Tamil Nadu

North Chennai

CC/200/2016

R.Sivaramalingam,S/o.N.Ramasamy - Complainant(s)

Versus

The Divisional Manager United India Insurance company Ltd - Opp.Party(s)

Party in Persion

28 Nov 2017

ORDER

                                                            Complaint presented on:  22.12.2016

                                                                Order pronounced on:  28.11.2017

 

  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.,         PRESIDEN

                    THIRU. M.UYIRROLI KANNAN B.B.A., B.L.,      MEMBER - I

TUESDAY THE 28^th  DAY OF NOVEMBER 2017

C.C.NO.200/2016

 

 

1.R.Sivaramalingam,

S/o N.Ramasamy,

16/141 “N” Block 4^th Street,

Agathiyar Nagar, Villivakkam,

Chennai – 49.

 

2.K.Gandhimathi,

W/o R.Sivaramalingam,

No. 16/141’N’ Block 4^th Street,

Agathiyar Nagar, Villivakkam,

Chennai – 600 049.

 

                                                                                    ….. Complainants

 

..Vs..

1.The Divisional Manager,

United India Insurance Company Ltd.,

No.64 Armenian Street,

Chennai – 600 001.

 

2.K.Murugan,

Vidal Health TPA Pvt  Ltd.,

Ammol Palani L2 88,

G.N. Chetty Road, T.Nagar,

Chennai – 600 017.

.....Opposite Parties

Date of complaint                                 : 30.12.2016

Counsel for Complainants                    : Party in Person

Counsel for 1^st  Opposite Party                : M/s.Nageswaran & Narichania

Counsel for 2^nd  Opposite Party                     : Ex – parte (03.03.2017)

O R D E R

 

Thiru. M.Uyirroli Kannan B.B.A., B.L., Member – I

          This complaint is filed by the complainant claiming medical expenses as claim amount and compensation for mental agony with cost of the complaint u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          The 1^st  and 2^nd complainants were senior couples they got a Medical Insurance Policy through  Indian Bank. Plan name is   “AROGYA RAKSHA – PLAN –B” and they  paid   a premium of Rs.10,840/- including the tax on 03.07.2014.   The period of policy was from 03.07.2014 to 30.06.2015 and the sum insured was Rs.7,00,000/-. The policy covers both the complainants.

          2. On 27.07.2014 at about 3.00 p.m. The 2^nd complainant   fell down  on National High Way while crossing it,  due to panic.  Her  shoulder got injured and developed pain. On return to Chennai on 04.08.2014 she took x-ray on Sridevi Hospital and undergone physiotherapy to get relief from pain. She got admitted as in-patient and  got discharged on 05.11.2014 with a expenditure of Rs.16,972/-. 

          3. The complainants made a claim for the above amount with  relevant documents by letter dated 11.11.2014.  Complying all the query raised by the 2^nd opposite party. But the 1^st opposite party repudiated the claim as the disease was pre-existing  one through the letter dated 10.04.2015. The complainant issued a notice to the opposite parties and thereafter the complainant filed this complaint claiming expenses as claim amount  and compensation for mental agony with cost of the complaint.

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

          The complaint itself is not maintainable as the 2^nd complainant is not signed and verified the complaint. The policy was taken by the second  complainant for herself and for her spouse. The opposite party admits that the complainant does not   have any grievance against the opposite parties.

          5. This opposite party admits that the Group Health Insurance Scheme “AROGYA RAKSHA – PLAN –B” is issued by them with no.2014/48410000105/13 for a period from 03.072014 to 30.06.2015 and the policy is subject to the terms and conditions as a part of the policy issued by the 1^st opposite party. The 1^st opposite party accept that the claim was registered as claim No.CHE 1114-CL-0004233 and the same was evaluated and repudiated by the 1^st opposite party on 10.04.2015, because, on scrutiny the 1^st opposite party  found that the complainant shoulder injury is for few months above,  which is prior to the commencement of the policy of insurance issued by the 1^st opposite party. So the claim is repudiated as per policy condition 4:1.

          6. The 1^st opposite party also submits that there is no deficiency in service on  their part as alleged by the complaint. So the claim for compensation for deficiency in service is not maintainable. Hence this opposite party prays to dismiss the complaint with cost.

 

7. 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?

8. POINT NO :1 

          It is admitted fact that the complainant was  having a Saving Bank account and through that the complainant and her spouse took one   Insurance Policy in the name of “AROGYA RAKSHA – PLAN –B” for the period of 03.07.2015 to 30.06.2015 and  the sum insured was Rs.7,00,000/- and that  certificate is marked as Ex.A1. The terms and conditions were marked as Ex.B1.

          09.  While crossing the road the complainant fell down and developed pain in her shoulder and for that she took treatment in a hospital and made a claim for Rs.16,972/- on 11.11.2014 and the claim was repudiated by the 1^st opposite party by their letter dated 10.04.2014. To repudiate a claim the Insurance Company took complete 5 months of time. There after the complaint is filed in this  Hon’ble Forum. This long period  took by the opposite parties itself shows the deficiency in service.

          10. The 2^nd opposite party who scrutinize the papers for claim made several query and all the queries were complied by the complainant. The reason why this claim has been rejected by the 2^nd opposite party was not able to indentify because of his non-appearance.     The 2^nd opposite party called absent and he was set ex-parte on 03.03.2016.

          11. The 1^st opposite raised  an  objection  that the complaint  is not signed by the 2^nd complainant.  No doubt the 2^nd complainant who is an aggrieved person has not signed in the complaint and also no authorization filed in favour of the 1^st complainant. The 2^nd complainant is the wife of the 1^st complainant.  The 1^st complainant stated in the complaint that he is filing this complaint on behalf of the 2^nd complainant and also on his own behalf. In view of such explanation in the complaint, the 2^nd complainant has not signed in the complaint cannot be a reason to reject the complaint.  Further the pleading in the complaint itself taken as authorization for the 1^st complainant to file this complaint, who is none other than her husband and therefore the objection raised in this regard by the 1^st opposite party is rejected.         

          12.  The Ex.A2 is the repudiation of the claim made by the 1^st opposite party on 10.04.2015. The rejection order in Ex.A2 is as follows:

     On Scrutiny of the claim documents, we observed that the claim is for ‘Post Traumatic Stiffness in Left Shoulder with Grade I Partial Rotator Cuff Injury’. We further noticed that the policy commenced from 03.07.2014 and date of admission is 03.11.2014. But the patient had a shoulder injury  5 months ago. Hence this comes under Pre-Existing disease exclusion. So the claim is medically repudiated under the clause 4.1 as per the policy condition.

In the rejection order  of  the 1^st opposite party stated that  she had shoulder injury 5 five months ago and hence there is Post Traumatic Stiffness in Left Shoulder with Grade I Partial Rotator Cuff Injury. In the repudiation letter the 1^st opposite party admitted that shoulder injury occurred 5 months ago. Therefore the incident alleged by the complainant took place is accepted. Since the shoulder injury occurred due to fall while crossing the road occurred, the claim repudiated on the ground of pre-existing disease as per clause 4:1 of the policy condition cannot be accepted. In view of such conclusion the opposite parties have committed deficiency in service in rejecting the claim made by the complainants.

13. POINT NO:2

           The complainant filed Ex.A12 to Ex.A16 bills  that the complainant  bear a sum of Rs.16,972/- towards medical expenses for the 2^nd complainant and for such amount, the complainants are entitled  for the same. Hence this Forum decides that the complainant is entitled for the medical expenses of Rs.16,972/-. The rejection of the claim after 5 months made the complainant to suffer with mental agony is accepted and for the same it would be appropriate to order a sum of Rs.10,000/- besides a sum of Rs.5,000/- towards litigation expenses.

        In the result the Complaint is partly allowed. The Opposite Parties 1 & 2 jointly or severally are ordered to pay a sum of Rs.16,972/- (Rupees sixteen thousand nine hundred and seventy two only) and also to a  sum of Rs.10,000/- (Rupees ten thousand only) towards compensation for pain and sufferings with mental agony, besides a sum of Rs. 5,000/- (Rupees five thousand only)  towards litigation expenses.

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 28^th  day of November 2017.

 

MEMBER – I                                                                PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANTS:

Ex.A1 dated 17.07.2014                   Certificate for Indian Bank Arogya Raksha

                                                     Plan –B

 

Ex.A2 dated 10.04.2015                   Insurance Company’s (1^st opposite party)

                                                Rejection letter towards claim of Rs.16,972/-

 

E.A3 dated07.05.2015            Legal notice issued to Insurance company (I

                                                    opposite party)

 

Ex.A4 dated 03.06.2015                   Insurance company’s (1^st opposite party) advice to

                                                    TPA (II opposite party)

 

Ex.A5 dated 02.08.2016                   Final legal notice to II opposite party

 

Ex.A6 dated 26.07.2000                   Orders of the hon’ble the District Consumer

                                                    Disputes Redressal Forum Chennai (South) in the

                                                    case of N.S.Kumar Vs United India Insurance

                                                    Company appeared in Indian Express dated

                                                    26.07.2000

 

 

Ex.A7 dated 07.05.2015                   Letter of authorization given to first complainant

 

Ex.A8 dated 11.11.2014                   Claim form – Part A furnished to the Hospital

 

Ex.A9 dated 11.11.2014                   Electronic Clearing Service (Credit clearing)

                                                    Mandate form

 

Ex.A10 dated Received on      Claim form – part B filled in by Hospital

11.11.2014

 

Ex.A11 dated 05.11.2014                 Discharge summary issued by Sridevi Hospital

 

Ex.A12 Bill No.4307               Cash receipt for the settlement of bill for

Dated 05.11.2014                         Rs.15,500

 

Ex.A13  Cash bill                     For Rs.513.50

Co1018847 dt: 03.11.2014

 

Ex.A14 Cash bill                     Cash receipt for Rs.139

Co.1018901 dt: 03.11.2014

 

Ex.A15 Cash Bill                    Cash receipt for Rs.132

Co 1019018 dt:05.11.2014

 

Ex.A16 Cash Bill                    Cash receipt for Rs.688

Co.1019089 dt:05.11.2014

 

Ex.A17 dated 04.11.2014                 1.5 T-MRI scan of cervical spine Aarthi Scans.

 

Ex.A18 dated 04.08.2014                 Advice to Radiology Lab

 

Ex.A19 dated 04.08.2014                 Radiology Report

 

Ex.A20 dated 18.08.2014                 Physiotherapy & pain Relief Clinic Advice

 

Ex.A21 Cheque leaf                 Indian Bank Cancelled Cheque leaf

No.863165 dt: NIL

 

Ex.A22 dated 03.10.2014                 Asi Clinic Ramnad Prescription dt:03.10.2014

                                                    with Medical Bill

 

Ex.A23 dated 09.12.2014                 Clarification letter issued by Medical Officer Sri

                                                    Devi Hospital                      

 

Ex.A24 dated 23.12.2014                 Further Clarification letter issued by Medical

                                                    Officer Sri Devi Hospital

 

Ex.A25 dated 17.12.2014                 E-mail issued to the second complainant by the

                                                   TPA

 

Ex.A26 dated 24.12.2014                 Letter addressed to TPA

 

Ex.A27 dated 07.02.2015                 E-mail dt:07.02.2015 addressed to the 2^nd

                                                    complainant

 

Ex.A28 dated 12.02.2015                 Letter addressed to TPA

 

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

Ex.B1 dated NIL                     Special Conditions attached to and forming part of

                                                    Indian Bank Co-Branded Health Insurance  Policy

                                                   ”Arogya Raksha” (Group Health Insurance

                                                    Scheme) 

                                     

 

MEMBER – I                                                                PRESIDENT