Tamil Nadu

North Chennai

227/2013

Mr.Nirmal kumar Maheshwari,S/o.Moolchand Maheshwar l - Complainant(s)

Versus

The Branch Manager,MDIINDIA Health care services(TPA) Pvt Ltd., - Opp.Party(s)

G.Munendran-com

19 Jul 2016

ORDER

 

                                                            Complaint presented on:  26.11.2013

                                                               Order pronounced on:  27.07.2016

 

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

                    TMT.T.KALAIYARASI, B.A.B.L.,           MEMBER II

 

WEDNESDAY THE 27^th    DAY OF JULY 2016

 

C.C.NO.227/2013

 

 

 

Mr.Nirmal Kumar Maheswari,

S/o. Moolchand Maheswar 1,

Aged about 55 years,

No.16, Crescent Park Street,

T.Nagar, Chennai – 600 017

   

                                                                                      ..... Complainant

 

..Vs..

 

1.The Branch Manager,

Mdindia  Health Care Services (TPA) Pvt. Ltd.,

260/16, 3^rd Floor, Mount Casa Blanca,

Anna Salai, Chennai – 600 006.

 

2. The Branch Manager,

M/s. National Insurance Company Ltd.,

Vijay Plaza Building, II Floor,

C-32, Second Avenue, Anna Nagar,

Chennai – 600 040.

	.....Opposite Parties

Date of complaint                                 : 02.12.2013

Counsel for Complainant                      :G.Munendran             

 

Counsel for opposite parties                  : N.Vijayaraghavan

 

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 IS IN BRIEF:

        The Complainant insured herself and her Family Members from the year 2004 with the Opposite Parties in the year 2010, similar medicalim policy No.500505/48/10/8500000921 commencing from 17.08.2010 to midnight of 16.08.2011 was taken by the Complainant for his family members namely 1.Mr.Nirmal Kumar, 2.Mrs.Aarti Maheswari and 3.Mr.Kartik Maheswari by paying a premium of Rs.6,634/- to the second Opposite Party through their agent. The Complainant was only given the Mediclaim policy certificate unaccompanied by any sort of terms and conditions. Mr.Kartik Maheswari, the son of the Complainant, had a sudden and unbearable pain in his upper lip and mouth while eating, chewing etc., that led to his consultation with an Orthodontist on 04.08.2011 who advised the Complainant to get his son hospitalized for few days to undergo corrective surgery in his mouth. Accordingly, the Complainant’s son was admitted in the Right Hospital in Kilpauk on 04.08.2011. On 05.08.2011 the son of the Complainant undergone surgery and was subsequently discharged on 08.08.2011. The Complainant chose to file Medical reimbursement claim for a sum of Rs.68,095.30 p with the second Opposite Party. When the Complainant approached the second Opposite Party, he was directed to approach the first Opposite Party for claim form and filed the same with the first Opposite Party. The 1^st and 2^nd Opposite Parties slept over the legitimate reimbursement claim of the Complainant for nearly 3 years except informing orally that the reimbursement claim was rejected without furnishing any reasons for such rejection. When questioned by the Complainant, both the Opposite Parties informed that the Repudiation of claim in written form would be sent shortly to the Complainant. The letter dated 25.04.2013 of the 1^st Opposite Party under copy to the 2^nd Opposite Party; the claim of the Complainant is allegedly rejected as per the alleged policy terms under alleged exclusion clause 4.8. Neither the 1^st Opposite Party nor the 2^nd Opposite Party ever bothered to send the alleged policy terms at any point of time to the Complainant. This too amounts to gross Deficiency in Service on the part of the 1^st and 2^nd Opposite Parties. It is learnt that the alleged exclusion clause 4.8 the congenital external illness is excluded from the scope of the policy. For this alleged congenital external illness, the 1^st Opposite Party wrongly concluded that the surgery was done for external illness only, while the fact remains that besides a corrective measure done on external illness, surgical intervention was done inside the mouth also can be verified from the discharge summary. Therefore, the Opposite Parties refused to honour the claim of the Complainant is Deficiency in Service and hence the Complainant filed this Complaint to reimburse the Medical Expenses and also compensation for mental agony with cost of the Complaint.

 

 

2. WRITTEN VERSION OF THE 2^nd OPPOSITE PARTY ADOPTED BY THE 1^st OPPOSITE PARTY:

          The Complainant had availed mediclaim policy No.500505/48/10/850000921 for the period 17.08.2010 to 16.08.2011 covering the risk to three persons including Master Karthik Maheswari. A claim was lodged for the treatment availed by the patient in Right Hospital, Kilpauk between 04.08.2011 to 08.08.2011 for a sum of Rs.68,095.30p.  It was found that the claim was lodged in respect of treatment for secondary problems of cleft lip and Palate Pre Alveolar Fistula. As per the claim form signed by the Complainant and medical report signed by Dr.G.Balakrishnan, Right Hospital in column No.12, it was mentioned that the disease was caused by a congenital defect. It was chronic in nature.  On scrutiny of the medical records/discharge summary read with the medical certificate it was concluded by the expert medical doctors team with 1^st Opposite Party the claim was not admissible vide clause 4.8 of the contract of insurance. As per clause 4.8 of the contract of insurance “congenital external disease” is not payable and it being a pre-existing physical condition is not payable vide clause 4.1 also. In such circumstances the 1^st Opposite Party declined cashless benefit and communicated by letter dated 25.04.2013. As per the terms of such policy, applied to the facts of claim, it was found inadmissible. Admittedly, the patient was suffering from cleft lip physical condition from birth or as congenital defect.  This physical condition was clearly admitted in the medical certificate dated Nil issued by Doctor G.Balakrishnan. Since the treatment was related to cleft lip problem which was pre-existing and a congenital defect, the claim is not admissible under the contract of insurance. The Opposite Parties have not committed any Deficiency in Service negligently and the Complaint is liable to be dismissed with cost.

 

3. 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?

4. POINT NO: 1

          It is an admitted fact that the Complainant insured himself and his family members with the Opposite Parties and for the period 17.08.2010  to 16.08.2011 under Ex.A1 by paying premium of Rs.6,634/- and the Complainant Karthi Maheswari undergone surgery  in the Right Hospital in Kilpauk on 04.08.2011 and under gone surgery on 05.08.2011 for his upper lip and discharged on 08.08.2011 and the discharge summary of the said hospital is marked as Ex.A3 & B2 and the inpatient hospital bill is marked as Ex.A2 and the Complainant made a claim with the Opposite Party for a sum of Rs.68,095.30/-  and the said claim made repudiated by the 1^st Opposite Party to the 2^nd Opposite Party that the same was not payable as per clause 4.8 of the terms and conditions of the policy.

          5. According to the Complainant her son had undergone surgery for cleft lip in the year 2007 and subsequently  he had  pain in the same lip and for the same he had undergone a surgery by crucial internal surgical and therefore the same was not excluded as per the policy conditions and hence he is entitled for the claim. Ex.B4 is the copy of the mediclaim medical report submitted by the Complainant for claiming the amount along with the claim application. In Ex.B5 in respect of column previous history of disease, it is mentioned as “Patient has cleft lip operated in early childhood. Had lip revision open rhinoplasty done on 29.09.2007”. In column No.8 present disease of diagnosis “Secondary problems of cleft lip and palate and pre alveolar – Fistula” and suffered for 2 years. In Ex.B2 discharge summary, the disease diagnosed as “secondary problems of cleft lip and palate pre alveolar –Fistula and the surgery done for Fistula closure lip scar revision. As  per Ex.B2 and Ex.B4 documents the patient was suffered with cleft lip   by birth and the same was operated early childhood and subsequently during 2007 lip revision open  rhinoplasty  was done and again for the same cleft lip a surgery was done on 05.08.2011 as  per Ex.B2.

          6. Secondary in the cleft lip occurs at the time  of birth itself. Admittedly the Complainant claim made to the Opposite Parties for the expenses incurred for the son in respect of cleft lip surgery. Ex.B1 is the terms and conditions of the insured policy of the 2^nd Opposite Party. As per the policy exclusion 4.7 dental treatment or surgery - corrective, cosmetics treatment and as per exclusion clause 4.8 congenital external disease and other disease mentioned there in the claim are excluded. Ex.B2 reveals that Surgery done at Right Hospital is a congenital (cleft lip) external disease and as per exclusion clause 4.8 the said disease is excluded. As the Complainant documents Ex.A3 and Ex.B2 discharge summary and Ex.B4 medical report proves that the Complainant son was undergone surgery early for congenital disease and subsequently for the same disease, the claim also is made and the said claim was not honoured by the Opposite Parties in view of exclusion clause 4.8 is acceptable and therefore we hold that the Opposite Parties have not committed any Deficiency in Service.

7. POINT NO: 2

          Since the opposite parties have not committed any Deficiency in Service, the Complainant is not entitled for any relief in this Complaint and the Complaint is liable to be dismissed without cost.

 

 

          In the result the Complaint is dismissed. No costs.

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 27^th    day of July 2016.

 

MEMBER – II                                                               PRESIDENT

 

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 13.08.2010                   Mediclaim Policy Certificate

Ex.A2 dated 08.08.2011                   Inpatient Bill of Right Hospitals

Ex.A3 dated 08.08.2011                   Discharge Summary of Right Hospitals

Ex.A4 dated 10.08.2011                   Fee Receipt of Right Hospitals

Ex.A5 dated 28.08.2011                   Fee Receipt of Right Hospitals & Medicine Bill

Ex.A6 dated 23.09.2011                   Claim Form

Ex.A7 dated 31.03.2013                   Legal Notice of the Complainant

Ex.A8 dated 22.04.2013                   Acknowledgement Card from the 1^st & 2^nd

                                                Opposite Parties

 

Ex.A9 dated 25.04.2013                   Reply letter to the Legal Notice by the 1^st Opposite

                                                Party

 

 

 

 

 

 

LIST OF DOCUMENTS FILED BY THE 2^nd OPPOSITE PARTY :

Ex.B1 dated NIL                     Insurance Policy with terms and conditions

Ex.B2 dated 08.08.2011                   Discharge Summary

Ex.B3 dated NIL                     Claim Form

Ex.B4 dated NIL                     Mediclaim Medical Report

Ex.B5 dated 07.10.2011                   Pre Repudiation statement from 1^st Opposite Party

                                                to 2^nd Opposite Party

 

 

 

 

MEMBER – II                                                               PRESIDENT