Tamil Nadu

North Chennai

250/2012

G.S.Ashok Kumar, - Complainant(s)

Versus

Reliance General Insurance Co. Ltd, havin Office at - Opp.Party(s)

M/s.N.A.S.Richard

17 Jun 2016

ORDER

                                                           Complaint presented on  :  11.10.2012

                                                                Order pronounced on  :  17.06.2016

 

      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

                    TMT.T.KALAIYARASI, B.A.B.L.,           MEMBER II

 

FRIDAY THE 17th   DAY OF JUNE 2016

 

C.C.NO.250/2012

 

 

G.S.Ashok Kumar,

No: 1, Wuthu Kattan Street,

Periamet,

Chennai – 600 003.

                                                                             ..... Complainant

 

..Vs..

	1.Reliance General Insurance Company, Having its branch officer at Reliance House 6th Floor, No.6 Haddows Road Nungambakkam, Chennai – 600 006.   2.Medi Assist India TPA Pvt. Ltd., No.1, Lakshmi Ammal Street, Ayyavu Naidu Colony, 1st Floor, (Above Spencer  Super Market) Razak Garden Main Road, Aminijikarai, Chennai – 600 029.   3.Billroth Hospital, 43, Lakshmi Talkies Road, Shenoy Nagar, Chennai – 30.   4. Dr.U.Ilayaraja, Interventional Cardiologist Billroth Hospital, 43, Lakshmi Talkies Road, Shenoy Nagar, Chennai – 30.
	...Opposite Parties

Date of complaint                                  : 20.11.2012

Counsel for Complainant                      :M/S N.A.S.Richard

Counsel for  1^st  Opposite party               :M/S Elveera Ravindran

 

Counsel for 2^nd opposite party                       : Ex parte

 

Counsel for 3^rd & 4^th opposite party               : M/S King and Partridge      

 

O R D E R

 

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

          This complaint is filed by the complainant u/s 12 of the Consumer Protection Act.1986.

1. THE COMPLAINT IN BRIEF:

          The Complainant subscribed policy no.1216/28251024747301 with the 1^st Opposite Party in the year 2006 and he continuously renewed the said policy. On 17.04.2010 he had certain difficulties while trekking in the Sabarimala hill and after return on 19.04.2010 he went for checkup in the 3^rd Opposite Party hospital. The 4^th Opposite Party doctor checked the Complainant and conducted Angioplasty and discharged him on 21.04.2010. The 4^th Opposite Party depicted in the discharge summary that the Complainant was a chronic smoker and drinker. Later, when the Complainant questioned the same the 3^rd Opposite Party consulted corrected the portion and also authenticated the same and also assured, he will stand by the corrected version. The Complainant made medical claim and the same was processed by the 2^nd Opposite Party and later the said claim was rejected by him, on the ground of exclusion clause that the Complainant is an alcoholic. Then the Complainant applied for reimbursement and that was also dismissed. The repudiation of the claim of the Complainant is unjust and not in accordance with the policy condition and that caused mental agony to him. Hence the Complainant filed this Complaint claiming reimbursement of medical expenses, compensation for mental agony and unfair trade practice and with cost of the Complaint and other expenses.

2. WRITTEN VERSION OF THE 1^st  OPPOSITE PARTY IN BRIEF:

          This Opposite Party admits that the Complainant availed Health Insurance Policy for the period 2009-2010 and subsequently renewed for the period 2010-2011. The Complainant made a claim on 05.06.2010 for treatment taken at the 3^rd Opposite Party hospital.  On scrutiny of discharge summary it was found the Complainant tampered the discharge by erasing a portion of contents of history of present illness with white fluid and such Act of the Complainant is fraudulent one.  Hence the Complaint is liable to be dismissed for tampering of the records in a fraudulent manner and also in view of the exclusion clause contained in the policy.

 

3.WRITTEN VERSION OF THE 3^rd  & 4^th  OPPOSITE PARTIES IN BRIEF:

          These Opposite Parties admits that the Complainant was admitted in the hospital on 19.04.2010 and the 4^th Opposite Party/doctor conducted angioplasty on him and he was discharged on 21.04.2010.  During the examination of the Complainant by the doctor, he has disclosed the habit of drinking alcohol and smoking regularly.  In the discharge summary it was recorded that the Complainant consuming alcohol and smoking 15 cigarettes per day for last 10 years. After receipt of the discharge summary, the Complainant met the 4^th Opposite Party and requested that, if he described as a chronic alcoholic and chronic smoker, it will cause personal stigma and requested the doctor to suitably amend the same. The 4^th Opposite Party considering the Complainant request by citing social stigma, he removed the word chronic alone in 3 places of the discharge summary and he had also disclosed the facts when it was enquired by the insurance company.  Therefore these Opposite Parties have not committed any Deficiency in Service and prays to dismiss the Complaint.

4.POINTS FOR CONSIDERATION:

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

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

5.POINT NO:1

          The admitted facts are that the Complainant had taken Ex.A3 Health insurance policy with the 1^st Opposite Party in the year 2010 and subsequently the said policy was renewed for the year 2011 and the  4^th Opposite Party done angioplasty surgery on the Complainant at the 3^rd Opposite Party hospital on 19.04.2010 and thereafter he was discharged on 21.04.2010 and also issued Ex.A5 discharged summary to him and thereafter based on the policy the Complainant made medical expenses claim with the 2^nd Opposite Party who is authorised by the 1^st Opposite Party to receive the claim and process  the same  and however the 2rd Opposite Party rejected the claim under Ex.A9 on the ground that as per the copy of the discharge summary patient is chronic alcoholic and smoker and on appeal the ombudsman also rejected the claim and Ex.A14 and against such rejection the Complainant filed this Complaint before this Forum.

          6. The contention of the Complainant is that the claim made by the Complainant during the subsistence of the policy issued by the 1^st Opposite Party and further there is no evidence on behalf of the 1^st Opposite Party that due to alcoholic and cigarette smoking only the Complainant had undergone angioplasty and further the Complainant himself admitted in the Complaint that in social gathering occasionally he had alcohol and smoke and therefore the repudiation of the claim by the 2^nd Opposite Party is Deficiency in Service.

          7. The 1^st Opposite Party contended that the claim was repudiated on the ground of tampering of record i.e discharge certificate in a fraudulent manner and the Complainant is a chronic alcoholic and therefore the repudiation made by the 2^nd Opposite Party is sustainable.

          8. No doubt in Ex.A5 discharge summary the patient is chronic alcoholic and chronic smoker was not found as found in Ex.B3 the discharge summary. Such act of the Complainant omitting the word in the above discharge summary will alone not disentitle the  claim of the Complainant. The Complainant relied on an judgment  of the Punjab – Haryana High Court reported in (2008) 151PLR 313(New India Assurance Company Vs. Usha Yadav & Ors) dated 22.04.2008 and contended that he is entitled for the claim. In the above decision, the Hon’ble High Court held that

“It has also been noticed that there is no specific finding by any medical expert that any deceased which the deceased was found suffering had developed on account of alcohol consumption” and further held that “it is accordingly noticed that alcohol consumption could not be the only cause for all those complicated disease which led to the death of the diseased”.

 As held by the   Hon’ble High Court, in the case hand also the 1^st Opposite Party has not adduced any evidence that due to consumption of alcohol only the Complainant undergone angioplasty surgery. Therefore in the circumstances of the case, the  rejection of the claim made  by the 2^nd Opposite Party is not sustainable and further the 2^nd Opposite Party is only a TPA and he has no authority to reject the claim and the 1^st Opposite Party who has issued policy alone is competent to reject or admit the claim and the 1^st Opposite Party has not rejected  the claim of the  Complainant and therefore the 1^st & 2^nd Opposite Parties have committed Deficiency in Service by rejecting the claim.

9. However the 3^rd Opposite Party is a hospital and the 4^th Opposite Party is a doctor who treated the patient has nothing to do with the claim made by the Complainant to the 1^st and 2^nd Opposite Parties and therefore, it is held that the 3^rd & 4^th Opposite Parties have not committed any Deficiency in Service.

10. POINT NO:2

          Since the 1^st & 2^nd Opposite Parties rejected the claim is not sustainable, the Complainant is entitled for medical expenses incurred by him for undergoing angioplasty. The Complainant filed Ex.A4 prescriptions and medical bills and claimed a sum of Rs.1,15,000/- towards incurring expenses and for such amount he is entitled for same. Further by rejection of claim of the Complainant suffered with mental agony is accepted and for the same it would be appropriate to award a sum of Rs.25,000/-  to meet ends of justice and apart from a sum of Rs.5,000/- towards litigation expenses. Further the Complaint against the 3rd & 4^th Opposite Parties and in respect of the other reliefs this Complaint is liable to be dismissed.

          In the result the Complaint is partly allowed. The Opposite Parties 1 & 2 jointly or severally ordered to pay a sum of Rs.1,15,000/- (Rupees one lakh and fifteen thousand only) towards medical expenses and also ordered to pay a sum of Rs.25,000/- (Rupees twenty five thousand only)towards compensation for mental agony, besides a sum of Rs.5,000/- ( Rupees five thousand only)  towards litigation expenses. 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 amount shall carry 9% interest till the date of payment. The Complaint against the 3^rd & 4^th Opposite Parties and in respect of the other reliefs this Complaint is dismissed.

        Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 17^th day of June 2016.

 

MEMBER – II                                                               PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated NIL           Terms and conditions of the Insurance Policy

Ex.A2 dated NIL           Guides for Claim

Ex.A3 dated 22.05.2010   Insurance Policy

Ex.A4 dated                     Various Prescriptions and medical bills

Ex.A5 dated 21.04.2010   Discharge certificate

Ex.A6 dated 31.05.2010   Acknowledgement for submission of claim with

                                          the 2^nd opposite party – TPA

Ex.A7 dated 12.07.2010   Explanation letter regarding the discharge

                                           certificate  submitted by the complainant with

                                           the 2^nd opposite   party -TPA

Ex.A8 dated 01.12.2010    Reminder letter issued by the complainant to the

                                           2^nd opposite party to deliver the decision

Ex.A9 dated 20.12.2010           Decision of the 2^nd opposite party – TPA

Ex.A10 dated 27.01.2011  Letter issued by the complainant to the customer

                                           cell of the 1^st opposite party – Reliance Insurance

                                           co. to consider the claim along with

                                            acknowledgement

Ex.A11 dated 29.03.2011   Letter issued by the complainant to the

                                            grievances  cell of the 1^st opposite party –

                                            Reliance Insurance co. to consider the claim

                                            along with acknowledgement

 

 

Ex.A12 dated 29.03.2011   Complaint lodged with the office of the

                                             Insurance Ombudsman, chennai

 

Ex.A13 dated 14.07.2011    Minutes of the hearing held on 13.07.2011 at

                                             the office of the Insurance Ombudsman,

                                             Chennai

 

Ex.A14 dated 25.08.2011   Order passed by the Insurance Ombudsman,                                             

                                            Chennai

LIST OF DOCUMENTS FILED BY THE OPPOSITE PARTIES:

Ex.B1 dated 21.04.2010            Copy of the Discharge summary

Ex.B2 dated NIL              Insurance Policy with terms and conditions

Ex.B3 dated 21.04.2010   Discharge Summary

Ex.B4 dated 25.08.2011   Award of Insurance  Ombudsman

 

MEMBER – II                                                               PRESIDENT