Tamil Nadu
South Chennai
CC/52/2022
Mr. R. Sujesh - Complainant(s)
Versus
New India Assurance Co Ltd., Rep. by its Manager - Opp.Party(s)
M/s. A. Shanmugaraj
16 May 2023
ORDER
Date of Complaint Filed : 16.12.2021
Date of Reservation : 27.04.2023
Date of Order : 16.05.2023
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 I
THIRU. S. NANDAGOPALAN., B.Sc., MBA., : MEMBER II
CONSUMER COMPLAINT No.52/2022
TUESDAY, THE 16th DAY OF MAY 2023
Mr. R. Sujesh,
No.11A, Ammakannamma Street,
Sarathy Nagar, West Saidapet,
Chennai – 600 015. … Complainant.
..Vs..
1.New India Assurance Co Ltd,
Rep. by its Manager,
BR Complexes, Woods Road,
Divisional Office,
Chennai – 600 002.
2.M/s. Vidal Health Insurance TPA PVT Ltd,
Rep. by its Manager,
No.38, 2nd floor, AnmolPalani,
G.N. Chetty Road,
T.Nagar, Chennai – 600 017. .. Opposite parties.
* * * * *
Counsel for the complainant : M/s. A. Shanmugaraj, S. Agalya
Counsel for Opposite parties : M/s. S. Radhadevi,
M. Swaminathan, S. Sathyasundari
On perusal of records and having heard the oral arguments of the Counsel for the Complainant and the Counsel for the Opposite Parties, this Commission delivered the following:
ORDER
Pronounced by Member-I, Thiru. T.R. Sivakumhar., B.A., B.L.,
(i) The Complainant has filed this complaint as against the Opposite Parties under section 35 of the Consumer Protection Act, 2019 and prays to pay a sum of Rs.98,735/- towards rest of the Medi Claim to the Complainant’s SB account by ECS and to pay the interest @18% P.A for above said Rs.98,735/- from the date of the receipts of Medical Bills on 20.04.2019 and to pay a sum of Rs.50,000/- as damages to the Complainant along with cost of the proceedings.
I. The averments of Complaint in brief are as follows:-
1. The Complainant has taken Medi claim policy from the Opposite Party since 2003 and the said Medi claim policy was renewed by him on 08.03.2018. At the time of renewing the Medi Claim policy, the 1st Opposite party included his son namely Abinav Sujesh by collecting a sum of Rs.12,219/- towards premium and issued renewal policy no. 71340034172800001053 for the period from 18.03.2018 to till 17.03.2019. As per the above said renewal(Floater) Medi claim policy, the coverage amount of Rs. 3,00,000/- could be availed by any one of the above said family members including the complainant. The 1st Opposite party had tie-up with 2ndOpposite party and the 2nd opposite party's is bound to receive Medical claim request from 1" Opposite party's customer and then sanction the Cash/Reimbursement benefits after scrutiny of the necessary medical records, Policy details, etc. The Opposite parties also issued health card to the complainant with effect from 18.03.2018.
2. He had suffered with back pain and took treatment on 08.03.2019 & 09.03.2019 as outpatient at Aster DM Health Pvt Ltd Hospital, Kochi and spent a sum of Rs. 14,490/- for MRI Scan, etc. Later he took treatment (Surgery) as in patient with Aster DM Health Pvt Ltd Hospital, Kochi from 10.03.2019 to 12.03.2019 for LS-S1 prolapsed inter vertebral disc and the said ailment and hospitalisation has been intimated to 2nd Opposite party through the said hospital by submitting the claim form on 10.03.2019. In turn, the 2ndOpposite party also gave prior approval for their initial estimation. After completion of the treatment, on 12.03.2019 the above said Hospital Authorities forwarded the discharge summary & entire treatment records including lab reports along with entire Bills for a sum of Rs. 1,55,270/- to 2ndOpposite party for settling the same.
3. After receipt of entire records from the Hospital, on the date of discharge 12.03.2019, the 2ndOpposite party instead of approving Rs.1,55,270/-, they agreed to pay only Rs.71,025/- out of Rs.1,55,270/-. Hence he was forced to pay the balance amount of Rs. 84,245/- to get discharge from the hospital on 12.03.2019.
4. After completion of his treatment he had approached the 2ndOpposite party in the 1st week of April 2019 to get the reimbursement amount in respect of Pre-Hospitalisation medical expenses Rs. 14,490/- and also the balance (In-patient) Hospitalisation expenses Rs. 84,245/- which was paid by complainant by handing over the original bills. But the 2nd Opposite party had declined to receive the same. Hence he had sent the above said Medical Bills Rs.84,245/- and Rs.14,490/- totalling to Rs.98,735/- to the Opposite parties through his counsel vide letter dated 20.04.2019 and requested the opposite parties to settle the balance Medi claim amount Rs.98,735/-. Upon receipt of the above said Medical Bills, the Opposite parties had replied on 04.05.2019 wherein they have requested him to submit the original lab reports and duly filled ECS form and cancelled cheque leaf. Thereafter he had sent a reply on 19.06.2019 to the 2nd Opposite party stating that the lab reports, entire bills and discharge summary were already submitted to 2nd Opposite party by Hospital Authorities and then only, the 2nd Opposite party had approved to pay the part of Medi Claim amount Rs.71,025 and paid the said amount directly to the Hospital Authorities. Further, in the above said letter dated 19.06.2019, complainant also informed to the 2nd Opposite party that he did not received the ECS form, hence requested the 2nd Opposite party to furnish the ECS form which enable the complainant to comply the requirements.
5. The Opposite parties become quite and they didnot choose to send any suitable reply, even after receipt of letter dated 19.06.2019. Hence another reminder letter dated 28.06.2019 was sent along with his cancelled cheque for crediting the rest of the Medi Claim amount by ECS in his Federal Bank, Chennai-600 017, SB account No. 13864100001340 (IFSC. Code No. FDRL0001386), and requested the 2nd Opposite party to consider and reimburse his balance claim amount into his bank account directly.
6. Even after receipt of his above said letters, the 2ndOpposite party neither send any reply, nor deny the collection of the earlier Lab Reports from the above said Hospital, when they approved the part of his Medi claim amount Rs.71,025. But on the contrary, the 2nd Opposite party had closed his claim on 17.08.2019, due to non-compliance of the documents.
In spite of he having explained already to both opposite parties that the original documents were already collected by 2ndOpposite party, when he was admitted at Aster Dm health Pvt Ltd Hospital and only thereafter the 2nd Opposite party approved his Medi claim partly a sum of Rs.71,025/- on 12.03.19, when he was discharged from Hospital. Though the Opposite parties had received original lab reports from the hospital at the time of complainant's discharge and the same was well remaindedwith 2nd opposite party, when they sought such documents, the 2nd Opposite party had chosen to decline his legitimate reimbursement of the balance claim amount.
7. He had sent a letter dated 27.08.2019 to Aster DM Health Pvt Ltd Hospital and requested the Hospital Authorities to furnish the Lab reports or attested copy of the lab reports and the Hospital Authorities furnished the attested copies of lab reports on 08.09.2019 and on receipt the same was sent to the 2nd Opposite party on 12.09.2019 and requested them to settle the balance Medi Claim Rs.98,735/- by ECS. Even after receipt of the above said letter, the 2nd Opposite party had not taken any appropriate steps to settle the claim so far. The act of the Opposite Parties clearly amounts to deficiency in service and he is suffering by serious mental agony. Hence the complaint.
II. Written Version Of Opposite Parties 1 & 2 in brief:
8. The Opposite Parties had admitted that the Complainant had taken New India Floater Medi claim Policy from the 1stOpposite Party Vide Policy No. 71340034172800001053 Valid from 18.03.2018 to 17.03.2019 and the said Insurance Policy Copy along with the terms and conditions was handed over to the Complainant. The 2ndOpposite Party is their third Party administrator to settle Medi claims.
9. The 1st Opposite Party is a well reputed Government Insurance Company and they are the custodian of Public funds. Therefore they could settle the claims only as per terms and conditions of New India Floater Mediclaim Policy and the said Policy is governed by health Insurance Regulations issued by IRDA of India.
10. The Complainant underwent Surgery for L5-S1 prolapsed inter vertebral disc and was in patient from 10.03.19 to 12.03.2019 at Aster DM Health Pvt Ltd Hospital, Kochi. The complainant had submitted his claim form on 10.03.2019 for the inpatient treatment alone and not for pre-Hospitalization expenses.
11. Further they could settle the claim only after verification of documents submitted by the Complainant and as per terms and conditions of New India Floater Mediclaim Policy. On scrutiny of the documents, the 2nd Opposite Party, according to the terms and conditions of said medi claim policy had approved a sum of Rs.71,025/-and immediately settled the Said amount to the Hospital. Further in the Pre-Authorization Approval Letter dated 12.03.2019 given by the 2nd Opposite Party to the Hospital under the heading remarks it was clearly mentioned that "Approved as per the Final Bill, Non-Medical and Non admissible expenses to be collected from the patient, room rent difference amount deducted to be collected from the patient, Proportionate deduction amount to be collected from the patient ". Accordingly the opposite Parties settled a sum of Rs.71,025/- following the terms and conditions of the New India Floater Mediclaim Policy, as per Annexure I List of expenses excluded (Non Medical).
12. Further the Complainant had submitted claim Form on 26.04.2019 to the 2nd Opposite Party claiming a sum of Rs.14,490/- towards pre Hospitalization expenses and also sent advocate notice claiming Rs.14,490/- towards pre Hospitalization expenses and Rs.84,245/- balance amount paid by him. The 2ndOpposite Party on scrutiny of the documents submitted by the Complainant had sent a reply letter dated 04.05.2019 requesting the complainant to provide all original Lab Reports, duly filled in ECS Form and cancelled cheque.
13. Further the 2nd Opposite Party sent a reminder letter on 08.07.2019. Finally on 17.08.2019 closed the above claim for the reason non-compliance of the required documents and intimated the same to the Complainant. The Complainant had submitted only bills and not the reports to the Opposite Parties. As he had not furnished the required documents, the claim was closed by the Opposite Parties. The Opposite Parties further state that they had received lab reports and medical bills from the Hospital Authorities only for the period of hospitalization and for which entire amount had been settled. They had received original lab reports for the hospitalization expenses and with regard to the Pre hospitalization expenses it is the duty of the Complainant to furnish the same to the opposite Parties on time. The opposite Parties had sent several reminders to the Complainant to produce original lab reports but the Complainant had not produced the required documents.
14. As per Policy terms and conditions they had already settled the amount of Rs.71,025/- and the same was very well explained in the Pre-Authorization Approval Letter dated 12.03.2019 given by the 2nd Opposite Party to the Hospital Authorities.
15. The Claim could be settled only as per terms and conditions of Policy. The 2nd Opposite Party had not at all repudiated the claim of the Complainant. They had settled a sum of Rs.71,025/- as per the Policy Clause. Hence there is no deficiency of Service on their part of the Opposite and there was no delay in payment of said amount. The Opposite Parties had not caused any mental agony, mental cruelty, mental harassment and stress.
16. The allegations of mental agony and deficiency of service made by the Complainant are baseless and motivated with a view to extract money from them, as the claim was settled as per the terms and conditions of the Policy and not repudiated by the opposite parties.
17. The claim made towards medical expenses with interest is not maintainable as the amount was already settled as per terms and conditions of Policy and further claim of damages and cost of complaint as compensation are unjustified and baseless. The Claim amount made under all the heads were not payable by them as there was no deficiency of Service whatsoever on their Part of and the claim amount was already settled.
18. The Complainant has not come to this Hon'ble forum with Clean hands and is guilty of suppression of material facts and this Complaint is devoid of merits and has been indulged in by the Complainant with a view to harass and cause agony to the Opposite Party for no justifiable reasons whatsoever. The Complaint has been filed by the Complainant with absolutely false and baseless allegations. There is no deficiency of service on their part and therefore there is no cause of action for the present claim. The complaint is not maintainable before this Forum as the complaint is false and baseless and no fault on the part of the opposite Parties. Hence prayed to dismiss the complaint.
III. The complainant has filed his proof affidavit, in support of his claim in the complaint and has filed documents which are marked as Ex.A1 to A22. The opposite parties had submitted their proof affidavit and Ex.B1 to Ex.B3 were marked on the side of Opposite Parties. Both side written arguments filed.
IV. Points for Consideration:-
1.Whether there is any deficiency in service on the part of the Opposite Parties?
2.Whether the Complainant is entitled for the reliefs sought for?
3. To what other relief, the Complainant is entitled to?
Point No.1 :
19. It is an undisputed fact that the Complainant had availed Medi claim policy from the Opposite Party and the said Medi claim policy was renewed on 08.03.2018 under policy no. 71340034172800001053 for the period from 18.03.2018 to 17.03.2019. It is also not in dispute that as per the above said policy, the coverage amount of Rs.3,00,000/- could be availed by the Complainant or by any of his family any one of the above said family members including the members. It also not in dispute that the Complainant had taken treatment as in-patient in respect of L5-S1 prolapsed inter vertebral disc Surgery at Aster DM Health Pvt. Ltd Hospital, Kochi from 10.03.2019 to 12.03.2019.
20. The dispute arose when the Complainant was not paid of the entire treatment amount of Rs.1,55,270/- in spite of pre-authorization approval given by the Opposite Parties and in spite of receipt of all the records including lab reports, Medical bills etc., along with final Bills, only a sum of Rs.71,025/- alone has been paid to the said Hospital by the Opposite Parties and the balance amount of Rs.84,245/- was paid by him. When he had submitted for claiming the balance amount of Rs.84,245/- along with the pre-hospitalisation expenses for a sum of Rs.14,490/- the Opposite Parties had failed and neglected to settle the same instead had sought for the reports from the Complainant, in spite of having collected all the bills and records from the above said Hospital and had closed the claim on 17.08.2019 for non submission of required documents.
21. The contentions of the Opposite Parties are that the complainant had submitted claim form on 10.03.2019 for the inpatient treatment only and not for Pre-Hospitalization expenses. They can settle the claim only after verification of documents submitted by the Complainant and as per terms and conditions of New India Floater Mediclaim Policy. On scrutiny of the documents, their Third Party administrator, had approved a sum of Rs.71,025/- according to the terms and conditions of said medi claim policy and immediately settled the said amount to the Hospital. Further in the Pre- Authorization Approval Letter dated 12.03.2019 given by the 2nd Opposite Party to the Hospital under the heading remarks it was clearly mentioned that "Approved as per the Final Bill, Non Medical and Non admissible expenses to be collected from the patient, room rent difference amount deducted to be collected from the patient, Proportionate deduction amount to be collected from the patient ". Accordingly they have settled a sum of Rs.71,025/- as per the terms and conditions of the New India Floater Mediclaim Policy and as per Annexure I List of expenses excluding Non- Medical expenses. In spite of their repeated demands the Complainant had failed to submit the documents required by them inspite of having provided opportunity and having waited for a long time, the claim request of the Complainant was closed by them. Hence there was no deficiency of service on their part.
22. On discussions made above and on perusal of records, it is clear from Ex.A1 and Ex.B1, the Complainant availed Mediclaim Policy No.71340034172800001053 for the period from 18.03.2018 to 17.03.2019 covering sum assured of Rs.3,00,000/-. Ex.A-3 is the discharge summary issued by Aster DM Health Pvt. Ltd Hospital, Kochi for the in-patient treatment taken by the Complainant from 10.03.2019 to 12.03.2019 in respect of L5-S1 prolapsed inter vertebral disc surgery and Ex.A-4 Final Bill along with entire treatment records including lab reports, Medical bills etc., for a sum of Rs. 1,55,270/-. Ex.A-5 is the Pre-Approval authorisation given by the 2nd Opposite party to the said Hospital. Ex.A-6 is the Bill dated 12.03.2019 for payment of balance amount of Rs.84,245/- by the Complainant to the said Hospital. Ex.A-8 is the Bills for a sum of Rs.14,490/- spent towards taking MRI Scan, being the pre-Hospitalisation expenses.
23. Though the Complainant had sent legal notice dated 20.04.2019, Ex.A-7, he had not disclosed about the receipt of Ex.B-2 Letter dated 30.03.2019 issued by the Opposite Parties along with calculation of Approved amount based on the documents collected from the Hospital, further though he had not denied the same, he had relied and claimed certain expenses as entitled. Hence, it is clear that he is aware of the details of eligible amounts settled to the Hospital on receipt of the claim on 10.03.2019. It is also clear that in spite of submitting the pre-hospitalisation reports as claimed by the Opposite Parties the Complainant had not submitted the same and had claimed that the Opposite parties had collected all the records from the Hospital and had failed to settle the same. It is also clear from Ex.A-5 Pre-Approval letter dated 12.03.20219, the 2nd Opposite Party had advised to the Hospital that the Complainant is eligible for applicable amount of Rs.71,025/- and to collect the balance amount from the Complainant, which would clear show that as per the terms and conditions of the Policy the Complainant is entitled only for the said sum, which he is aware of the same on that date itself.
24. From Ex.A-10, letter dated 04.05.2019 sent by the 2nd Opposite Party to the Complainant, it has been clearly mentioned about the submission of required documents and only on submissions they may proceed further and the Complainant was asked to comply with the same within 7 days from the date of the said letter, having admitted the receipt of the said letter, the complainant had not taken any steps to submit the documents as required by the 2nd Opposite Party, instead had sent many communications, Exs.A-11, A-12, legal notices dated 19.06.2019 and 28.06.2019. Further, from Ex.A-17 closure letter dated 17.08.2019 sent by the 2nd Opposite Party to the Complainant, the 2nd Opposite Party had closed the claim of the complainant for non submission of required documents, only on receipt of Ex.A-17, the Complainant had requested the hospital in which he took treatment as found in Ex.A-18 and by Ex.A-19 the Complainant had forwarded the documents sought for by the 2nd Opposite Party, which is clearly after the given time for submission of required documents.
25. Further the Complainant had not produced the split up bills to substantiate his claim made and his entitlements under different heads on the computation sheet sent by the 2nd Opposite Party along with letter dated 30.03.2019, Ex.B-2.
26. The Complainant had relied upon a Judgement of our Hon’ble Supreme Court passed in Civil Appeal No.4071 of 2022 in Gurmel Singh Vs. Branch Manager, National Insurance Co. Ltd, wherein it was observed that the Insurance Company has become too technical while settling the claim and has acted arbitrarily. Further observed that in many case, it is found that the Insurance Companies are refusing the claim on flimsy grounds and/or technical grounds. While settling the claims, the Insurance Company should not be too technical and ask for documents, which the insured is not in a position to produce due to circumstances beyond his control, which does not apply to the instant case, as the Opposite Parties had asked for the documents pertaining to pre-hospitalization expenses incurred by the Complainant, which the Complainant had not submitted within the stipulated time to the Opposite Parties.
Further the Opposite Parties had relied upon two Judgements,
- Civil Appeal No.1375 of 2003 in M/s. Suraj Mal Ram Niwas Oil Mills (P) Ltd Vs United India Insurance Co Ltd & Another, passed by Hon’ble Apex Court on 08.10.2010, and
- R.P No.692 of 2011 in New India Assurace Co Ltd Vs. M/s KTC Kedia Chemicals Pvt Ltd, passed by Hon’ble National Consumer Disputes Redressal Commission on 04.06.2015.
In the Judgement first cited the Hon’ble Apex court has emphasised that in construing the terms of contract of Insurance, the words used therein must be given paramount importance, and it is not open for the Court to add, delete or substitute any words. It is also well settled that since upon issuance of an insurance policy, the insurer undertakes to indemnify the loss suffered by the insured on account of risks covered by the policy, its terms have to be strictly construed to determine the extent of liability of the insurer. Therefore, the endeavour of the court should always be to interpret the words in which the contract is expressed by the parties.
In the second cited Judgement our Hon’ble National Commission had observed that the construction of contract/insurance policy entered into between the parties assumes importance. It is a settled law that court should refrain from any interpretation which would result in injustice and absurdity, AIR 1963 SC 25. The question to be considered is not what was intended, but what has been said. We cannot amend or substitute anything in the contract, as per law laid down in Suraj Mal Ram Niwas Oil Mills (P) Ltd Vs. United India Insurance Co. Ltd& Anr., (2010) 10 SCC 567, General Assurance Society Ltd. Vs. Chandmull Jain, 1966 ACJ 267 (SC), Harchand Rai Chandan Lal’s case, 2005 ACJ 570 (SC).
The above mentioned Judgements are applicable to the instant case, as the Opposite Parties following the terms and conditions of the policy provided to the Complainant, had settled the entitled amount to the Hospital.
27. Hence it is clear that the Opposite Parties had settled the eligible amount of Rs.71,025/- as per the terms and conditions of the policy and the Complainant having failed to submit the required documents for the pre-hospitalization expenses within the time given by the 2nd Opposite Party, as condition No.3.1(e) of the Mediclaim Policy under expenses admissible, clearly states that pre-hospitalization expenses, not exceeding thirty days. Therefore this Commission is of the considered view that there is no deficiency of service on the part of the Opposite Parties. Accordingly, Point No.1 is answered.
Point Nos. 2 and 3:-
28. As discussed and decided Point Nos. 1 against the Complainant, the Complainant is not entitled for any reliefs claimed in the complaint and also not entitled for any other relief/s. Accordingly Point Nos.2 and 3 are answered.
In the result, the complaint is dismissed. No costs.
S. NANDAGOPALAN T.R. SIVAKUMHAR B.JIJAA
MEMBER II MEMBER I PRESIDENT
List of documents filed on the side of the Complainant:-
Ex.A1 | 08.03.2018 | Medi-Claim policy issued by 1st Opposite Party |
Ex.A2 | 18.03.2018 | Health Card Issued by 2nd Opposite Party to Complainant |
Ex.A3 | 12.03.2019 | Discharge summary issued by Aster DM Health Care Pvt. Ltd |
Ex.A4 | 12.03.2019 | Final bill issued by Aster DM Health Care Pvt Ltd |
Ex.A5 | 12.03.2019 | Pre-Authorised approval letter of 2nd Opposite Party to Hospital |
Ex.A6 | 12.03.2019 | Copy of Hospital receipt for Rs.84,245/- paid by complainant |
Ex.A7 | 20.04.2019 | Complainant’s counsel letter by which sending bills Rs.98,735/- to the Opposite Party |
Ex.A8 | 08.03.2018 09.03.2018 | Copy of Pre-Hospittalisation bills Rs.14,490/- |
Ex.A9 |
| Acknowledgement card signed by 1st Opposite Party |
Ex.A10 | 04.05.2019 | 2nd Opposite Party’s reply to Complainant |
Ex.A11 | 19.06.2019 | Complainant’s counsel letter to Opposite Parties |
Ex.A12 |
| Acknowledgement card signed by 1st Opposite Party |
Ex.A13 |
| Acknowledgement card signed by 2nd Opposite Party |
Ex.A14 | 28.06.2019 | Complainant’s counsel letter to 2nd Opposite Party |
Ex.A15 |
| Cancelled cheque leaf of Complainant |
Ex.A16 | 29.06.2019 | Postal tracking report about service to 2nd Opposite Party |
Ex.A17 | 17.08.2019 | 2nd Opposite Party’s closure letter to the Complainant |
Ex.A18 | 27.08.2019 | Complainant’s counsel letter to Aster DM Health Card Pvt Ltd |
Ex.A19 |
| Acknowledgement card signed by Hospital |
Ex.A20 | 12.09.2019 | Final Rejoinder notice sent to 2nd Opposite Party along with attested copy of lab reports furnished by Aster DM health care |
Ex.A21 | 13.09.2019 | Acknowledgement card signed by 2nd Opposite Party |
Ex.A22 | 09.03.2019 11.03.2019 | Copy of the lab reports submitted to 2nd Opposite Party |
List of documents filed on the side of the Opposite Parties:-
Ex.B1 |
| Terms and conditions of New India Floater Mediclaim Policy |
Ex.B2 | 30.03.2019 | Claim Approval Letter |
Ex.B3 | 26.04.2019 | Claim Form |
S. NANDAGOPALAN T.R. SIVAKUMHAR B.JIJAA
MEMBER II MEMBER I PRESIDENT
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