Date of Filing : 20.11. 2013
Date of Order : 13.02.2015.
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.B.L., : MEMBER II
C.C.NO.383/2013
FRIDAY THIS 13TH DAY OF FEBRUARY 2015
V. Sukumaran Nair,
7/18, Lakshmi Nagar,
4th Stage, 4th Cross Street,
Nanganallur
Chennai 600 061. ..Complainant
..Vs..
1. The Manager,
M/s. National Insurance Company Ltd.,
500400 – NIC, Chennai DO-IV Second Floor,
169 Anna Salai,
Chennai 600 002.
2. The Manager,
M/s. Vipul Med Corp TPA Pvt. Ltd.,
New No.517, Old No.338, 2nd Floor,
Anna Salai, Nandanam (opp. To G.R. Complex),
Chennai 600 035. .. Opposite parties.
For the Complainant : Party-in-person
For the Opposite pary-1 : M/s. V. Ramakrishnan
For the opposite party-2 : exparte.
This complaint is being filed by the complainant u/s 12 of the C.P. Act 1986 to pay the reimburse initial claim of Rs.20,069/-with interest and to pay Rs.2476/- for the medicines purchased post hospital discharge with interest and Rs.1,00,000/- for causing mental agony and expenditure with cost of this complaint to the complainant.
ORDER
THIRU. B. RAMALINGAM PRESIDENT
1.The case of the complainant is briefly as follows:-
The complainant is covered under the insurer’s individual mediclaim policy for a sum insured Rs.1,00,000/- from the 1st opposite party during the period from 26.3.2012 to 25.3.2013. The complainant went for medical treatment for his suffering of pain in back left knee in the Poly Arthritis and Diabetic Neuritis in a Ayurvedic Hospital from 8.8.2012 to 21.8.2012. On 21.8.2012 the complainant got discharged from the hospital after curing the disease. On 22.8.2012 the complainant had forwarded the Mediclaim from duly completed with required documents by speed post to the 2nd opposite party and the same was received back by the complainant with a remark “Address not found”. Further on 24.9.2012 the complaint received the letter dt.20.9.2012 from the 2nd opposite party informing rejection of claim due to treatment in Ayurveda Hospital citing Exclusion clause 4.24 of terms and conditions of mediclaim policy. Further the complainant represented the case on 1.10.12 to the 2nd and 1st opposite party stating that the claim cannot be rejected under clause 4.24 as it was not a mere massage done for luxury. Since there was no response to the representation letter dt. 1.10.2012 either from 2nd opposite party or 1st opposite party, the complainant sent another reminder dt.19.10.12. On 7.11.2012 the complainant received a letter dt.2.11.2012 from the 1st opposite party informing that the finding of their TPA M/s. Vipul Med Corp. rejecting the claim is in order and the claim falls under exclusion clause 4.24 and claim cannot be considered. On 14.2.2013 the complainant sent the required forms duly filled in with relevant documents to insurance Ombudsman and after the complainant got a letter dt. 3.10.2013 from Insurance Ombudsman with copy of award granting an Ex-gratia of Rs.5000/-. As such the act of the opposite parties is amounts to deficiency of service and which caused mental agony and hardship to the complainant. As such the complainant has sought for reimburse initial claim of Rs.20,069/- with interest and reimbursement of Rs.2476 for the medicines purchased post hospital discharge with interest and to pay a sum of Rs.1,00,000/- for causing mental agony and hardship with cost of this complaint.
2. Written version of 1st opposite party is as follows:-
The 1st opposite party denies all and several of the allegations made in the complaint. The opposite party had issued a policy to the complainant for the period from 26.3.2012 to 25.3.2013 cover hospitalization benefit and the policy is subject to terms and conditions agreed between the parties to the contract. During the policy period on 8.8.2012 the complainant was admitted to Pankaja Kasthuri Ayurveda Medical Hospital, Trivandrum and on discharge and he had submitted the claim, along with hospital records bills claiming a sum of Rs.20609/-. Further he had also submitted claim for post hospitalization treatment amounting to Rs.2476/-. The same was referred to Vipul Med Corp. Pvt. Ltd. Authorized claim setting authority for processing the claim. The 2nd opposite party TPA, as admitted by the complainant had communicated on 24.9.2012 itself the rejection of the claim invoking condition 4.24 of the policy of Insurance on the ground that Ayurvedic treatment is not covered under the policy. Further the 1st opposite party had also confirmed the inadmissibility of the claim vide their letter dt. 26.11.2012. Hence there is no deficiency of service on the part of the 1st and 2nd opposite parties. As admitted by the complainant he had approached the Grievance Cell of the Insurance Company and the Insurance Ombudsman who also held that the claim was validly repudiated. Even in the proceedings of the Insurance Ombudsman there was an ex-gratia order of Rs.5,000/- invoking the provisions of Public Grievances Rules 1998. Hence it is very clear the complainant has no ground to agitate against the repudiation. There is no deficiency of service on the part of the opposite party and prays to dismiss the complaint.
3. Even after receipt of the notice, the 2nd opposite party did not appear before this Forum and did not file any written version. Hence the 2nd opposite party was set exparte on 21.1.2014.
4. Complainant has filed his Proof affidavit and Ex.A1 to Ex.A22 were marked on the side of the complainant. Opposite party-1 has filed his proof affidavit and Ex.B1 to Ex.B5 were marked on the side of the opposite party-1.
5. The points that arise for consideration are as follows:-
- Whether there is any deficiency in service on the part of the opposite parties ?
- To what relief the complainant is entitled to?
6. Point Nos.1 & 2:
On perusal of the both side pleadings, documents and the submissions made by the complainant and counsel for the 1st opposite party there is no dispute that the complainant has insurer’s individual mediclaim policy during the period from 26.3.2012 to 25.3.2013 from the 1st opposite party and the complainant went for medical treatment for his suffering of pain in back left knee in the Poly Arthritis and Diabetic Neuritis in a Ayurvedic Hospital from 8.8.2012 to 21.8.2012 and also made claim from the 1st opposite party / insurance company for the reimbursement of the medical expenses and post discharge medical expenses. The same was rejected by the 1st opposite party on the ground that as per exclusion clause No.4.24 of the terms and conditions of the said insurance policy. As the complainant has taken Ayurvedic hospital the treatment of Massages / Steam bath / Sirodhara and the like ayurvedic treatments.
7. Therefore the point to be considered in this case is whether the decision of the insurer to reject the claim with reference to the exclusion clause No.4.24 of the terms and conditions of the insurance policy is valid or not. On perusal of the hospital certificate issued for the complainant for his treatment by the Pankajakasthuri Ayurveda Medical college Hospital. It was mentioned that the complainant was admitted in the hospital with complaint of pain in back left knee since suffering from one month and Oedema in all the joints especially in upper limbs and the knee joints. During the hospitalization, the treatment process included Abhyanga with Dhanwantharam and Kasheerabala – three days, SPS – two days, Snchavasti – two days, and Kashayavastri – one day in addition to ayurvedic medications. Therefore the above contents of the said hospital certificate proves that the complainant under gone Ayurvedic treatment for his suffering and pain in bank left knee and the complainant also stated that after treatment he was cured from the said suffering. Therefore as submitted by the complainant the treatment taken for the complainant for his actually suffering and though the treatment was taken in the Ayurvedic Hospital it cannot be said that the said exclusion clause No.4.24. of the policy will applicable and the complainant claim is to be rejected. Further though it is true that the insurance is a contract governed by its terms and conditions which are to be followed by both the parties, the 1st opposite party contention of rejecting of the claim of the complainant with reference to exclusive clause 4.24 is not acceptable when considering the nature of treatment taken by the complainant. Further the complainant had brought to the notice to this forum that he was not informed of the inadmissibility of the claim when he approached the TPA for cashless approval through the hospital on admission. The 1st opposite party has not commented anything on this aspect of the complaint made by the complainant. Further even in Ex.B5 award passed by the Insurance Ombudsman proceedings dt.3.10.2013, it was observed that the treatment rendered to the insured during the course of hospitalization does not seem to be entirely of the same type as the one which is excluded under the policy and the insurer has not established the same. The policy does not altogether exclude any Ayurvedic treatment. The treatment includes various other procedures in addition to Abhyanga which is excluded under the policy. Considering the above said findings mentioned in the Ex.B5 also the treatment taken by the complainant in the Ayurvedic Hospital is not exclusively the same as such of the treatment mentioned in the exclusion clause No.4.24 of the terms and conditions of the insurance policy. Therefore we are of the opinion that the rejection of the claim of the complainant for the reimbursement of medical expense of Rs.20,069/- and post hospital discharge expense of Rs.2476/- totally Rs.22,545/- is not valid and not sustainable. Accordingly the insurance company / 1st opposite party have committed deficiency of service and caused mental agony and hardship to the complainant is also acceptable. Therefore the 1st opposite party / insurance company is liable to pay a sum of Rs.20,069/- under Ex.A4 for reimbursement of medical expense and Rs.2476/- under Ex.A6 for the post hospital discharge totally Rs.22,545/- to the complainant and after deducting the amount of Rs.5000/- award passed by the Insurance Ombudsman proceedings paid if any and also to pay just compensation of Rs.10,000/- and also to pay a sum of Rs.5,000/- towards cost of the complaint and the Points 1 & 2 are answered in favour of the complaint. As far as the 2nd opposite party is concerned this complaint is to be dismissed.
In the result, the complaint is partly allowed. The 1st opposite party is directed to pay a sum of Rs.20,069/- (Rupees Twenty thousand and sixty nine only) for reimbursement of the medical expense and Rs.2476/- (Rupees two thousand four hundred and seventy six only) for the post hospital discharge i.e. totaling Rs.22,545/- (Rupees twenty two thousand five hundred and forty five only) to the complainant and after deducting the amount of Rs.5000/- award passed by the Insurance Ombudsman proceedings paid if any and also to pay a sum of Rs.10,000/- (Rupees ten thousand only ) towards compensation for mental agony and hardship and also a sum of Rs.5000/- (Rupees Five thousand only) as cost of the complaint to the complainant. The above amount shall be payable within six weeks from the date of receipt of copy of this order, failing which the amount shall carry interest at the rate of 9% per annum from the date of order passed till the date of payment. In respect of the opposite party-2 this complaint is dismissed.
Dictated to the steno-typist transcribed and typed by her corrected and pronounced by us on this the 13th day of February 2015.
MEMBER-II PRESIDENT.
Complainant’s Side documents :
Ex.A1 – 20.3.2012 - Copy of 1st opposite party Mediclaim policy.
Ex.A2- 8.8.2012 - Copy of Complainant’s hospitalization intimation.
Ex.A3- 9.8.2012 - Copy of complainant’s hospitalization intimation.
Ex.A4- 22.8.2012 - Copy of complainant’s mediclaim bills prescriptions discharge card
Medical certificate etc.
Ex.A5- 28.8.2012 - Copy of complainant resent the mediclaim form.
Ex.A6- 18.9.2012 - Copy of Complainant’s post discharge medical bill for Rs.2476/-
Ex.A7- 20.9.2012 - Copy of 2nd opposite party’s letter rejecting the mediclaim.
Ex.A8- 1.10.2012
Ex.A9- 19.10.2012 - Copy of complainant’s representation letter & reminder to ops.
Ex.A10- 2.11.2012 - Copy of 1st opposite party’s rejection of mediclaim.
Ex.A11- 15.11.2012 - Copy of complainant’s representation to opposite parties.
Ex.A12- 26.11.2012 - Copy of 1st opposite party’s rejection of mediclaim.
Ex.A13- 10.12.2012 - Copy of complainant’s representation to Insurance Ombudsman.
Ex.A14- 12.12.2012 - Copy of reply from Insurance Ombudsman.
Ex.A15- 26.12.2012 - Copy of complainant representation to Grievance Cell of 1st opposite
Party.
Ex.A16- 5.2.2013 - Copy of complainant letter to Insurance Ombudsman.
Ex.A17-8.2.2013 - Copy of reply from Insurance ombudsman.
Ex.A18- 14.2.2013 - Copy of complainant letter to Insurance Ombudsman.
Ex.A19- 17.7.2013 - Copy of Insurance Ombudsman’s letter asking to attend hearing.
Ex.A20- 20.7.2013 - Copy of complainant’s letter to Insurance Ombudsman.
Ex.A21- 3.10.2013 -Copy of Insurance Ombudsman’s Award.
Ex.A22- 21.10.2013 -Copy of Complainant’s representation to the 1st opposite party.
Opposite party’s side documents: -
Ex.B1- 20.3.2012 - Copy of Insurance Policy with terms and conditions.
Ex.B2- 20.9.2012 - Copy of Repudiation letter of TPA.
Ex.B3- 2.11.2012 - Copy of repudiation letter of opposite party-1.
Ex.B4- 26.11.2012 - Copy of repudiation letter of opposite party-1.
Ex.B5- 3.10.2013 -Copy of award of Insurance Ombudsman, Chennai.
MEMBER-II PRESIDENT.
