Tamil Nadu

StateCommission

A/23/2021

The Manager, m/s. united india Insurance Co. Ltd., Tiruvannamalai. - Complainant(s)

Versus

T.A.S. Vetri, No.42, thiruvoodal Street, Thiruvannamlai Town - Opp.Party(s)

M/s. M.B.Gopalan Asso

29 Mar 2023

ORDER

IN THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI

 

BEFORE :       Hon’ble Thiru Justice R. SUBBIAH               PRESIDENT

Thiru R  VENKATESAPERUMAL                   MEMBER

                        

F.A.NO.23/2021

(Against order in CC.NO.10/2018 on the file of the DCDRC, Thiruvannamalai)

 

      DATED THIS THE 29^th DAY OF MARCH 2023

 

The Manager                                                          M/s. M.B.Gopalan

M/s. United India Insurance Co. Ltd.,                               Counsel for

Thiruvannamalai                                                 Appellant / Opposite party

 

                                                         Vs.

 

T.A.S.Vetri                                                             M/s. R. Gopinath

No.42, Thiruvoodal Street                                             Counsel for

Thiruvannamalai Town                                         Respondent / Complainant

 

          The Respondent as complainant filed a complaint before the District Commission against the opposite party, praying for certain direction. The District Commission had allowed the complaint. Against the said order, this appeal is preferred by the opposite party praying to set aside the order of the District Commission dt.9.12.2020 in CC.No.10/2018.

 

          This appeal coming before us for hearing finally today, upon hearing the arguments of the counsel appearing for the appellant and on perusing the documents, lower court records, and the order passed by the District Commission, this commission made the following order in the open court:

 

ORDER

 

JUSTICE R. SUBBIAH,  PRESIDENT  (Open court)

 

 

1.       This appeal has been filed by the appellant/ opposite party as against the order dt.9.12.2020 in CC.No.10/2018 passed by the District Consumer Disputes Redressal Commission, Thiruvannamalai,  in allowing the complaint in part.   

 

2.       For the sake of convenience, the parties shall be referred as per the rankings before the District Commission.

 

3.       The brief facts which are necessary to decide the appeal is as follows:

           The complainant has taken an Individual Health Insurance Policy from the opposite party on 24.11.2002 vide Policy No.2809002817P112283484.  In the said policy, there is a coverage of Rs.2 lakh for the complainant and Rs.150000/- for his wife and Rs.1 lakh for his daughter.  Thereby the complainant was paying a sum of Rs.6900/-, Rs.3900/- and Rs.1300/- respectively, towards the premium amount.  The policy period was from 30.11.2017 to 29.11.2018.  While so, the complainant’s wife Mrs.Rani was admitted in the Sundaram Medical Foundation Hospital, Anna Nagar, on 23.5.2018.  She took treatment as an inpatient till 26.5.2018.  The total amount spent by the complainant for treatment was Rs.1,35,833.34/-.  Since there was a policy coverage, the complainant made a claim with the opposite party.  But the opposite party had allowed the claim of the complainant only for @Rs.45000/-, and disallowed the rest of the claim @Rs.90,833/-  Hence the complainant filed a complaint before the District Commission, praying for a direction to the opposite party to pay a sum of Rs.90,833/- towards the claim amount alongwith compensation of Rs.3 lakhs. 

 

4.       The case of the complainant was resisted by the opposite party, by filing their version as follows:

          This opposite party issued individual health policy bearing policy No.2809002817P112283484 for the period from 30.11.2017 to 29.11.2018. The complainant’s wife Tmt.Rani was admitted at Sundaram Medical Foundation Dr.Rangarajan Memorial Hospital, as an inpatient on 23.5.2018 at about 1.26 AM.  She was an inpatient for the period upto 1.31 PM on 26.5.2018.  As per the Gold Policy condition, she is entitled to room rent eligibility @ 1% of the sum insured under Gold Policy condition in coverage 1.2A.  But the complainant claim a sum of Rs.30,740/- as room rent, which is not permissible under the policy condition.  Similarly, the other claim also has to be considered only in accordance with the terms and conditions of the policy.  The complainant cannot claim more than what was admitted under the terms of the policy.  Hence as per the policy condition, a sum of Rs.90,833/- was disallowed and Rs.48,130/- was allowed out of the total medical expenses of Rs.1,44,828/-.  Thus they sought for dismissal of the complaint. 

 

5.       In order to prove the claim, on the side of the complainant, alongwith proof affidavit, 4 documents were filed, which were marked as E.A1 to A4 and 3 documents were filed on the side of the opposite party, which were marked as Ex.B1 to B3. 

 

6.       The District Commission, after analysing the evidence, has come to the conclusion that the policy conditions are printed in a micro level print, which cannot be easily readable.  Further the conditions are only in English not in the vernacular language.  Therefore, the defence raised by the opposite party may not be applicable to a normal consumer.  Thus holding, had allowed the complaint, by directing the opposite party to pay a sum of Rs.86,870/- towards the balance medical expenditure, alongwith compensation of Rs.10000/- and cost of Rs.5000/-.  Aggrieved over the order impugned, the present appeal is filed by the opposite party, as appellant.

 

7.       We have heard the submissions  on either side, and perused the materials available on record.

 

8.       It is the sum and substance of the submission of the learned counsel for the opposite party that the claim has to be considered only in accordance with the terms of the policy.  Therefore, the complainant cannot claim anything more than that what is provided for under the terms of the policy. 

          In view of the submission made by the learned counsel for the opposite party, it would be appropriate to see the details given in the sanction letter, with regard to the claim amount and disallowed amount. 

Description	Claimed amount	Disallowed amount	Settled amount
Room rent	30740	25490	5250
Professional fee	53585	42549	11036
Investigations	12165	9660	2505
Pharmacy	8994	1138	7856
OT related	21292	5889	15403
Others	18052	11972	6080
Total settled	144828	96698	48130

 

          In the above column, the reasons stated for disallowing the claim, in each column has been stated mostly as ‘proportionate applied’.  In the bill for pharmacy charges, amount specified for some of the items viz. Non medical dressing, gloves, syringe, thermometer, swab, makintosh, electrodes, urine bag etc. are denoted as excluded. 

          In this connection, a reading of relevant clauses in the policy would   denote :

          “Room, boarding and nursing expenses including RMO charges, IV fluids/ Blood transfusion/ Injection administration charges- 1% of sum insured per day or actual expenses whichever is less”.

 

          In view of the above, it is clear that so far as the room rent is concerned, the policy conditions clearly denote that 1% of sum insured per day or actual expenses, whichever is less is payable.  Therefore, amount granted in the caption for room rent is undisputable. 

 

9.       So far as the other claims in the heads of professional fee, investigation, OT related charges, pharmacy expenses are concerned, there is no clear calculation found for the disallowed portion of the actual expenses.   A perusal of the policy condition also would show that there is no mention about the proportionate payment in the manner made by the appellant in the sanction letter as per Ex.B3.  Without clear terms in the policy, the calculation made in the tabular column with regard to the sanctioned amount and the disallowed portion of amount, by the third party administrator, cannot be accepted.  When the policy condition do not contain clear specification about the sanction of the claim amount towards other heads, the deduction of the amount towards the expenses made in connection with the treatment, pharmacy bills and medical tests, seems to be an arbitrary decision, which in our opinion is not correct.   Therefore, we hereby hold that except the award of Rs.5250/- towards the room rent i.e, at the rate of 1% of actual expenses, amounts under the other heads are liable to b allowed as it is .

 

10.     The District Commission, has held that as per Ex.A3, the complainant has paid Rs.135000/- only towards the hospital charges.  Therefore, though the policy sum assured @Rs.150000/-, the complainant is entitled only for the actual amount spent.  Accordingly, the complainant is entitled to claim only Rs.135000/-.  Out of Rs.135000/-, the complainant’s claim was settled to an extent of Rs.48,130/-.  Therefore, the complainant is entitled for the balance amount of Rs.86,870/-. 

 

          Since the calculation/ deduction with regard to the room rent is hereby upheld, after deducting Rs.25490/-, the complainant is entitled to the balance amount of Rs.61,380/-.  Since there is a considerable delay, the above said amount is liable to be paid alongwith interest @9% p.a.,   Further, we are of the opinion that , there is deficiency in service on the part of the opposite party, in not settling the amount as per the policy and hence the opposite party is liable to pay compensation, as directed by the District Commission.   Therefore, the order of the District Commission is liable to be modified to the following extent

 

11.     In the result, the appeal is allowed in part, by modifying the order of the District Commission, Thiruvannamalai in CC.No.10/2018 dt.9.12.2020, and the appellant/ opposite party is directed to pay a sum of Rs.61,380/- instead of Rs.86870/- towards the medial expenditure, alongwith interest @9% p.a., from the date of complaint till realisation. The award towards compensation of R.10000/- and cost of Rs.5000/- is hereby confirmed.  There is no order as to cost in this appeal.

         

 

 

  R VENKATESAPERUMAL                                               R. SUBBIAH

               MEMBER                                                                      PRESIDENT