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G.S.Ashok Kumar, filed a consumer case on 17 Jun 2016 against Reliance General Insurance Co. Ltd, havin Office at in the North Chennai Consumer Court. The case no is 250/2012 and the judgment uploaded on 13 Jul 2016.
Complaint presented on : 11.10.2012
Order pronounced on : 17.06.2016
DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (NORTH)
2nd 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 1st Opposite party :M/S Elveera Ravindran
Counsel for 2nd opposite party : Ex parte
Counsel for 3rd & 4th 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 1st 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 3rd Opposite Party hospital. The 4th Opposite Party doctor checked the Complainant and conducted Angioplasty and discharged him on 21.04.2010. The 4th Opposite Party depicted in the discharge summary that the Complainant was a chronic smoker and drinker. Later, when the Complainant questioned the same the 3rd 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 2nd 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 1st 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 3rd 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 3rd & 4th OPPOSITE PARTIES IN BRIEF:
These Opposite Parties admits that the Complainant was admitted in the hospital on 19.04.2010 and the 4th 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 4th 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 4th 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 1st Opposite Party in the year 2010 and subsequently the said policy was renewed for the year 2011 and the 4th Opposite Party done angioplasty surgery on the Complainant at the 3rd 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 2nd Opposite Party who is authorised by the 1st 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 1st Opposite Party and further there is no evidence on behalf of the 1st 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 2nd Opposite Party is Deficiency in Service.
7. The 1st 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 2nd 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 1st 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 2nd Opposite Party is not sustainable and further the 2nd Opposite Party is only a TPA and he has no authority to reject the claim and the 1st Opposite Party who has issued policy alone is competent to reject or admit the claim and the 1st Opposite Party has not rejected the claim of the Complainant and therefore the 1st & 2nd Opposite Parties have committed Deficiency in Service by rejecting the claim.
9. However the 3rd Opposite Party is a hospital and the 4th Opposite Party is a doctor who treated the patient has nothing to do with the claim made by the Complainant to the 1st and 2nd Opposite Parties and therefore, it is held that the 3rd & 4th Opposite Parties have not committed any Deficiency in Service.
10. POINT NO:2
Since the 1st & 2nd 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 & 4th 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 3rd & 4th 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 17th 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 2nd opposite party – TPA
Ex.A7 dated 12.07.2010 Explanation letter regarding the discharge
certificate submitted by the complainant with
the 2nd opposite party -TPA
Ex.A8 dated 01.12.2010 Reminder letter issued by the complainant to the
2nd opposite party to deliver the decision
Ex.A9 dated 20.12.2010 Decision of the 2nd opposite party – TPA
Ex.A10 dated 27.01.2011 Letter issued by the complainant to the customer
cell of the 1st 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 1st 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
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