Tamil Nadu

North Chennai

195/2014

Mr.P.Dhanesh - Complainant(s)

Versus

Oriental Insurance Company Ltd., Rep by its Regional Manager, - Opp.Party(s)

K.Lavan

26 Apr 2018

ORDER

 

                                                            Complaint presented on:  08.10.2014

                                                                Order pronounced on:  26.04.2018

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (NORTH)

    2^nd Floor, Frazer Bridge Road, V.O.C.Nagar, Park Town, Chennai-3

 

        PRESENT: THIRU.K.JAYABALAN, B.Sc., B.L.,        PRESIDENT

              THIRU. M.UYIRROLI KANNAN B.B.A., B.L.,      MEMBER - I

 

THURSDAY THE 26^th  DAY OF APRIL 2018

 

C.C.NO.195/2014

 

 

Mr.P.Dhanesh,

No.118, Anna Pillai Street,

4^th Floor, Sowcarpet,

Chennai – 600 079.

                                                                                    ….. Complainant

 

..Vs..

Oriental Insurance Company Ltd.,

Rep by its Regional Manager,

P.B.No.1877, U.I.L. Building,

IV Floor, No.4, Esplanade,

Chennai – 600  108.

.....Opposite Party

Date of complaint                                 : 15.10.2014

Counsel for Complainant                       : M/s.K.Lavan, Abhishek, Chhallani

 

Counsel for Opposite Party                     : Mr.N.Maheswaraiah

 

 

 

 

 

O R D E R

 

BY PRESIDENT THIRU. K.JAYABALAN B.Sc., B.L.,

          This complaint is filed by the complainant to direct the opposite party to pay hospital expenses of Rs.1,76,555/- with 12%  interest and also to pay compensation for mental agony with cost of the complaint u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          The complainant had taken a Mediclaim individual policy in the year 1999 and he renewed the same from time to time without any break. He had migrated from individual policy to Happy Family Floater Policy with effect from 22.01.2010 and also renewed the same continuously. The complainant was admitted at Apollo Hospital, Chennai on 17.07.2013 for getting treatment for Acyanotic Congenital Heart Disease Ostium Secundum  Asd. He has denied cashless claim by the opposite party. After treatment the complainant had settled the hospital dues a sum of Rs.1,76,555/-. After that he made claim to the opposite party and the same was denied by the letter dated 27.07.2013 under exclusion clause 4.8 of the policy.

          2. Aggrieved by the denial of the claim, the complainant sent a letter dated 20.08.2013 to the opposite party, Delhi by marking  a copy to the Royapuram Branch. The opposite party replied that if he aggrieved by the denial of the claim he can approach the Ombudsman.  Nowhere, in the Family Floater Policy details were shown about the exclusion of the said disease. The complainant had issued legal notice dated 07.11.2013 to the opposite party and no reply received by him. The complainant approached Ombudsman and after hearing, he accepted his contention and passed an award of Rs.20,000/- as exgratia by order dated 17.03.2014. The complainant made review to the ombudsman also failed. Due to the denial of the claim, the opposite party committed deficiency in service and the complainant suffered with mental agony. Hence the complainant filed this complaint to direct the opposite party to pay hospital expenses of Rs.1,76,555/- with 12%  interest and also to pay compensation for mental agony with cost of the complaint.    

3. WRITTEN VERSION OF THE   OPPOSITE PARTY IN BRIEF:

          This opposite party admits that the complainant had individual Mediclaim Policy and he had migrated the said policy and had taken Happy Family Floater Policy with him for complainant and his wife from 22.01.2013 to 20.01.2014.  It is further admitted that this opposite party received medical expenses of Rs.1,76,555/- on 26.07.2013 for the treatment of  Acyanotic Congenital Heart Disease Ostium Secundum  Asd along with bills. The TPA perused claim papers and rejected the claim after due application of the mind that the disease was excluded under the policy condition No: 4.8.

4. The treatment taken for the disease is an internal congenital and such illness is excluded from the policy and hence the opposite party is not liable to pay the claim amount of the complainant. The order of the ombudsman was passed after due application of mind with proper appreciation. Hence this opposite party prays is not liable to pay any amount to the complainant and prays to dismiss the complaint with costs.

5. POINTS FOR CONSIDERATION:

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

          2. Whether the complainant is entitled to any relief? If so to what extent?

6. POINT NO :1 

          The admitted facts are that the  complainant had taken a Mediclaim individual policy in the year 1999 and he renewed the same from time to time without any break and he had migrated from individual policy to Ex.A12  Happy Family Floater Policy with effect from 22.01.2010 and also renewed the same continuously till 21.01.2014  and the complainant was admitted at Apollo Hospital, Chennai on 17.07.2013  for getting treatment for Acyanotic Congenital Heart Disease Ostium Secundum  Asd  as per Ex.A2 discharge summary  and further he was denied cashless claim made to the opposite party and however the complainant had settled the hospital dues a sum of Rs.1,76,555/- and after that he made claim to the opposite party and the same was denied as the disease is an congenital external disease by the Ex.A3 rejection letter dated 18.07.2013 under exclusion clause of 4.8  of the policy. However, the ombudsman passed an order Ex.A7 at para 6 of his order that the wrong repudiation of the cashless authorization by the TPA is highly objectionable and further passed an exgratia   amount of Rs.20,000/-.            

          7. The complainant counsel relied on Ex.A1 Mediclaim Insurance  Policy prospects, referring  exclusion clause 4.8 covers only congenital external disease and whereas the complainant was treated for internal disease and therefore as per Ex.A1, the claim made by the complainant is maintainable. The opposite party counsel pointed out that the complainant availed Ex.B1 Happy Family Floater Policy and in the conditions of the said policy in exclusion clause 4.8, it has been specifically mentioned that congenital external and internal diseases are excluded and the complainant underwent treatment for internal congenital disease excluded in that clause and therefore the rejection of the claim made by the opposite party is sustainable.

          8. Ex.A1 is the prospectus of policy for the individual mediclaim policy. Admittedly the complainant moved from individual policy to the Happy Family Floater Policy. Therefore, for the claim of the complainant Ex.B1 Family Floater Policy conditions only applicable.

          9. According to the complainant, he was having individual policy with the opposite party from the year 1999 without any break and migrated to Happy Family Floater with effect from 22.01.2010 and renewed without any break. Ex.A1 Mediclaim Individual policy issued to the complainant for the period 22.01.2009 to 21.01.2010. From 22.01.2010 to 21.01.2014 the complainant availed Ex.A12 Family Floater Policy issued by the opposite party. Therefore, from 22.01.2009 till the complainant admitted in the hospital on 17.07.2013 (Ex.A2 Discharge Summary), more than four years the complainant was having continuous policy issued by the opposite party. In Ex.B1 terms and conditions of the Family Floater Policy clause 4:1 deals about pre-existing health condition or disease that if such insured person is having policy upto four years, the exclusion clause 4:8 will not be applicable. In the case in hand, the complainant on the date of treatment was having continuous policy for more than four years and therefore the internal  disease for which he had taken treatment cannot be treated as pre-existing disease. In view of the same, the claim in respect of medical expenses rejected by the opposite party is not sustainable and therefore, it is held that the opposite party has committed deficiency in service in rejecting the claim of the complainant.

10. POINT NO:2

          We held above that the opposite party committed deficiency in service in rejecting the complainant  claim of Rs.1,76,555/- towards medical expenses and therefore the opposite party can be directed to pay the said claim amount of Rs.1,76,555/- towards the medical expenses. Due to rejection of the claim the complainant suffered with mental agony  is accepted and for the same it would be appropriate to direct the opposite party to pay a sum of Rs.50,000/- towards compensation, besides a sum of Rs.5,000/- towards litigation expenses. The complainant in respect of the other relief is liable to be dismissed.

          In the result the Complaint is partly allowed. The Opposite Party is ordered to pay a sum of Rs.1,76,555/- (Rupees one lakh seventy six thousand   five hundred and fifty five  only) towards the medical expenses to the Complainant and also to pay  a sum of Rs. 50,000/- (Rupees fifty  thousand only) towards compensation for mental agony, besides a sum of Rs. 5,000/- (Rupees five thousand only)  towards litigation expenses. The complainant in respect of other relief is dismissed.

The above amount shall be paid to the complainant within 6 weeks from the date of receipt of the copy of this order failing which the above said medical expenses and compensation amount shall carry 9% interest till the date of payment.

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 26^th day of April 2018.

 

MEMBER – I                                                                PRESIDENT

 

 

 

 

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated NIL                     Medical Insurance Policy

Ex.A2 dated NIL                     Discharge Summary & Hospital Bills

Ex.A3 dated 17.07.2013                   Rejection letter from TPA – for Cashless claim &

 & 18.07.2013                              for Re-imbursement of claim

 

Ex.A4 dated 20.08.2013                   Letter issued by ct to the opposite party

 

Ex.A5 dated 03.10.2013                   Letter issued by opposite party to the complainant

 

Ex.A6 dated 07.11.2013                   Legal Notice issued by complainant counsel to the

                                                     opposite party with acknowledgement cards

Ex.A7 dated 17.12.2013                   Letter issued by complainant to the insurance

                                                   Ombudsman

 

Ex.A8 dated 18.02.2014                   Letter issued by insurance ombudsman to the

                                                    Complainant

 

Ex.A9 dated 17.03.2014                   Award given by Insurance Ombudsman

 

Ex.A10 dated NIL                             Letter issued by complainant to the Insurance

                                                    Ombudsman for reviewing the award

 

Ex.A11 dated NIL                             The Oriental Insurance Company Ltd.,

 

Ex.A12 dated NIL                             Happy Family Floater Policy Schedule

 

 

LIST OF DOCUMENTS FILED BY THE  OPPOSITE PARTY :

 

Ex.B1 dated NIL                      Terms and conditions of the policy

 

Ex.B2 dated 18.01.2013                   Policy Schedule

 

Ex.B3 dated NIL                      Proposal Form

 

Ex.B4 dated NIL                      Discharge Summary

 

Ex.B5 dated 18.07.2013                   Repudiation Letter

 

 

 

 

MEMBER – I                                                               PRESIDENT