Date of filing : 11.10.2013
Date of Order: 03.06.2022
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, VELLORE AT VELLORE DISTRICT.
PRESENT: THIRU. A. MEENAKSHI SUNDARAM, B.A., B.L PRESIDENT
THIRU. R. ASGHAR KHAN, B.Sc. B.L. MEMBER – I
SELVI. I. MARIAN RAJAM ANUGRAHA, M.B.A. MEMBER - II
FRIDAY THE 3rd DAY OF JUNE 2022
CONSUMER COMPLAINT NO.58 / 2013
D. Dayalan, (Died)
S/o. Late Deivasigamani,
Old No. 3/42, New No. 3/90,
Main Road, K. Sevoor, Kapadi,
Vellore 632 106.
2. D. Kousalya,
W/o. Late D. Dayalan,
No. 3/90, Main Street,
Sevoor Village, Katpadi,
Vellore District.
3. K. Sankari,
W/o. Kothandaraman,
D/o. Late D. Dayalan,
Kavari Street, Chetpet,
Kanchipuram.
4. D. Ramachandiran,
S/o. Late Dayalan,
No.3/90, Main Street,
Sevoor Village, Katpadi,
Vellore District.
5. V. Radha,
D/o. Late Dayalan,
W/o. Mr. S. Velavan,
Residing at 208, Periya Koil Street,
Kamakur Village & Post,
Arni, T.V. Malai District.
6. D. Siranjeevi,
S/o. Late Dayalan,
No. 3/90, Main Street, Sevoor Village,
Katpadi, Vellore District. …Complainants
(Amended as per order in CMP 37/19 dated 14/11/19)
-Vs-
1. MD India Healthcare Services (TPA) Pvt. Ltd.,
Represented by its Manager,
Office at S. No.46/1, E-Space,
A-Wing, 3rd Floor, Pune Nagar Road,
Vadgaonsheri, Pune 411 014.
2. MD India Healthcare Services (TPA) Pvt. Ltd.,
Represented by its Branch Manager,
Office at Old Door No. 702, New Door No.260/16,
3rd Floor, Mount Casa Blanca Building,
Anna Salai, Chennai 600 006
3. United India Insurance Co., Ltd.,
Represented by its Senior Divisional Manager,
Office at Divisional Office-XI, E85,
Himalaya House, 8th Floor, K.G. Marg,
New Delhi 110 001.
4. Steel Authority of India Limited,
Represented by its Junior Manager,
(Pers-MPP), Office at Burnpur Steel Plant,
P.O. Asansol, Burnpur 713325,
West Bengal.
5. The professor Head Department of Haematology,
The Christian Medical College & Hospital,
Ida Scudder Road, Vellore. …Opposite parties
Counsel for complainants : Tmt. V.J. Nirmala,
Opposite parties- 1, 2 & 4 : Set exparte
Counsel for opposite party -3 : Thiru. L. Pandurangan
Counsel for opposite party – 5 : Thiru. M.R. Ramanan
(Formal party)
ORDER
THIRU. A. MEENAKSHI SUNDARAM, PRESIDENT
This complaint has been filed under section 12 of Consumer Protection Act, 1986. Directing the opposite parties are jointly and severally to pay a sum of Rs.63,395/- towards the medical bills with interest and also to pay a sum of Rs.50,000/- (Rupees fifty thousand only) towards mental agony, pain, physical strain and loss suffered by the complainant and also to pay Rs.1,500/- towards cost of this proceedings.
1. The case of complaint is briefly as follows:
The complainant’s father was a retired employee of the SAIL (Steel Authority of India Limited). Herein after may be called as SAIL. The SAIL introduce a group Insurance Scheme for their retired employees and their family welfare. The third opposite party is the insurer to provide health care insurance services on cashless basis for hospitalization and settlement of claim on behalf of the SAIL. As per the certificate issued by the department of Haematology, Christian Medical College, Vellore. The complainant’s father has been diagnosed to have Chronic Myeloid Leukaemia (in chronic phase). The identification card was issued to the complainant’s father that he is one of the member in SAIL Group Mediclaim Scheme. The complainant’s father made a request for pre-authorization was given on 29.08.2012 for his treatment. He was admitted at Christian Medical College, Vellore on 09.09.2012 where he was treated for Chronic Myeloid Leukemia in chronic phase and discharged on 21.09.2012 for which he was charged Rs.63,395/- (Rupees Sixty three thousand three hundred and ninety five only). This information was communicated to the second opposite party. Though the complainant request for pre- authorization on 29.08.2012 the second opposite party did not paid the bill amount issued by the CMC hospital. The complainant’s father himself had settled the bill amount of Rs.63,395/-. Thus there was negligence on the part of the first, second and third opposite parties. Hence this complaint
2. The Written version of third Opposite Party is as follows:
The alleged Chronic Myeloid Leukaemia (in Chronic phase) illness is not covered under the policy issued by this Opposite Party. As per the policy conditions that the complainant has to inform this opposite party within 24 hours after admission in hospital is mandatory, but the complainant failed to do so. The complainant failed and neglected to comply the requisite documents called for by this opposite party as per conditions, inspite of letters dated 30/10/2012 and 19/11/2012 which are mandatory as per policy conditions. Hence, this opposite party closed the claim made by the complainant. There is no deficiency in service on the part of the opposite party as alleged by the complainant.
3. The Written version of fifth Opposite Party is as follows:
It is true that the complainant was diagnosed to have chronic myeloid leukaemia (in chronic phase) and was treated in CMC Hospital Vellore-4. The complainant was admitted as in-patient on 19/09/2012 and after treatment discharged on 21/09/2012 as mentioned in the Discharge Summary issued to the Complainant. There was no privity of contract between CMC Hospital and the opposite parties-1 to 4 and any arrangement for payment or reimbursement of the medical Bill could have been between the complainant and the Opposite parties 1 to 4.
4. The first, second and fourth opposite parties are called absent and set exparte. During the pendency of the case, the complainant died. His legal heirs were impleaded as a complainant in complaint. D. Kousalya who is wife of the deceased complainant filed proof affidavit and marked Exhibits A-1 to A-21 were marked. Proof affidavit of third and fifth opposite parties filed. No documents were filed. Written argument on behalf of the complainant and opposite parties not filed and oral arguments of both sides heard.
5. THE POINTS THAT ARISES FOR CONSIDERATION ARE:
- Whether there is any deficiency in service on the part of the opposite
Parties – 1 to 5 ?
2. Whether the complainant is entitled for relief as claimed in the complaint?
3. To what relief, the complainant is entitled to?
6. POINT NOS. 1 & 2: The complainant’s father was employer of the Steel Authority of India Limited. The SAIL introduce a group Insurance Scheme for their retired employees and their family welfare. The insurance policy was marked as Ex.A2. Ex.A3 is identity card issued by the third opposite party. The complainant’s father diagnosed for Chronic Myeloid Leukaemia (in chronic phase) by the CMC Hospital, Vellore. The said certificate was marked as Ex.A4. The complainant’s father requested for pre-authorization vide Ex.A7. He has been discharged from the hospital on 21.09.2012. The discharge summary was marked as Ex.A8. Since, the third opposite party did not pay the bill of the CMC Hospital, Vellore. The complainant’s father himself paid the entire bill amount vide Ex.A9. The claim of the complainant’s father was acknowledge by the first opposite party. The copy of the acknowledgment was marked as Ex-A-10. The first opposite party requested for additional document vide Ex.A11. Since, the opposite parties – 1 to 3 did not pay the medical bill of the complainant’s father, he has issued the legal notice against the opposite parties - 1 to 3 calling upon to pay a sum of Rs.63,395/- towards the medical bills paid to CMC Hospital, Vellore and to pay a sum of Rs.50,000/- towards mental agony and to pay Rs.1,500/- as cost. The said legal notice dated 06.05.2013 was marked as Ex.A12. There was no reply from the opposite parties -1 to 3. However the Steel Authority of India requested the first and second opposite parties expedite the claim of the complainant’s father and settled the bill of the CMC Hospital, Vellore at the earliest. On perusal of the Ex.A2 mediclaim policy issued by the third opposite party it has been specifically made for retired employees of the Steel Authority of India. The said policy was clause 10 B (b) which says that cashless Hospitalization. In view of the aforesaid clause the complainant ‘s father availed the group mediclaim Scheme of the third opposite party under the impression that once he will admitted in the hospital, the third opposite party will directly pay the bill from the hospital. However, in the present case though the complainant intimated to the opposite parties regarding his admission in the hospital. The opposite parties 1 to 3 some or other reason dragging the complainant without settled the bill of the complainant. Further the third opposite party did not settled the claim of the complainant despite order of the Steel Authority of India. Hence, the acts of the third opposite party’s amounts to clearly deficiency in service.
In the recent case
The Hon’ble Supreme Court of India
In Civil Appeal No. 4071 of 2022, Gurmel Singh
(Vs)
Branch Manager, National Insurance Co. Ltd.
Held that,
…“ In many cases, it is found that the insurance companies are refusing the claim on flimsy grounds and/or technical grounds. While settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control”….
Hence, these point Nos. 1 and 2 are decided in favour of the complainant.
7. Point No.3: As we have decided that the point Nos.1 and 2 that there is a deficiency in service on the part of the third opposite party. The third opposite party is hereby directed to pay a sum of Rs.63,395/- (Rupees Sixty Three Thousand Three Hundred and Ninety Five Only) with interest at the rate of 9% p.a. from 24.09.2012 to till the date of this order and also to pay a sum of Rs.50,000/- (Rupees Fifty Thousand Only) as compensation for deficiency in service and mental agony. This point No.3 is also answered accordingly.
8. In the result this complaint is allowed. The third opposite party is hereby directed to pay a sum of Rs.63,395/- (Rupees Sixty Three Thousand Three Hundred and Ninety Five only) with interest at the rate of 9% p.a. from 24.09.2012 to till the date of this order and also to pay a sum of Rs.50,000/- (Rupees Fifty Thousand only) as compensation for deficiency in service and mental agony and also to pay a sum of Rs.5,000/- (Rupees Five Thousand only) towards cost of this proceedings, within one month from the date of this order, failing which the above compensation amount shall carry interest at the rate of 9% per annum from the date of order to till the date of realization. As against first, second, fourth and fifth opposite parties this complaint is dismissed.
Dictated to the steno-typist transcribed and typed by her corrected and pronounced by us in the open Commission on this the 3rd June, 2022.
Sd/- Sd/- Sd/-
MEMBER –I MEMBER – II PRESIDENT
LIST OF COMPLIANANT SIDE DOCUMENTS:
Ex.A1 - Copy of identification slip of complainant (retired case)
of complainant
Ex.A2 - Copy of booklet for Group Mediclaim Scheme 2012
for retired employees of SAIL by opposite party No.3
Ex.A3 - Copy of identification slip issued by SAIL Group
Mediclaim Scheme and United India Insurance Co.
Ltd to complainant
Ex.A4 – 01.04.2009 - Copy of letter by Dr. Alok Srivastava, professor and
head, Dept. of Haeatology to SAIL, Jharkand
Ex.A5 – 15.10.2011 - Copy of order superannuation of complainant issued
by ISP – SAIL
Ex.A6 – 01.09.2012 - Copy of Authorsation status for the query raised dated
29.08.2012 by the opposite party No.2
Ex.A7 - Copy of provider code – request for pre-authorisation
by CMC, Vellore to opposite party No.2
Ex.A8 – 21.09.2012 - Copy of discharge summary issued by CMC
Ex.A9 – 21.09.2012 - Copy of Bill No. BO22998063 and Receipt
No.52335R157359 by CMC
Ex.A10 – 24.09.2012 - Copy of acknowledgement given by opposite party
No.2
Ex.A11 – 04.04.2013 - Copy of claim details by the opposite party No.2
Ex.A12 – 06.05.2013 - Copy of Legal notice issued to opposite parties with
enclosures
Ex.A13 - Acknowledgement card from the opposite party No.1
Ex.A14 - Acknowledgement card from opposite party No.2
Ex.A15 - Returned cover from opposite party No.3
Ex.A16 – 27.05.2013 - Copy of reply from opposite party No.4
Ex.A17 – 20.06.2013 - Copy of reply from opposite party No.4
Ex.A18 – 15.07.2013 - Copy of letter by opposite party No.4 with copy to
complainant and opposite party No.3
Ex.A19 – 21.03.2015 - Copy of reply received from the 4th opposite party to
1 to 3 opposite parties with copy to complainant’s
counsel to pay the compensation (3 Nos. series)
Ex.A20 – 28.04.2016 - Copy of the Legal Heir ship Certificate issued by
Tahsildar, Katpadi
Ex.A21 – 10.02.2016 - Copy of the Death Certificate issued by the Vellore
City Municipal Corporation Vellore
LIST OF OPPOSITE PARTIES SIDES DOCUMENTS: -NIL-
Sd/- Sd/- Sd/-
MEMBER –I MEMBER – II PRESIDENT
