Tamil Nadu

South Chennai

CC/38/2006

S.J.Jagadev - Complainant(s)

Versus

Royal Sundaram Alliance Insurance Company - Opp.Party(s)

P.V.Preeja

05 Oct 2017

ORDER

                                                                        Date of Filing :   22.11.2005

                                                                        Date of Order :   05.10.2017

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, CHENNAI (SOUTH)

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

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

                  TMT. K.AMALA, M.A. L.L.B.,                                 : MEMBER I

             DR. T.PAUL RAJASEKARAN, M.A ,D.Min.PGDHRDI, AIII,BCS : MEMBER II

C.C.NO.38/2006

THURSDAY THIS  5^TH DAY OF OCTOBER 2017

Mr. S.J.Jagadev,

S/o. V.G.S. Raju,

NO.122/2, Sapthagiri Colony,

15^th Main Road, Thirumangalam,

Anna Nagar West,

Chennai 600 040.                                          .. Complainant

 

                                        ..Vs..

 

The Managing Director,

Royal Sundaram Alliance Insurance Company,

Sundaram Towers,

45 & 46 Whites Road,

Chennai 600 014.

 

2. The Managing Director,

Medicare TPA Services India (P) Limited,

No.1, Circular Road,

United India Colony,

Kodambakkam, Chennai 600 024.

 

3. Apollo Hospital,

Rep. by its Managing Director,

21, Greams Lane,

(off) Greams Road,

Chennai 600 006.

 

4. The General Manager,

Standard Chartered Bank,

No.1, Haddows Road,

Chennai 600 006.                                           .. Opposite parties.

 

Counsel for Complainant            :   M/s. P.V. Preeja & another          

Counsel for opposite party-1       :   M/s. 

Counsel for opposite party-2         :

Counsel for opposite party-3         :

Counsel for opposite party-4         :

 

ORDER

THIRU. M. MONY, PRESIDENT

 

This complaint has been filed by the complainant against the opposite parties under section 12 of the Consumer Protection Act 1986 seeking direction .

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

         The complainant submit that  he availed insurance policy namely (i.e.) Health Shield Policy under the Group Insurance Scheme of the customers of 4^th opposite party.    As per the policy  the complainant entitled cashless treatment and various facilities.  The complainant joined to the policy for himself and his family consisting of his wife and his only son w.e.f. 20.4.2004 to 19.4.2005 by sending the proposal form along with brouchers for a sum of Rs.2,00,000/-.   Further the complainant state that he has renewed the policy from 20.4.2005 to 19.4.2006 for the same amount of Rs.2,00,000/- with cumulative bonus of Rs.30,000/-.     The complainant’s wife had  severe pain in the abdomen.  After due diagnosed  as having “Umbilical Hernia”.  Dr. R.Surendran advice to undergo operation  at Apollo Hospital, Chennai.   The said fact was duly informed to the Apollo Hospitals and Medicare TPA services Pvt. Limited, the 2^nd opposite party more than ten days before the operation date.    The 2^nd opposite party also requested the complainant to produce the copy of the policy and Ultra scan report for processing the pre authorization letter dated 6.9.2005 and confirming a cashless facility of Rs.40,000/-; accordingly the complainant’s wife admitted in Apollo Hospital on 15.9.2005 and due operation was undergone on 16.9.2005 and she was discharged on 20.9.2005.   The complainant’s wife also entitled post operative treatment charges.   The complainant informed the 2^nd opposite party TPA about the operation and discharged and requested to settle the bill to the Hospital.       At about 10.00 a.m.  the 2^nd opposite party informed that the cashless facility sanctioned by the TPA has been withdrawn since the complainant’s wife undergone “Hysterectomy” operation 10 years ago was suppressed.  Hence the complainant was constrained to pay the amount due to the hospital and get discharged from the hospital.   On 23.9.2005 the complainant issued notice to the opposite parties.   But the opposite parties 1 & 2 failed to comply the demand of the complainant.    As such the act of  the opposite parties amounts to deficiency in service which caused mental agony and hardship to the complainant.  Hence this complaint is filed.

2.    The brief averments in Written Version of  the opposite party is  as follows:

      The opposite parties deny each and every allegations except those that are specifically admitted herein.   The opposite party state that the

  Hence there is no deficiency in service on the part of the opposite party and the complaint is liable to be dismissed.

3.     In order to prove the averments of the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A9 marked.  Proof affidavit of opposite parties filed and Ex.B1 to Ex.B3  marked on the side of the opposite parties.

4.   The points for the consideration is:  

Whether the complainant is entitled to a sum of Rs Whether the complainant is entitled to a sum of Rs.46,800/-, Rs.3350/-, Rs.700/-, towards medical treatment as prayed for ?

Whether the complainant is entitled to a sum of Rs.1,00,000/- towards mental agony and Rs.5,00,000/- towards exemplary damages  with cost of Rs.10,000/-  as prayed for ?

POINTS 1 & 2:

          Heard both sides.  Perused the records.   The learned counsel for the complainant contended that admittedly the complainant availed insurance policy namely (i.e.) Health Shield Policy under the Group Insurance Scheme of the customers of 4^th opposite party.  Ex.A1 is  the policy.  As per the policy  the complainant entitled cashless treatment and various facilities.  The complainant joined to the policy for himself and his family consisting of his wife and his only son w.e.f. 20.4.2004 to 19.4.20065 by sending the proposal form along with brouchers for a sum of Rs.2,00,000/-.  But the complainant has not produced any such documents.    Further the contention of the complainant is that he has renewed the policy from 20.4.2005 to 19.4.2006 for the same amount of Rs.2,00,000/- with cumulative bonus of Rs.30,000/- as per Ex.A4.   But on a careful perusal of Ex.A1 & Ex.A4 the policy stands the name of the complainant alone in the month of April and May 2005.   The complainant’s wife had  severe pain in the abdomen.  After due diagnosed  as having “Umbilical Hernia”  as per Ex.A6.  Dr. R.Surendran advice to undergo operation  at Apollo Hospital, Chennai.   The fact was duly informed to the Apollo Hospitals and Medicare TPA services Pvt. Limited, the 2^nd opposite party more than ten days before the operation date.    The 2^nd opposite party also requested the complainant to produce the copy of the policy and Ultra scan report for processing the pre authorization letter dated 6.9.2005 and confirming a cashless facility of Rs.40,000/-; accordingly the complainant’s wife admitted in Apollo Hospital on 15.9.2005 and due operation was undergone on 16.9.2005 and she was discharged on 20.9.2005.   The complainant’s wife also entitled post operative treatment charges.   The complainant informed the 2^nd opposite party TPA about the operation and discharged and requested to settle the bill to the Hospital.

          At about 10.00 a.m.  the 2^nd opposite party informed that the cashless facility sanctioned by the TPA has been withdrawn since the complainant’s wife undergone “Hysterectomy” operation 10 years ago was suppressed.  Hence the complainant was constrained to pay the amount due to the hospital and get discharged from the hospital.  On 23.9.2005 the complainant issued notice Ex.A20 to the opposite parties.  Further the complainant contended that as per Ex.A1 the opposite parties requested the complainant to provide photographs of all members covered and to affix the photographs in the enclosed form.   If the other members of the family were not covered there was no to affix the photographs of  all the family members enclosed in the form.   The said contention deserves no importance because the policy is issued only to the complainant a single person.    Further the contention of the complainant  is that the insurance policy meant for Standard Chartered Bank customers only, which contain the terms and conditions of the policy.  Under the heading “A” Persons who can be insured.    It clearly says  “This insurance also provides cover for Family comprising of the insured any one or more of the following.     

          Spouse

Dependent Children means all your unmarried children, Stepchildren or legally adopted children who are between 91 days and under 18 years of age and

1. Are financially dependent on you.

 

2. Permanently reside with you.

Under Additional feature on page-4 of the Typed set “cashless facilities.  

        Under Clause 2 (a) of the heading-D Exclusion it is mentioned as follows:

“First Year Exclusions:  During the first year of the operation of the policy the expenses on treatment of

1. Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal Diseases, Fistula in Anus, Piles, Sinusitis are not payable…

 

But in this case, the policy is issued only in the name of complainant alone.Further the contention of the complainant is that as per Ex.A4 the certificate ofinsurance which is renewed up to 19.4.2006 establishes the allegation to transfer of Hysterectomy 10 years back.Further the contention of the complainant is that as per Ex.A7 pre-authorization letter a sum of Rs.40,000/- towards cashless facilities initiallysanctionedby the TPA was repudiated for no reason immediately.After the operationand at the time of discharged from the hospital caused severe mental agony which amounts to deficiency of service and unfair trade practice.

Further the learned counsel for the complainant cited a decision reported in

I (2003) CPJ 41 (NC)

NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DLEHI

ABHILASH JEWELLERY

..Vs..

NEW INDIA ASSURANCE CO. LTD

Held that

In a consumer dispute like this District Forum should not have allowed the Insurance Company to take up the plea of violation of clause X of the policy which was not a ground for repudiation.Such a ground was clearly an afterthought and advanced for the first time in the written version.Perhaps Insurance Company became wiser on advice received subsequently to deny the valid claim on every possible ground.This itself would amount to deficiency in service.Accordingly, we set aside the orders of the State Commission and District Forum, allow this revision petition and hold that loss was surely covered under the policy. “

 

 

The  learned counsel for the 1^st and 2^nd opposite parties contended that the complainant has not claimed any relief against the 3^rd and 4^th opposite parties.    The complainant claiming relief against only 1^st and 2^nd opposite parties.    The contention of the 1^st and 2^nd opposite parties that admittedly the complainant availed Health Shield Insurance Policy for the period 20.4.2004 to 19.4.2005 for a sum of Rs.2,00,000/- against the hospitalization expenses in the event of illness  as per the terms and conditions of the opposite parties.  The complainant also renewed the policy till  19.4.2006 with bonus amount.  The complainant is claiming cashless treatment facilities for his wife.   The Third Party Administrator licensed by the Insurance Regulatory & Development Authority receives intimation of hospitalization etc Ex.B3 given approval of Cashless treatment without going into the details of the policy.    After careful perusal of the policy and the treatment details the opposite parties 1 & 2 came to the conclusion that the policy stands in the name of the complainant a single person.  The policy in no way extended to the family or others.   In this case admittedly the treatment undergone by the wife of the complainant.   Further as per the terms and conditions the complainant’s is not entitled to suppress any of the pre-ailment.    Hence without any operation the opposite parties repudiated the claim.  Considering the facts and circumstances of the case this forum is of the considered view that the complainant is not entitled for any relief as prayed for in the complaint and the points 1 & 2 are answered accordingly. 

                        In the result the complaint is dismissed.  No cost.

 

       

 

 

 

 

 

 

 

 

 

            Dictated by the President to the Assistant, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 4^th day  of  October  2017.  

 

MEMBER-I                        MEMBER-II                             PRESIDENT.

 

Complainant’s side documents:

Ex.A1- 2.3.2015    - Copy of receipt cum ack. Of payment.

Ex.A2- 11.4.2015  - Copy of summarized bill.

Ex.A3- 2.3.2015    - Copy of order acceptance letter.

Ex.A4- 21.3.2015  - Copy of conversation with the customer care.

Ex.A5- 1.7.2015    - Copy of email correspondence.

Ex.A6- 10.7.2015  - Copy of email correspondence.

Ex.A7- 11.7.2015  - Copy of bill.

Ex.A8- 11.12.2015         - Copy of bill.

Ex.A9- 11.1.2015  - Copy of bill.

 

Opposite party’s side document: -     

Ex.B1-         -       - Copy of Details of service request raised

                               by the complainants.

Ex.B2-         -       -  Bill for the period of April & May 2015.

Ex.B3-         -       -  Copy of Details of the usage of the complainant.

 

 

 

MEMBER-I                        MEMBER-II                             PRESIDENT.