3.2010 to 20.3.2011 (Ex.B2) while renewing with opposite party’s Mount Branch at 738 Mount Road, the complainant increased the basic sum assured from Rs.1,50,000/- to Rs.2,00,00/- for self and spouse and from Rs.50,000/- to Rs.1,50,000/- for both the children and Rs.1,00,000/- to Rs.1,50,000/- for the dependent mother. The complainant again increased of sum assured from 1,50,000/- to Rs.2,00,000 for the dependent mother from 23.3.2013 to 23.3.2014 again on the subsequent renewal the complainant increases sum assured from 2,00,000/- to Rs.2,50,000/- for the dependent mother (Ex.A1). The insurer specifically mentioned in the policy under Ex.B3, Ex.B5, Ex.B6 “ for increasing sum insured more than 2/3 slab the waiting period as in exclusion 4.1/4.2/4.3 of the policy shall apply on the enhanced sum insured as if it is a new policy. The benefit shall accrue for pre-existing disease or waiting period diseases once a policy with enhanced sum insured completes waiting period noted in the policy for these diseases. “
8. The complainant was admitted in net work & Hospital of concerned TPA the Billroth Hospital on 28.2.2014 and discharged on 4.3.2014 with diagnosis of “Type-2 DM CAD – acute IWMI with complete heart block – Coronary Angiogram which is a two vessel disease, Mild LV systolic dysfunction” as an inpatient, she was treated and hospital has charged Rs.80,000/- which was paid by insured to hospital, on filing the claim with opposite party and the opposite party had reimbursed Rs.52,435/-, subject to the basic sum assured limit and the limitation furnished for subsections of the policy (Room rent, ICU, Doctors consultant fees, and Pathological test etc.). Again the complainant’s dependent mother was admitted in the same hospital (Billroth Hospital) Chennai on 5.3.2014 on discharged on 10.3.2014 with diagnosis DM HT / CAD and procedure of PPI (St.Jude) done on 6.3.2014 with mild LV systolic Dysfunction. The discharge summary furnished Hysterectomy done 10 years back Catract surgery 7 years back the hospital authority charged a bill of Rs,1,69,000/- (PPI alone cost about Rs.1,23,100/-). Which was paid by insured The complainant claimed reimbursement from the opposite party and the opposite party settled a sum of Rs.54,985/- subject to the basic sum assured limit and the limitation furnished for subsections of the policy (Room rent, ICU, Doctors consultant fees, and Pathological test etc.). The complainant allegation is that he has incurred total expense Rs.2,73,224/- but a lesser amount was sanctioned and 6% of the total premium chargeable on the table of rates were paid to the 3rd party administrator by the insurer from the premium of the complainant and the 3rd party is liable to provide “cashless facility “ But this facility was not extended to the complainant where by the complainant had mental agony and tension for running pillar to post when the patient was kept under critical stage.
9. The complainant under Ex.A5 sent a trial message to the opposite party (page No.45) opposite party committed “ as patient is suffering from DM since 2010 the said disease suffered by the patient has been treated as a preexisting one only to the extent of the increase sum insured. “ Based on this the balance payment has been denied by honoring the basic sum assured. Under Ex.A7 the complainant served legal notice to the opposite party on 25.4.2014 . The complainant had submitted a letter from Dr.Elayaraja dated 21.3.2014 which Ex.A10 the patient was a known case of hypertension and diabic mellitus since 2010. The learned counsel of the opposite party submitted an evidence (Ex.B1 to Ex.B7) argued that the National Mediclaim policy condition No.5.17 which clearly describes “sum insured under the policy can be enhanced only at the time of renewal sum insured can be enhanced up to Rs.5,00,000/- subject to description of the company the waiting period and conditions as mentioned under exclusion 4.1., 4.2, and 4.3 will apply to incremental portion of the sum assured” . The learned counsel of the complainant argued on the basis of condition No.4.3 that the waiting period for DM is only for two years.
10. In pursuant of the learned counsels arguments and the written version, proof affidavits and documents filed by the complainant and the opposite party, we have thoroughly verified and each and every aspect of the policy, the rules and conditions stipulated in the National Mediclaim policy which clearly mentions in condition 5.17 which over rides all the conditions stipulated in 4.1.4.2 and 4.3 of the conditions. Hence the patient / insured person has to complete 48 months of claim free years from the date of enhancement under these circumstances the patient who had undergone treatment and the amount claimed by the complainant has not completed 48 months for waiting period from the date of increased in sum insured. Hence the opposite party as the liability only for the basic for sum insured and not for enhanced sum insured. Moreover we observed there was a difference in the age furnished in the policy and in the discharge summary, we are of the view that we cannot accept the claim made by the insured for the bill the difference of payment for the bills filed and the amount settle
d. We direct the opposite party to give the breakup details of the claim settlement made in both the claims submitted by the complainant. Since the condition No.5.17 of the National Mediclaim Policy which clearly stipulates that 48 months waiting period holds good from the date of increase in sum assured for making the claim for increased sum assured. Therefore the deficiency of service attributed by the complainant against the opposite party in the complaint is not sustainable, as such the complainant is not entitled for any relief sought for in the complaint against opposite party and the complaint is liable to be dismissed. Considering the facts and circumstances parties have to bear their own cost of litigation and as such the points 1 & 2 are decided accordingly.
In the result this complaint is dismissed. No cost.
Dictated directly by the Member-II to the Assistant, transcribed and computerized by her, corrected by the Member-II and pronounced by us in the open Forum on this the 11th day of February 2016.
MEMBER-I MEMBER-II PRESIDENT.
Complainant’s side documents :
Ex.A1- - - Copy of Various Medi claim policies.
Ex.A2- - - Copy of Mediclaim policy condition.
Ex.A3- 4.3.2014 - Copy of Discharge Summary & bill.
Ex.A4- 10.3.2014 - Copy of Discharge Summary & bill.
Ex.A5- - - Copy of emails communications.
Ex.A6- 21.3.2014 - Copy of TPA Card.
Ex.A7- 25.4.2014 - Copy of Notice.
Ex.A8- 12.5.2014 - Copy of reply notice.
Ex.A9- 14.5.2014- Copy of rejoinder to email communication.
Ex.A10-26.5.2014 –Copy of Additional reply notice.
Opposite parties’ side documents:
Ex.B1- - - Copy of Mediclaim Insurance policy
Ex.B2- - - Copy of Mediclaim Insurance Policy
Ex.B3- - - Copy of Mediclaim Insurance policy.
Ex.B4- - - Copy of Mediclaim Insurance Policy.
Ex.B5- - - Copy of Mediclaim Insurance Policy.
Ex.B6- - - Copy of Mediclaim Insurance Policy.
Ex.B7- 21.3.2014 - Copy of Certificate issued by complainant’s
Dr.U.Illayaraja.
Ex.B8- 4.3.2014 - Copy of discharge summary.
Ex.B9- 9.4.2014 - Copy of letter from the complainant to opposite party.
MEMBER-I MEMBER-II PRESIDENT.
