Tamil Nadu

South Chennai

CC/59/2019

Jesudasan Paul - Complainant(s)

Versus

New India Assurance Co Ltd., - Opp.Party(s)

J Chellappa

09 Jan 2020

ORDER

                                                                                 Date of filing  : 11.03.2019

                                                                                   Date of Order : 09.01.2020

                                                                                  

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (SOUTH)

@ 2^ND Floor, T.N.P.S.C. Road, V.O.C. Nagar, Park Town, Chennai – 3.

 

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

TR. R. BASKARKUMARAVEL, B.Sc., L.L.M., BPT., PGDCLP.  : MEMBER

 

C.C. No.59/2019

DATED THIS THURSDAY THE 09^TH DAY OF JANUARY 2020

                                 

Jesudasan Paul,

No.1, 9^th Trust Cross Street,

R.A. Puram,

Chennai – 600 028.                                                        .. Complainant.                                                     

..Versus..

 

1. The Regional Manager,

New India Assurance Company Limited,

Bengaluru,

D03, Mahalaxmi Chambers,

2^nd Floor, M.G. Road,

Bengaluru – 560 001. 

 

2. The Manager,

Vidal Health Insurance TPA Pvt. Ltd.,

Tower 2, 1^st Floor, Suri Park,

EPIP Zone, Whitefield,

Bengaluru – 560 066.                                              ..  Opposite parties.

 

Counsel for the complainant  :  Mr. J. Chellappa

Opposite parties 1 & 2           :  Exparte

 

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite parties 1 & 2 under section 12 of the Consumer Protection Act, 1986 prays to pay a sum of Rs.1,08,305/- towards compensation for deficiency in service, mental agony, harassment etc with cost to the complainant.

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

The complainant submits that he availed medi-claim policy with United India Insurance Company in Collaboration with Canara Bank from 01.11.2009 till 31.10.2017 and paid a total sum of Rs.1,82,499/- to cover hospitalization expenses. The complainant submits that consequent to the termination of services with United India Insurance Company and shifted to the New India Assurance Company, the complainant renewed the existing Cancomfort Insurance Policies without any default with New India Assurance Company.  Accordingly, the existing policy of the members are renamed as New India Assurance Group Medi-claim for Cancard Holders and administered through Canara Bank.   The complainant submits that the New India Flexigroup Medi-claim Policy is from 01.11.2017 to 31.10.2018 and paid a sum of Rs.26,523/- and again renewed from 01.11.2018 upto 31.10.2019 after paying a total sum of Rs.53,046/-. Thereby, the complainant paid a total sum of Rs.2,35,545/- towards medi-clam policy.  The complainant submits that on 09.11.2018, the complainant undergone treatment with CSI Kalyani General Hospital, Mylapore as out-patient.  After due surgery, CSI Kalyani General Hospital, Mylapore claimed a sum of Rs.8,305/- towards treatment. The complainant issued a letter dated:22.11.2018 to the Insurance Third Party Administrator namely; M/s. Vidal Health Insurance TPA Pvt. Ltd. to settle the claim. 

2.     The complainant submits that he had submitted all the original documents including original certificate dated:09.11.2018 issued by the said surgeon along with Part A and claim form Part B, to the TPA, Vidal Health, 2^nd opposite party.   It may be noted that the complainant has not taken copies of the original certificate issued by Dr. Muralidharan and also not taken Xerox copies towards purchase of medicines earlier submitted to the TPA, the 2^nd opposite party since the amount involved towards the complainant’s surgery was very meager, e-mail dated:21.11.2018 from Vidal Health and Form Part A and Part B sent to Vidal duly filled in as directed to send by RPAD on 01.12.2018 and email from Vidal on 06.12.2018 requested to provide cancelled cheque and copy of bank pass book and hospitalization detail which was complied with.  The complainant submits that all the documents related to treatment and policy has been already given to the Insurance Third Party Administrator, M/s. Vidal Health Insurance TPA Pvt. Ltd.   In spite of my answering all the queries raised by the Vidal, the 2^nd opposite party till date, they have not cared to settle the meagre amount of Rs.8,305/- to the complainant vide letter dated 07.12.2018.  Hence, the complainant issued legal notice dated:22.01.2019 to the opposite parties but has not sent any reply.   The act of the opposite parties 1 & 2 caused great mental agony and inconvenience to the complainant.   Hence, the complaint is filed.

3.     In spite of receipt of notice, the opposite parties 1 & 2 have not appeared before this Forum and hence, the opposite parties 1 & 2 were set ex-parte.

4.     Though the opposite parties 1 & 2 were remained Ex-parte, this Forum is to dispose of this compliant fully on merits with available materials evidences before this Forum. 

5.     In such circumstances, in order to prove the allegations made in the complaint, the proof affidavit is filed by the complainant as his evidence and also documents Ex.A1 to Ex.A10 are marked.  

6.      The point for consideration is:-

Whether the complainant is entitled to a sum of Rs.1,08,305/- towards compensation for deficiency in service, mental agony, harassment etc with cost as prayed for?

7.      On point:-

The opposite parties 1 & 2 after due service of notice not appeared in this Forum and remained ex-parte.  The complainant filed proof affidavit, documents, written arguments etc.   Heard the complainant’s Counsel also.  Perused the records.  The complainant pleaded and contended that he availed medi-claim policy with United India Insurance Company from 01.11.2009 till 31.10.2017 and paid a total sum of Rs.1,82,499/- to cover hospitalization expenses.   But the complainant has not filed any document.   Further the contention of the complainant is that consequent to termination of services with United India Insurance Company shifted to the New India Assurance Company.  The complainant renewed the existing Cancomfort Insurance Policies without any default with New India Assurance Company.  Accordingly, the existing policy of the members are renamed as New India Assurance Group Medi-claim for Cancard Holders as per Ex.A1 to Ex.A3.   Further the contention of the complainant is that the New India Flexigroup Medi-claim Policy is from 01.11.2017 to 31.10.2018 and paid a sum of Rs.26,523/- as per Ex.A2 and renewed upto 31.10.2019 after paying a sum of Rs.26,523/- as per Ex.A3.  Thereby, the complainant paid a total sum of Rs.2,35,545/- towards medi-clam policy.  

8.     Further the contention of the complainant is that on 09.11.2018, the complainant undergone treatment with CSI Kalyani General Hospital, Mylapore.   After due surgery, CSI Kalyani General Hospital, Mylapore claimed a sum of Rs.8,305/- towards treatment. The complainant issued a letter dated:22.11.2018 as per Ex.A4 to the Insurance Third Party Administrator namely; M/s. Vidal Health Insurance TPA Pvt. Ltd. to settle the claim.  But M/s. Vidal Health Insurance TPA Pvt. Ltd. has not responded till date.  Ex.A5 is the email from M/s. Vidal Health Insurance TPA Pvt. Ltd.   Ex.A6 (S) is the claim form.   Further the contention of the complainant is that M/s. Vidal Health Insurance TPA Pvt. Ltd. sent a letter dated:06.12.2018 as per Ex.A6 (S) demanding certain documents towards clarifications.  Further, the contention of the complainant is that all the documents related to the treatment and policy has been already given to the Insurance Third Party Administrator, M/s. Vidal Health Insurance TPA Pvt. Ltd.   Inorder to deny the Insurance claim, the Third Party Administrator, M/s. Vidal Health Insurance TPA Pvt. Ltd. has not taken any steps to process the claim proves the deficiency in service.  Hence, the complainant issued detailed e-mail and legal notice dated:07.12.2018 & 22.01.2019 as per Ex.A7 & Ex.A8  to the opposite parties but they have not sent any reply proves the unfair trade practice.   The complainant is claiming the medical expenses of Rs.8,305/- with a compensation of Rs.1,00,000/-.   Considering the facts and circumstances of the case, this Forum is of the considered view that the opposite parties 1 & 2 are jointly and severally liable to pay a sum of Rs.8,305/- being medical expenses incurred and a compensation of Rs.15,000/- for mental agony with cost of Rs.10,000/- to the complainant.

In the result, this complaint is allowed in part.   The opposite parties 1 & 2 are jointly and severally liable to pay a sum of Rs.8,305/- (Rupees Eight thousand three hundred and five only) being medical expenses incurred and to pay a sum of Rs.15,000/- (Rupees Fifteen thousand only) towards compensation for mental agony with cost of Rs.10,000/- (Rupees Ten 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 Steno-typist, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 09^th day of January 2020. 

 

MEMBER                                                                                PRESIDENT

 

COMPLAINANT SIDE DOCUMENTS:-

Ex.A1		Copy of letter from the New India Assurance Company Limited advising regarding renewal of Mediclaim by them
Ex.A2	01.11.2017	Copy of NIA Flexigroup Mediclaim policy certificate – renewal of policy from 01.11.2017 to 31.10.2018 for Rs.26,523/-
Ex.A3	01.11.2018	Copy of NIA Flexigroup Mediclaim policy certificate – renewal of policy from 01.11.2018 to 31.10.2019 for Rs.26,523/-
Ex.A4	22.11.2018	Copy of requisition for payment of Rs.8,305/- sent by RPAD to Vidal Health
Ex.A5	21.11.2018	Copy of email from Vidal
Ex.A6	01.12.2018	Copy of Sent Part A & Part B duly filled in by RPAD and e-mail received from Vidal on 06.12.2018
Ex.A7	07.12.2018	Copy of the complainant’s detailed letter to Vidal Health sent under protest
Ex.A8	22.01.2019	Copy of legal notice by the complainant’s Counsel, Mr. J. Chellappa
Ex.A9	29.01.2019	Copy of RPAD received from NIA
Ex.A10	22.01.2019	Copy of email from NIA, directing Vidal Health to settle the claim ASAP

 

 

 

MEMBER                                                                                                                                                PRESIDENT