Tamil Nadu

North Chennai

161/2013

S.Damodaran, - Complainant(s)

Versus

Reliance General Insurance Co. Ltd, Rep. By its Manager, - Opp.Party(s)

M/s.P.V.S.Giridhar Associates

02 Aug 2017

ORDER

 

                                                            Complaint presented on:  30.08.2013

                                                                Order pronounced on:  02.08.2017

 

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

 

WEDNESDAY THE 02^nd   DAY OF AUGUST 2017

C.C.NO.161/2013

 

 

S.Damodaran,

S/o Sudalai Andi Nadar,

Residing at Old No.117 – 118,

New No.8, Seven Wells Street,

George Town,

Chennai – 600 001.

                                                                                    ….. Complainant

 

..Vs..

 1. Reliance General Insurance Co. Ltd.,

Represented by its Manager,

C-151 Okhla Industrial Area,

Phase – 1, New Delhi 110 020.

 

2. E-Meditek,

Represented by its Manager,

Plot No.577, Udyog Vihar,

Phase- V Gurgaon 122 016,

Haryana.

 

3. E.Meditek,

Represented by its Manager,

New No.169, Old No.76, 3^rd Floor,

TTK Road, Alwarpet,

Chennai – 600 018. (above Bank of Baroda)               …… (Given up)

 

4. E-Meditek,

Represented by its Manager,

No.93, Harrington Road,

Shenoy Nagar, Chennai – 600 030.

 

.

.....Opposite Parties

Date of complaint                                 : 03.09.2013

Counsel for Complainant                      : M/s.P.V.S.Giridhar & Sai Associates

                                                                 A.Ganapatheeswaran      

 

Counsel for 1^st Opposite Party                       : M/s Elveera Ravindran & K.Vinod

Counsel for 3rd Opposite Party               : Given up (Dismissed)

Counsel for 2^nd & 4^th Opposite Parties    : Ex – parte

 

O R D E R

 

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

          This complaint is filed by the complainant to direct the 1st Opposite Party to pay a sum of Rs.2,07,892/- towards the claim amount with 12% interest from the date of claim and to direct the Opposite Parties 2 & 3 to pay a sum of Rs.5,00,000/- towards 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 has availed Reliance Health Policy from the 1^st Opposite Party in the year 2008 for himself, his wife and his daughter Amutha which expires on 29.06.2010. The policy was renewed for a further period from 30.06.2010 to 28.06.2012. The total premium paid was at Rs.11,429/-. The policy provides benefit of Rs.3,00,000/- towards hospitalization . The 2^nd Opposite Party is the 3^rd party administrator (TPA) of the 1^st Opposite Party.

       2. The Complainant was admitted in the Apollo Hospital for a suspected tumor in the kidney on 28.10.2010. He underwent a medical procedure called Radical Nephrectomy and thereafter discharged on 05.11.2010. The Complainant made a claim of Rs.2,07,892/-  towards medical expenses to the Opposite Parties. The 2^nd Opposite Party asked for certain documents by letter dated 20.12.2011 and the same was provided by the Complainant. The Complainant sent documents along with letter dated 10.01.2011 which was acknowledged by the 2^nd Opposite Party. The 2^nd Opposite Party by another letter dated 18.01.2011 sought for further documents. The Complainant submitted the further documents by his letter dated 02.02.2011 to the 3^rd Opposite Party. The 2^nd Opposite Party sent a letter dated 03.02.2011 claiming that they had not received the documents and treating the claim as “No Claim” for want of documents.

          3. The 2^nd Opposite Party acknowledged the documents by letter dated 14.03.2011 and further asked for previous history of diseases. The Complainant sent reply dated 24.03.2011 that there has been no misrepresentation and seeking early settlement. However, the 2^nd Opposite Party sent another letter dated 11.04.2011 seeking consultation papers of the doctor from September 2009 to October 2010. The Complainant reply letter dated 18.05.2011 that there was no medical treatment during the said period and however he sent his Master Health Check report dated 17.06.2008. The Complainant after sent a remainder on 08.06.2011 and also caused legal notice dated 21.03.2012 & 18.07.2012 to the Opposite Parties to pay the amount and however there was no reply for the legal notices. Hence the Complainant filed this Complaint to direct the  1^st Opposite Party to pay a sum of Rs.2,07,892/- towards the claim amount with 12% interest from the date of claim and to direct the Opposite Parties 2 & 3 to pay a sum of Rs.5,00,000/- towards compensation for mental agony with cost of the Complaint.

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

          The Complainant is put to strict proof that he obtained policy from the 1^st Opposite Party for his family. The Complainant was admitted in the Apollo Hospital on 28.10.2010 and underwent medical procedure for Radical Nephrectomy. The Complainant made claim to the Opposite Parties for a sum of Rs.2,07,892/- on 31.01.2011 towards medical expenses.  The Opposite Parties sent various correspondences to the Complainant seeking various documents from him to consider the claim.  The Complainant also submitted reply with necessary documents then and there.  There was no deficiency on the part of this Opposite Party 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 parties?

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

6. POINT NO :1

          The Complainant availed Reliance Health Policy from the 1^st Opposite Party initially in 2008 for himself, his wife and his daughter Amutha  which expires on 29.06.2010 and the policy was renewed for a further period from 30.06.2010 to  28.06.2012 and the said policies are marked as Ex.A3    and the policy provides benefit for Rs.3,00,000/- towards hospitalization and the Complainant was admitted in the Apollo Hospital for a suspected tumor in the kidney on 28.10.2010 and  he underwent a medical procedure called Radical Nephrectomy and thereafter discharged on 05.11.2010 and the Complainant made a claim of Rs.2,07,892/-  towards medical expenses to the Opposite Parties.

7. Ex.A5, Ex.A6, Ex.A8 letters sent by the 2^nd & 3^rd Opposite Parties to the Complainant seeking certain documents to consider the claim and for the same the Complainant sent Ex.A7, Ex.A10 reply to them with documents. However, the 2^nd Opposite Party treated the claim as no claim for want of certain documents.  Again the 2^nd Opposite Party sent Ex.A12 & Ex.A14 seeking further documents and for the same the Complainant replied through Ex.A14, Ex.A16 & Ex.A17 with documents sought by them. However, the Opposite Parties have not paid the claim to the Complainant. Then the Complainant sent Ex.A17, Ex.A18 notices to the Opposite Parties and thereafter filed the Complaint. Till filing of the Complaint, the claim was not paid to the Complainant.

8. Admittedly the Complainant filed this Complaint during September 2012 and several returns were made and after compliance, it was numbered during October 2013. The Complainant made claim for a sum of Rs.2,07,892/-. The Complainant admits in his evidence of proof affidavit that after filing the Complaint, the 2^nd Opposite Party paid a sum of Rs.1,94,048/- to the Complainant through a cheque No.24268 dated 05.02.2013. The Complainant had not claimed the deficit amount in the claim amount. Hence, the Complainant is satisfied with the amount of Rs.1,98,048/- as claim amount paid to him. Therefore, it is held that there is no due from the Opposite Parties in respect of the claim amount by the Complainant.

9. The Complainant modified the prayer in the proof affidavit and sought relief only interest for the delay in payment of 27 months i.e., from the date of claim 25.11.2010 to till the date of payment on 13.02.2013. After making claim the Opposite Parties sought certain documents through various letters. The Complainant also submitted those documents then and there. The 2^nd Opposite Party lastly sought documents under Ex.A15 letter dated 18.05.2011. For this letter, the Complainant lastly submitted documents in Ex.A16 letter dated 08.06.2011. Thereafter, the Opposite Parties did not ask for any further documents from the Complainant. This shows that the Opposite Parties are satisfied with the documents submitted by the Complainant to consider the claim. At least the Opposite Parties should have considered the claim in May 2011itself and paid the claim in May 2011 itself. However, after May 2011 with a delay of 20 months, the 2^nd Opposite Party paid the amount on 13.02.2013 is deficiency on the part of the 2^nd Opposite Party. The 2^nd Opposite Party is the TPA of the 1^st Opposite Party and the 2^nd Opposite Party processed the claim only for the 1^st Opposite Party who had issued the policy. Therefore, the 1^st Opposite Party has also committed deficiency in this regard.

10. The 3^rd Opposite Party was given up by the Complainant and no relief sought against the 4^th Opposite Party. Hence the 3^rd & 4^th Opposite Parties have not committed any deficiency. Therefore, it is held that the Opposite Parties 1 & 2 has committed deficiency in service and the Opposite Parties 3 & 4 has not committed any deficiency in service.

11. POINT NO:2

          The 1^st & 2^nd Opposite Parties paid the claim with a delay of 20 months. Hence the Complainant made claimed interest for the delay period. Though the Complainant claimed 12% interest, it would be reasonable to order 9% for the claim amount of Rs.1,94,048/- for the delay of 20 months i.e  a sum of Rs.29,107/- payable to the Complainant by the Opposite Parties 1 & 2. Even though the Complainant submitted documents well before filing of the Complaint, the Opposite Parties should have paid the claim before filing the Complaint.  Failed to pay such claim, the Complainant suffered with mental agony is accepted and for the same it would be appropriate to order to pay a sum of Rs.10,000/- towards compensation for  mental agony, besides a sum of Rs.5,000/- towards litigation expenses. The Complaint in respect of the Opposite Parties 3 & 4 is liable to be dismissed.

          In the result the Complaint is partly allowed. The Opposite Parties 1 & 2 jointly or severally are ordered to pay a sum of Rs.29,107/- (Rupees twenty nine thousand hundred and seven  only) towards interest  to the claim amount paid to the Complainant and also to pay  a sum of Rs. 10,000/- (Rupees ten  thousand only) towards compensation for mental agony, besides a sum of Rs. 5,000/- (Rupees five thousand only)  towards litigation expenses. The Complaint in respect of the Opposite Parties 3 & 4 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 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 02^nd day of August 2017.

 

MEMBER – I                                                                PRESIDENT

 

 

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 02.07.2008	Letter written 1st Opposite Party to the Complainant
Ex.A2 dated 12.01.2010	Letter written 1st Opposite Party to the Complainant
Ex.A3 dated 30.06.2010	Intimation from 1st Opposite Party to the Complainant stating policy has been issued to him for the period from 30.06.2010 to 28.06.2010. 2nd Opposite Party has been stated as TPA Insurance Certificate for policy bearing number 1304702825002436
Ex.A4 dated 25.11.2010	Claim acknowledgement issued by 3rd Opposite Party Chennai Office
Ex.A5 dated 20.12.2010	Letter sent by 2nd Opposite Party to the Complainant requesting for some documents
Ex.A6 dated 05.01.2011	2nd letter sent by 2nd Opposite Party to the Complainant requesting for some documents
Ex.A7 dated 10.01.2011	Reply given by the Complainant to the 2nd Opposite Party
Ex.A8 dated 18.01.2011	3rd letter sent by 2nd Opposite Party to the Complainant requesting for some more documents
Ex.A9 dated 31.01.2011	Copy of the claim form submitted by the Complainant
Ex.A10 dated 02.02.2011	Letter submitted by the Complainant along with the documents
Ex.A11 dated 03.02.2011	No claim letter issued by the 2nd Opposite Party
Ex.A12 dated 14.03.2011	4th letter sent by 2nd Opposite Party to the Complainant requesting for some more documents and previous medical history.
Ex.A13 dated 24.03.2011	Complainant’s reply to the 3rd Opposite Party enclosing the Master Health Check-up report
Ex.A14 dated 11.04.2011	5th Letter sent by 2nd Opposite Party to the Complainant requesting for some more documents and previous medical history for the period from Sep 2009 to October 2010
Ex.A15  dated 18.05.2011	Complainant’s reply and request for speedy settlement of his claim
Ex.A16 dated 08.06.2011	E-mail sent by the Complainant to the 2nd Opposite Party with the soft copies of the documents
Ex.A17 dated 21.03.2012	Legal Notice sent by the Complainant
Ex.A18 dated 18.07.2012	2nd legal notice sent by the Complainant to the Opposite Parties with the acknowledgement card
Ex.A19 dated 17.06.2008	Master Health Check-up report with bill

 

LIST OF DOCUMENTS FILED BY THE 1^st OPPOSITE PARTY :

 

Ex.B1 dated 12.06.2010                   Policy of Insurance

 

Ex.B2 dated NIL                     Policy Wordings (Terms and Conditions)

 

 

 

MEMBER – I                                                               PRESIDENT