Tamil Nadu

South Chennai

CC/203/2012

D.Ramiah - Complainant(s)

Versus

T.T.K.Health Care TPA Pvt Ltd. - Opp.Party(s)

K.P.Kiran Rao

24 Aug 2015

ORDER

                                                                         Date of Filing :  27.08.2012

                                                                        Date of Order : 24.08.2015.

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, CHENNAI(SOUTH)

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

 

PRESENT: THIRU. B. RAMALINGAM M.A.M.L.,                      : PRESIDENT

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

                 TR. T.PAUL RAJASEKARAN, M.A PGDHRDI, AIII,BCS : MEMBER II

 

                            C.C.NO.203/2012

MONDAY THIS 24^TH  DAY OF AUGUST 2015

 

D. Ramiah,

No.20, NewNo.22, 2^nd Street,

State Bank officer’s Colony,

Poonamalle High Road,

Arumbakkam,

Chennai 600 106.                                          ..Complainant

 

                                                 ..Vs..

1.  T.T.K. Health Care TPA Private Limited,

Rep. by its Director,

“Anmol Palani,

NO.88,

L2, G.N. Chetty Road,

T.Nagar,

Chennai 600 017.

 

2. The New India Assurance Co. Limited,

Rep. by its Branch Manager,

80 Arcot Road, Porur,

Chennai 600 116.

 

3. The New India Assurance Co. Limited,

Regional office, Grievance Cell,

Rep. by its Manager,

Spencer Towers NO.770-A,

Anna Salai,

Chennai 600 002.                                   .. Opposite parties.

 

For the Complainant             :  M/s. K.P. Kiran Rao      

 

For the Opposite parties       :  M/s. Nageswaran & Narichania   

 

 

        This complaint is being filed by the complainant u/s 12 of the C.P. Act 1986 for a direction to the opposite parties to pay a sum of Rs.40,975/- together with interest and also to pay a sum of Rs.1,00,000/- as compensation for mental agony and to pay costs of the proceedings to the complainant.      

ORDER

 

THIRU. B. RAMALINGAM PRESIDENT        

 

         

1.The case of the complainant is briefly as follows:-

    

 The complainant was covered under the SBI Group Mediclaim policy for the period from 31.3.2009 to 30.3.2010 and the sum assured was Rs.1,00,000/-.  The complainant was suffering from Lumbar Disc Disease, Cervical Spondylosis and was hospitalized between 3.3.2010 to 5.3.2010 at Billroth Hospital.  After treating the complainant for three days they pleaded inability to cure complainant’s problem and advised him to take further treatment at Back and Neck Clinic.   As advised by the Billroth hospital the complainant took spinal decompression treatment at Back and Neck clinic for 20 sessions from 6.3.2010 to 25.3.2010 which totally cured his pain.   The complainant submitted a claim form dated 25.3.2010 by registered post enclosing a file containing discharge & treatment summaries and three original bills amounting to Rs.40,975/-    His claim was repudiated by the first opposite party on 20.4.2010 stating that the treatment is possible on OPD basis and not payable by insurance company.   The complainant approached the SBI Pensioner’s Association to take up the matter since it was a group insurance mediclaim policy, who in turn took up the matter with the insurance company vide their letter dated 9.6.2010 stating that post hospitalization expenses are permitted in group insurance policies.   In response to this the 1^st opposite party bargained to pay 50% of the expenses which was not agreeable to the complainant.   Despite of several demands made by the complainant  the opposite parties failed to  settle his claim.    As such the act of the opposite parties amounts to deficiency of service and unfair trade practice and the same has caused him great mental agony and hardship to the  complainant.  Hence the complaint.  

 

2.      Even after receipt of the notice, the 1^st opposite party did not file written version.  Hence, the 1^st opposite party was set exparte on  18.2.2013. 

3.      Written version of  2^nd and 3^rd opposite parties  is  as follows:-

It denies all the averments and allegation contained in the complaint except those that are specifically admitted herein.   The claim of the complainant was repudiated on 20.4.2010 by the 1^st opposite party.  The complainant ought to be filed on or before 20.4.2012 instead the complainant filed on 27.8.2012. The complainant has not given any valid reason for the delay in filing the complaint nor has approached this forum to condone the delay and therefore the complaint is barred by limitation and is liable to be dismissed.  The insured State Bank of India Pensioner’s Association insured the members under the Group Medical Policy which is Hospitalization benefit policy in which the complainant was also included.  The 1^st opposite party has sanctioned two payments while the complainant was being treated to the Billroth Hospital for this lumbar disc disease.     The complainant filed the claim form on 7.4.2010 and upon scrutinizing the claim form and supporting documents, it was found that the complainant undertook the treatment from the Back and Neck Clinic as per the advice of the Billroth Hospital and the first opposite party repudiated the claim on 20.4.2010 on the ground that the said treatment can be treated under outpatient department basis and therefore the claim was repudiated by the 1^st opposite party.   Since the file was closed on the above ground the treatment can be done on OPD basis, the complainant presented the claim before the Insurance Ombudsman, who dismissed the claim on merits and gave a findings that this complainant did not submit proper receipt from the clinic where he underwent treatment, after giving several opportunities to file the original documents, the complainant did not submit the original documents which are essential to process any claim by the insurer under the terms and conditions of the policy.   The complainant did not reveal  any valid reason why he did not submit the original receipts.    Hence there is no deficiency of service on the part of the opposite parties as claimed by the complainant for which compensation has been claimed by the complainant.    Hence the complaint deserves to be dismissed.   

4.   Complainant has filed his Proof affidavit and  Ex.A1 to Ex.A26 were marked on the side of the complainant.    2^nd and 3^rd Opposite parties have filed their proof affidavit and no document was marked on the side of the opposite parties.  

5.         The points that arise for consideration are as follows:-

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

 

2. To what relief the complainant is entitled to?

 

6. POINTS 1 & 2 :

        Perused the complaint filed by the complainant and written version filed by the opposite parties, proof affidavit of both sides, complainant documents Ex.A1 to Ex.A26 and  considered the both side arguments.   There is no dispute that the complainant had taken a Group of Mediclaim Policy with the 2^nd and 3^rd opposite parties Insurance company which was in force during the period from 31.3.2009 to 30.3.2010 when the said mediclaim policy was in force the complainant was suffering from Lumbur Disc Disease, Cervical Spondlylosis and was hospitalized between 3.3.2010 to 5.3.2010 at Billroth Hospital, there after three days further treatment advised him to take treatment at Back and Neck clinic.  As per the said advise of the Billroth Hospital as mentioned in the discharge summary Ex.A4  the complainant has taken spinal decompression treatment at Back and Neck clinic for twenty session from 6.3.2010 to 25.3.2010  which totally  cured his pain.   For the treatment take by the complainant in the Billroth Hospital for the period from 3.3.2010 to 5.3.2010  the claim was made to payment of Rs.9,000/- and Rs.25,000/-  for his treatment at Billroth Hospital and for medical treatment taken in the Back and Neck clinic from 6.3.2010 to 25.3.2010 by registered post enclosing a necessary discharge and treatment summaries and  three original receipts amounting  to Rs.40,975/-.  The complainant further alleged that the said claim made by the complainant was not settled  the opposite party have repudiated the claim has resisted the complainant stating that the claim is barred by limitation and original documents for the treatment were not produced by the complainant to the 1^st opposite party and the claim is relating to the Post hospitalization treatment and the nature of treatment taken as outpatient and not covered by the medi claim policy.

7.     The Exhibit filed by the complainant as stated in the complaint the claim was made by the complainant on 25.3.2010 as per Ex.A8.  Whereas the 1^st opposite party by letter Ex.A11 dated 20.4.2010 has repudiated the claim stating that the treatment is possible as outpatient and not possible by insurance company.  After the complainant made demand Ex.A12, dated 9.6.2010 through the SBI Pensioner’s Association and the legal notice Ex.A14 sent by the complainant dated 1.3.2011  the insurance company by letter Ex.A5 had informed the complainant  stating that this complaint was taken up with consent of TPA and the original receipts for Rs.40,200/- in the Hospital head (The Back and Neck clinic) may be provided to M/s. TTK as early as possible.  So that they may be proceeded, further as per the above letter sent by the opposite party insurance company dated 4.3.2011 the said claim of the complainant was taken up action  and was processed. Even then  as required by the insurance company / 1^st opposite party though the complainant has furnished the photo copy of hospital document for his treatment, since the original documents were already submitted to the opposite party and were lost and again copies were sought for by the opposite party,  have not settled the claim of the complainant and hence filed this complaint  before this forum on 27.8.2012.  Therefore this complaint filed by the complainant for the claim is medical expense under the medi claim policy cannot be considered to be time barred. 

        Further in support of the same the decision rendered in the case 

NATIONAL INSURANCE CO. LTD.,

VS..

SANDHYA DEVI

Published in IV (2014) CPJ 7A (CN) (Jhar.)

 

The above citation will be squarely applicable for this present case.   Therefore the contention of the opposite party that the complaint is barred by limitation is not acceptable and rejected as not sustainable.

8.     As per Ex.A4 discharge summary issued by the Billroth Hospital where the complainant has taken hospitalized treatment from 3.3.2010 to 5.3.2010 which prove that the “complainant was advised to undergo Spinal Decompression treatment for 20 sessions “.  Therefore the complainant has taken complaint mentioned treatment in the Back and Neck Clinic for 20 session from 6.3.2020 to 25.3.2010 which is proved by Ex.A9 dated 25.3.2010.  The copy of the bill issued by the  for the treatment of Bank and Neck clinic.  Therefore the said treatment taken by the complainant which is  Post Hospitalization treatment on the advise of the treatment given by Billroth Hospital.   As such for the expense of such treatment the complainant is entitled to claim under the said medi claim policy and the said medi claim policy is covered and the same is acceptable.   On this aspect only the 1^st opposite party / claim processing agency and the insurance company the opposite parties have dealt with the said claim made by the complainant for reimbursement of the said expenses by the complainant.  Therefore the opposite parties at the initial repudiation stating that it is the nature of the treatment can be taken as an outpatient as such the claim cannot reimbursable under the policy is not acceptable.  Further subsequent to the demand made by the opposite party though the complainant has given the original document for the said treatment along with the claim dated 25.3.2010 despite of the duplicate copies of the documents obtained from the said hospital the act of the opposite party not settling the claim of the complainant on the ground the original document  called for not produced by the complainant  is not valid and sustainable.  Therefore as submitted by the learned counsel for the complainant that the said attitude of the opposite party in not settling the complainant’s genuine claim though the age of the complainant is 84 year amount to deficiency of service and unfair trade practice and the same has caused great mental agony and hardship to the complainant is acceptable.

 

9.     Therefore we are of the considered view that the opposite parties 2 & 3 are liable to settle the claim made by the complainant for the medi claim expenses incurred by the complainant mentioned in the complaint for Rs.40,975/-as per the medi claim policy.   The opposite parties having  failed to settle the said claim  from 25.3.2010 have committed deficiency of service  and which caused mental agony and hardship to the complainant.  Therefore the opposite parties 2 & 3  jointly and severally liable to pay  a sum of  Rs.40,975/- with interest at the rate of 9% per annum from 25.3.2010 to till the date of payment and also to pay a sum of  Rs.5,000/- as cost of the complaint to the complainant and as such the points 1 & 2 are answered in favour of the complainant.

          In the result, the complaint is partly allowed.   The 2^nd and 3^rd    opposite parties are jointly and severally   directed to pay  a sum of Rs.40,975/- (Rupees Forty thousand nine hundred and seventy five only) for the reimbursement of the medical expense  with interest at the rate of 9% p.a. from 25.3.2010 to till the date of payment  and also to pay  a  sum of Rs.5000/- (Rupees Five thousand only) as cost of the complaint  to the complainant within six weeks from the date of receipt of copy of this order.   In respect of the  opposite party-1  this complaint is dismissed.          

 Dictated to the Assistant transcribed and typed by her corrected and pronounced by us on this  24^th   day of August  2015.

 

MEMBER-I                                        MEMBER-II                                          PRESIDENT.

Complainant’s Side documents :

Ex.A1- 30.3.2009      - Copy of Policy Schedule.

Ex.A2- 24.2.2010      - Copy of receipt.

Ex.A3- 4.3.2010        - Copy of Billroth Certificate.

Ex.A4- 5.4.2010        - Copy of Billroth Discharge Summary.

Ex.A5- 5.3.2010

         12.3.2010       - Copy of bills and receipts of Back and Neck Clinic.

 

Ex.A6- 24.3.2010      - Copy of Back and Neck Clinic Treatment summary.

 

Ex.A7- 24.3.2010      - Copy of TTK Medical Certificate.

 

Ex.A8- 25.3.2010      - Copy of Claim Form.

 

Ex.A9- 25.3.2010      - Copy of bill and split bill of Back and Neck Clinic.

 

Ex.A10- 7.4.2010      - Copy of complainant’s letter to 1^st opposite party.

 

Ex.A11- 20.4.2010     - Copy of letter from 1^st opposite party  

 

Ex.A12- 9.6.2010      - Copy of SBI Pensioner’s Association letter to 2^nd opposite party

 

Ex.A13- 4.3.2011      - Copy of 3^rd opposite party’s letter to complainant.

 

Ex.A14- 1.3.2011      - Copy of Complainant’s letter to 3^rd opposite party.

 

Ex.A15- 4.3.2011      - Copy of 3^rd opposite party’s letter to complainant.

 

Ex.A16- 24.3.2011     - Copy of 3^rd opposite party’s letter to complainant.

 

Ex.A17- 29.3.2011     - Copy of complainant’s letter to 3^rd opposite party.

 

Ex.A18- 23.6.2011     - Copy of complainant’s letter to Insurance Ombudsman.

 

Ex.A19- 23.6.2011     - Copy of Minutes of the meeting Insurance Ombudsman.

 

Ex.A20- 16.8.2011     - Copy of letter from Insurance Ombudsman enclosing the

                               Award  dated 29.7.2011.

 

Ex.A21- 26.9.2011     - Copy of complainant’s letter to first opposite party enclosing

                               Duplicate original bills.

 

Ex.A22- 22.12.2011   - Copy of the complainants letter to consumer Association to India.

 

Ex.A23- 28.12.2011   - Copy of letter from Consumer Associating to India to 1^st opposite

                               party with copy to 2^nd opposite party.

 

Ex.A24- 15.2.2012     - Copy of certificate from SBI pensioner’s association.

 

Ex.A25- 5.7.2011      - Copy of disability certificate.

 

Ex.A26- 22.4.1997     - Copy of Cancer Institute Report.     

 

 

Opposite parties’ side documents: -    

 

            .. Nil. 

 

 

MEMBER-I                                        MEMBER-II                                          PRESIDENT.