Tamil Nadu

South Chennai

90/2012

S.Ganapathi - Complainant(s)

Versus

National Insurance Company Ltd - Opp.Party(s)

M/s.Sugumar

07 Sep 2015

ORDER

                                                                                     Date of Complaint  : 20.03.2012

                                                                                     Date of Order      : 07.09.2015

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (SOUTH)

2^nd 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

                   TR.T.PAUL RAJASEKARAN, M.A PGDHRDI, AIII,BCS : MEMBER II

 

C.C.No. 90 / 2012

THIS MONDAY  THE 7^th   DAY OF SEPTEMBER  2015

 

S. Ganapathi,

S/o. Sinnasamy,

No.AP 699 H Block,

12^th Main Road, IV Street,

Anna Nagar,

Chennai 600 040.                                                        .. Complainant.

 

- Vs- 1.  National Insurance Company Limited, Mount Road Branch, Rep. by its Branch Manager, Khivraj Mansion II Floor, No.738, Anna Salai, Chennai 600 002.   2.  Vipul MedCorp TPA Private Limited, Rep. by its Authorized Signatory, Claims Department, Old No.12/2, New No.29, Seshachalam Street, Saidapet, Chennai 600 015.                                    .. Opposite parties.		.. Opposite party.

For the complainant                     :  M/s. Sugumar & other     

For the opposite party-1               :   Mr. R.Ravichandran.

For the opposite party-2               :  Exparte.

      Complaint under section 12 of the Consumer Protection Act, 1986 for a direction to the opposite parties  to pay a sum of Rs.78,441.97 towards medical expenses  and also to pay a sum of Rs.50,000/- for the mental agony and also to pay cost of the proceedings to the complainant.

ORDER

THIRU. B. RAMALINGAM,  PRESIDENT            

1.The case of the complainant is briefly as follows:-

          The complainant had taken the relevant medi claim policy from the 1^st opposite party for the complainant and  his wife  and the value of the sum assured for each Rs.1,00,000/- and the policy is for the covering period from 24.9.2010 to 23.9.2011 and the complainant who is the 1^st person insured as per the said policy was fell ill and has taken treatment in Christian Medical College, Vellore as an inpatient from 9.1.2011 to 12.2.2011 for his treatment for MRI-Brain – Cerebral – Cerebellar atrophy and incurred medical expenses for Rs.78,441.97  and the complainant has made claim for the said reimbursement of the said claim as per the policy. The same was repudiated by the 1^st opposite party by communication dated 27.7.2011 on the basis of the 2^nd opposite party’s report.

2.     The complainant was taking mediclaim for himself and his wife from 8.9.2006 onwards continuously for renewal of the said mediclaim policy for the period 2010-2011 has issued cheque dated 6.9.2011  drawn on Indian Bank for Rs.5348/- another cheque drawn on Indian Overseas Bank for Rs.4,000/- to the 1^st opposite party insurance agent among (the said cheque due to unavoidable circumstances) the cheque for Rs.4,000/- drawn on Indian Overseas bank  was returned as without encashment since the pension amount of the complainant was not credited in time in the said account.    Following instructions of his insurance agent the complainant paid full amount again through the said agent, the excess  payment which is paid  already for Rs.5348/- through Indian Bank cheque though it was encashed by the 1^st opposite party was returned by cheque dated 20.10.2010 to the complainant.  As such the policy for the relevant period is of the continuous policy not to be treated as new policy.   But  the opposite party  repudiated considering the said  policy being a new policy not taken in-continuous  of the previous policy by the complainant and the disease for which the complainant has taken treatment and claim was made is of the pre existing decease as far as policy is concerned, as  such the opposite party is not liable to reimburse under the said policy as it is not covered by the policy.  As such the opposite party  have committed deficiency of service and the complainant has claimed the reimbursement  of the said claim amount with compensation and cost.  Hence the above complaint.   

3.  Written version of  1^st  opposite party  is   as follows:-

   The 1^st opposite party does not admit any of the allegations contained in the complaint except those that are expressly admitted herein.  The 1^st opposite party admits that the complainant has took a medical insurance policy from the 1^st opposite party commencing from 8.9.2005 to 7.9.2006 and it was periodically extended from 8.9.2006 to 7.9.2007 , 8.9.2007 to 7.9.2008, 8.9.2008 to 7.9.2009, 8.9.2009 to 7.9.2010 and 24.9.2010 to 23.9.2011.  After 7.9.2010 the complainant has not renewed the above policy and it was renewed only after 16 days on 24.9.2010 and hence as per the policy terms and conditions the above policy will be treated as a fresh policy.   As per the conditions 4.3 under the  heading “Note” it is provided that if continuity of cover is not maintained then the subsequent cover will be treated as fresh for the application of other terms and conditions of the policy.   As per the medical opinion and discharge summary issued by the Christian Medical College Hospital the hospitalization is for stroke not specified as Haemorraage or infraction and the complainant has complaints of headache and decreased hearing since seven months which falls under the category of “Pre Existing Decease” as per the policy terms and conditions.   As per Clause 4.1 of the terms and conditions of the policy it is stated that “ The company shall not be liable to make any payment under this policy in respect of all decease / injuries which are pre-existing when the cover incepts for the first time.  Hence there is no deficiency of service on the part of the opposite party and prays to dismiss the complaint.  

4.     Even after receipt of the notice, the  2^nd opposite party  did not appear before this Forum and did not file any written version on his behalf.   Hence the  2^nd  opposite party was set exparte on 17.7.2013.

5.     Complainant has filed her Proof affidavit and  Ex.A1 to Ex.A14 were marked on the side of the complainant.   1^st Opposite party have filed his  proof affidavit and no document was marked on the side of the 1^st opposite party.

6. The points that arise for consideration are as follows:-

1. Whether there is any deficiency in service on the part of the opposite parties?

 

2. To what relief the complainant is entitled to?

7.  Point Nos.1 & 2: 

        Perused the complaint filed by the complainant, written version filed by the  1^st opposite party,  the  proof  affidavit filed by complainant and 1^st opposite party and Ex.A1 to Ex.A14  filed on the side of the complainant and considered both side arguments.

8.     The 2^nd opposite party is the TPA which is a processing agent of the 1^st opposite party who has processed the complaint mentioned claim remained exparte in this proceedings.

9.     There is no dispute between the complainant and the  1^st opposite party  that the complainant had taken the relevant medi claim policy Ex.A10 for the complainant and  his wife  and the value of the sum assured for each Rs.1,00,000/- and the policy is for the covering period from 24.9.2010 to 23.9.2011 and the complainant who is the 1^st person insured as per the said policy was fell ill and has taken treatment in Christian Medical College, Vellore as a inpatient from 9.1.2011 to 12.2.2011 for his treatment for MRI-Brain – Cerebral – Cerebellar atrophy and incurred medical expenses for Rs.78,441.97 as per the Hospital bills, test report and the discharge summary etc. filed as Ex.A11 and the complainant has made claim for the said reimbursement of the said claim as per the policy on 21.2.2011.  The same was repudiated by the 1^st opposite party by communication dated 27.7.2011 on the basis of the 2^nd opposite party’s report.

10.    The complainant has filed this complaint stating that the complainant was taking mediclaim for himself and his wife from 8.9.2006 onwards continuously for renewal of the said mediclaim policy for the period 2010-2011 has issued cheque dated 6.9.2011  drawn on Indian Bank for Rs.5348/- another cheque drawn on Indian Overseas Bank for Rs.4,000/- to the 1^st opposite party insurance agent among (the said cheque due to unavoidable circumstances) the cheque for Rs.4,000/- drawn on Indian Overseas bank was returned as without encashment since the pension amount of the complainant was not credited in time in the said account.   Following instructions of his insurance agent the complainant paid full amount again through the said agent, the excess  payment which is paid  already for Rs.5348/- through Indian Bank cheque though it was encashed by the 1^st opposite party was returned by cheque dated 20.10.2010 to the complainant.  As such the policy for the relevant period i.e. Ex.A10 is of the continuous policy not to be treated as new policy.   Contrary to this the opposite party repudiateding the claim  considering the said Ex.A10 policy being a new policy not taken in-continuous   of the previous policy by the complainant and the disease for which the complainant has taken treatment and claim was made is of the pre existing decease as far as Ex.A10 policy is concerned, as such the opposite party is not liable to reimburse under the said policy as it is not covered by the policy is not sustainable.    As such the opposite party  have committed deficiency of service and the complainant has claimed to reimburse  the said claim amount with compensation and cost.

11.    Whereas the 1^st opposite party the insurance company has repudiated the said claim made by the complainant stating that as per the medical opinion and discharge summary issued by the said Hospitalization is for stroke not specified as Haemorrage or infraction  which is related to the pre existing condition 4.1.  As such as per the exclusion mentioned in the said policy the company shall not be liable to make any payment under this policy in respect of all decease / injuries which are pre-existing when the cover incepts for the first time.    As such contending the Ex.A10 policy is of first time policy. 

12.    On going through Ex.A10 though there was mentioning about the previous policy in the said policy Ex.A10 and inception date also not mentioned in it as per the period of cover mentioned in the said policy is from 24.9.2010 to 23.9.2011 and the said policy said to have issued on 24.9.2010.    Whereas the previous policy of the complainant and his wife is for the period 8.9.2009 to 7.9.2010 i.e. Ex.A7.   As such the immediate previous policy said to have been taken by the complainant i.e. Ex.A7 is expired on 7.9.2010.   Whereas Ex.A10 the relevant policy is issued on 24.9.2010 with coverage period from 24.9.2010 to 23.9.2011, as such there is a breakage of continuation of the said policy from 10.9.2010 to 23.9.2010 about 13 days break up period.  Therefore the Ex.A10 as contended by the opposite party is not a policy taken as in continuation of the complaint mentioned previous policy taken by the complainant is acceptable and  Ex.A10 the relevant medi claim policy is considered to be a new policy is acceptable. 

13.    However the claim made by the complainant for reimbursement of his medical treatment taken in the Christen Medical College Hospital, Vellore for the period from 19.1.2011 to 12.2.2011 for the disease suffered by the complainant is of MRI-Brain – Cerebral – Cerebellar atrophy.   According to the opposite party the said disease for which the complainant has taken treatment is of pre existing disease as per discharge summary issued by the said Hospital attached with Ex.A11.  On going through the said discharge summary there is mentioning before in the beginning of the said discharge summary that the complainant was presented with complaint of decreased Bilateral hearing left more than right ear for past one year, Headache seven months back for three months duration and giddiness for past one month and in particular with the complaint of for the past eight months he noticed worsening of hearing loss on left side.  It is also mentioned in the said discharge summary after about seven days of onset of Headache he noticed insidious onset tremors in hands along with slurring of speech.    It was initially affortful and clear but later it became slurred and unclear.    After  about three months he showed slight improvement in tremors and speech with complete recovery from headache with medication.  About four months back his wife noticed unsteadiness of gait.  It was insidious in on set, he was swaying to either sides with tendency to fall but no such episodes till last month.    “…… Since last one month he again started getting episodic giddiness for duration of  1 to 2 seconds followed by ataxia and tendency to falls.    Considering the above complaints of suffering by the complainant at the time or before admitting for treatment the said complaint are considered to be a disease which were incidental and caused due to old age, since the complainant was the age of 74 years.

14.    Further even in the discharge summary in the paragraph under the discussion

        Mr. S.Ganapathi a 74 years old gentle man presented with history of hearing loss with giddiness for past one month.  He is known hypertensive.  There was no h/o limb weakness or any cranial nerve deficits apart from 8^th.   There was no h/o. seizure or loss of consciousness.   On examination he had  B/L cerebeller sign Lt Rt.

 

According to the  above version found in the discharge summary given by the Hospital for the treatment given to the complainant shows that the  actually suffering were found out for medical examination i.e. BL cerebeller sing LT  RT  is of based one month from the date of admission for the treatment.  Therefore the said disease the complainant suffered and taken treatment in the Christen Medical College Hospital, Vellore  for the period from 19.1.2011 to 12.2.2011 is not considered to be a pre existing decease when considering the date of said policy which has been taken on 24.9.2010.  Further the Hospital bill which have been produced in Ex.A11 proves that the complainant has spent a sum of Rs.78,441.97 for his treatment.  The said quondam medical expense incurred by the complainant and the  claim under the policy to the 1^st opposite party is not disputed by the opposite party. Therefore we are of the considered view that the said claim of Rs.78,441.97 towards the medical expenses for the treatment of the complainant is genuine.   The said disease for which the complainant has taken treatment was happened to be suffered by the complainant just one month back from the date of admit in the hospital i.e. not considered to be pre existing disease.   Therefore  the 1^st opposite party being the insurer would have reimbursed the said genuine claim made by the complainant.  Contrary to this repudiating the said claim by the opposite party that the disease for which the medical expenses claimed by the complainant is pre existing disease, as such the policy will not cover the said claim under Clause 4.1 is not acceptable and sustainable.  The said act of the 1^st opposite party is amount to deficiency of service and caused mental agony and hardship to the complainant is acceptable.

15.    Therefore we are of the considered view that the 1^st opposite party is directed to pay a sum of Rs.78,441.97 (Rupees Seventy eight thousand four hundred and forty one and ninty seven paisa only) for the reimbursement of the medical expense  to the complainant  and also to pay a sum of Rs.25,000/- (Rupees twenty Five thousand only) as just and reasonable compensation for mental agony and also to pay  a  sum of Rs.5000/- (Rupees Five thousand only) as cost of the complaint  to the complainant and as such the points 1 & 2 are answered in favour of the complainant. 

In the result, the complaint is partly allowed.   The  1^st    opposite party is directed to pay a sum of Rs.78,441.97 (Rupees Seventy eight thousand four hundred and forty one and ninty seven paisa only) for the reimbursement of the medical expense  to the complainant   and also to pay a sum of Rs.25,000/- (Rupees twenty Five thousand only) as compensation for mental agony and also to pay  a  sum of Rs.5000/- (Rupees Five thousand only) as cost of the complaint  to the complainant within six weeks from the date of this order failing which the compensation amount of (Rs.78.441.97 & Rs.25,000/) shall carry interest at the rate of 9% per annum from the date of order  passed till the date of realization.  In respect of the  opposite party-2  this complaint is dismissed. 

   Dictated to the Assistant  transcribed and typed by her corrected and pronounced by us on this the 7^th    day of  September  2015.

 

MEMBER-I                                        MEMBER-II                                            PRESIDENT.

Complainant’s side documents :

Ex.A1- 2.9.2005        - Copy of Jurisdiction clause.

Ex.A2- 2.9.2005        - Copy of policy and related medical reports.

Ex.A3- 25.8.2006      - Copy of policy for the period of 8.9.06 to 7.9.2008

Ex.A4- 1.4.2007        - Copy of terms and conditions of 1^st opposite party.

Ex.A5- 6.9.2007        - Copy of policy for the period of 8.9.07 to 7.9.08.

Ex.A6- 5.9.2008        - Copy of policy for the period of 8.9.2008 to 7.9.2009.

Ex.A7- 7.9.2009        - Copy of policy for the period of 8.9.09 to 7.9.2010.

Ex.A8- 9.9.2010        - Copy of complainant’s bank account statement

Ex.A9- 28.9.2010      - Copy of complainant’s bank account statement.

Ex.A10- 24.9.2010     - Copy of policy for the period of 24.9.10 to 23.9.2011.

Ex.A11- 21.2.2001     - Copy of check list for claim submission with claim form

                                  Discharge summary and payment details.

 

Ex.A12- 27.7.2011     - Copy of communication from 1^st opposite party.

 

Ex.A13- 28.7.2011     - Copy of communication from 2^nd opposite party.

 

Ex.A14- 7.10.2011     - Copy of legal notice.

 

 

Opposite party’s  side documents : -    Nil  

 

MEMBER-II                                       MEMBER-II                                PRESIDENT.