Tamil Nadu

South Chennai

CC/276/2017

R.Radhakrishnan - Complainant(s)

Versus

The Manager, National Insurance Company., - Opp.Party(s)

R.Vasudevan

13 Oct 2022

ORDER

Date of Complaint Filed : 19.07.2017

Date of Reservation      : 19.09.2022

Date of Order               : 13.10.2022

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

CHENNAI (SOUTH), CHENNAI-3.

 

PRESENT: TMT. B. JIJAA, M.L.,                                           : PRESIDENT

                     THIRU. T.R. SIVAKUMHAR, B.A., B.L.,          :  MEMBER  I 

                   THIRU. S. NANDAGOPALAN., B.Sc., MBA.,     : MEMBER II

 

CONSUMER COMPLAINT No. 276/2017

THURSDAY, THE 13^th DAY OF OCTOBER 2022

R.Radhakrishnan,

Room No.3, 2nd Floor,

No.20, Beach House,

2^ndLine Beach,

Chennai-600 001.                                                                …Complainant

-Vs-

1.The Manager,

   National Insurance Company,

   No.66, Greams Road,

   Thousand lights,

   Chennai-600 006.

 

2.The Manager,

   TPA Vidal Health TPA Pvt. Ltd.,

   2^nd Floor, L2, Anmol Palani,

   No.88, G.N.Chetty Road,

   T.Nagar,

   Chennai-600 017.

 

3.V.Sridharan,

   Business Sources (046621),

   National Insurance Company,

   No.66, Greams Road,

   Thousand lights,

   Chennai-600 006.                                                  ...  Opposite Parties

 

******

Counsel for the Complainant                 : M/s. R. Vasudevan

Counsel for the 1^stOpposite Party            : M/s. Nageswaran & Narichania

Counsel for the 2^nd& 3^rdOpposite Party     : Exparte 

        On perusal of records and having heard the Oral arguments of the Counsel for the Complainant and Counsel for the 1^st Opposite Party, we delivered the following:

ORDER

Pronounced by Member-I, Thiru.,T.R. Sivakumhar., B.A., B.L.,

1.      The Complainant has filed this complaint as against the Opposite Party under section 12 of the Consumer Protection Act, 1986 and prays to direct the Opposite Parties to reimburse the claim amount of Rs.15,499.50/- and  to pay a sum of Rs.5,00,000/- towards the cost of mental agony for committing unfair trade practice and deficiency of service and to pay a sum of Rs.25,000/- towards litigation cost.

2.     The averments of Complaint in brief are as follows:-

The Complainant had availed Mediclaim policy for himself and his family members consist of his wife and two children, and insured for Rs.5,00,000/- each for himself and his wife and for Rs.3,00,000/- each for his two children, with the 1^st and 2^nd Opposite Party through 3^rd Opposite Policy. He was paying the premium amount every year without any default and renewed from time to time, the policy is in force for more than 15 years.It was informed to him by the 3^rd Opposite Party on behalf of the 1^st Opposite Party that under the said policy cashless facilities are available in the approved hospitals and even if cashless facility is not available, the 1^st Opposite Party would reimburse the claim after discharge from Hospital. If the policy is continuously in existence for more than 4 years, pre-existing diseases are excluded and he is holding the Policy for more than 4 years. Policy bearing No.500100561510000545 was issued in his name including his family members, by the 1^st Opposite Party and the TPA ID No.CHE-NC-0000HO-11571-Bissued by 2^nd Opposite Party on behalf of the 1^st Opposite Party wherein his wife was covered under the said policy. Due to Gynecological problem his wife was admitted on 22.08.2016 for a surgery, Cut removal under SGA in Lakshmi Maternity Hospital at Adyar, when he approached the Opposite Parties for cashless facility it was informed that the said Hospital was not in approved list and advised to submit reimbursement claim after discharge. His wife was discharged 23.08.2016 and thereafter on 01.09.2016 he had sent the Claim form along with the discharge summary, medical bills in originals and a cancelled cheque, to the 2^nd Opposite Party through 3^rd Opposite Party by hand within statutory period of 15 days from the date of discharge vide reimbursement claim No. CHE- 0701401 for an amount of Rs.15,499.50p. He has not received any proper feed back on refund of claim from the Opposite Parties, as the claim should be disbursed with 15 days as per IRDA norms. The 2^nd Opposite Party joined with other Opposite parties and kept the claim under cold storage with utter violation of policy regulations which caused irreparable loss, mental agony, harassment and deficiency in service. He was made to run from pillar to post, in spite had not received any communication till date. Only later he come to know about the lethargic attitude of the 3^rd Opposite Party to whom many of his business and family circle contacts been offered, he had bothered to update the pending claim status nor responded to his call. As he has not received any communication from the Opposite Parties, on 14.03.2017 he had sent a legal notice to disburse the claim amount with immediate effect and also to replace the 3^rd Opposite Party with any competent agent, in spite of receipt of the said notice there was no response from the Opposite Parties, which amounts to Unfair trade practice on the part of the Opposite Parties. Hence the Complaint.

3.    Written Version filed by the 1^stOpposite Party in brief are as follows:-

The Complaint is not maintainable as the same was not filed by the aggrieved party under the policy issued by the 1^st Opposite Party. No where in the complaint it was averred that the Complainant had suffered loss and also he is authorized to file the complaint. The policy issued was admitted and the same was valid from 25.09.2015 to 24.09.2016 which was governed by various terms and conditions. The surgery underwent by the Complainant’s wife, namely, Cut removal under SGA (Small gestational age). Intrauterine growth restriction (IUGR) is nothing but when a baby in the womb fails to grow at the expected rate during the pregnancy. In other words, at any point of time in the pregnancy, the baby is not as big as would be expected for how far long the mother is in her pregnancy. Further IUGR is a fetal weight that is below 10^th Percentile for gestational age as determined through an ultrasound. The treatment was done for a complaint for SGA due to misplace CuT, and the said treatment was excluded under clause 4.6 of the terms and conditions of the Policy, which deal with fertility/infertility/sub-fertility, assisted conception procedure, therefore the claim was not payable. Hence the reimbursement of hospitalization charges under the policy was not maintainable. They had not committed any breach of policy and there was no deficiency in service on their part. The policy issued is for one year, which has to be renewed every year, hence there cannot be any continuous coverage as mentioned for 15 years by the Complainant, further it was not a family insurance policy. The 3^rd Opposite Party as an agent did the job assigned to him. They strictly follows the guidelines of IRDA and fulfill various norms regarding settlement of claims. The compliance made as per procedures towards lodgment of a claim with the 2^nd Opposite Party has to be proved by the Complainant. The Claim is not payable as per clause 4.6 of the terms and conditions of the policy and hence the same was not considered. The contention that withholding the claim was cheating and unfair trade practice was not correct and the complainant was called upon to prove as how he was cheated. The Complainant was not personally aggrieved by the act of the 1^st Opposite Party, hence the Complaint filed by him was not maintainable and liable to be dismissed. There was no contract for payment of interest, hence the claim for interest was not maintainable and there was no deficiency in service, unfair trade practice on their part to compensate. The Complainant had not substantiated the reasons for mental agony and that too for a compensation of Rs.5,00,000/- as claimed in the complaint. Hence prayed to dismiss the Complaint with costs.

4. The Complainant submitted his Proof Affidavit and Written Arguments. On the side of the Complainant, documents Ex.A-1 to Ex.A-5 were marked. The 1^st Opposite Party submitted his Proof Affidavit and Written Arguments. On the side of the 1^stOpposite Party no documents was marked.

5.    The 2^nd and 3^rd Opposite Parties did not appear before this Commission even sufficient notice served and remained absent and set exparte.

Points for Consideration:-

 

1. Whether the Complaint filed by the Complainant is maintainable?
2. Whether there is deficiency in service on the Part of the Opposite Parties?
3. Whether the Complainant is entitled for reliefs claimed in the complaint and/or for any other relief/s?

Point Nos.1 and 2:-

It is an undisputed fact that the Complainant had availed Mediclaim policy bearing No.500100561510000545 with the 1^st Opposite Party through the 3^rd Opposite Party, was valid from 25.09.2015 to 24.09.2016 with an insured amount of Rs.5,00,000/- each for the Complainant and his wife and for Rs.3,00,000/- each for his two children and the TPA ID No.CHE-NC-0000HO-11571-B  issued by 2^nd Opposite Party on behalf of the 1^st Opposite Party wherein the Complainant’s wife was covered under the said policy.

The disputed fact is that when the Complainant had approached the Opposite Parties for cashless facility on 22.08.2016 where his wife was admitted to undergo a surgery, CuT removal under SGA (small gestational age) in Lakshmi Maternity Hospital, Adyar and the same was denied as the said Hospital was not in their approved list and had advised to submit reimbursement claim form after discharge from the said Hospital. Accordingly the Complainant had sent the Claim Form on 01.09.2016 along with the original bills, discharge summary, medical report, scan report together with a cancelled cheque to the 2^nd Opposite Party through the 3^rd Opposite Party by hand within statutory period of 15 days from the date of discharge vide reimbursement claim No.CHE-0701401 for an amount of Rs.15,499.50p, whereas the Complainant had not received any feed back about the claim submitted by him, in spite of receipt of the Legal notice dated 14.03.2017 by the Opposite Parties and thereafter till the date of filing of the Complaint.

The Contention of the 1^st Opposite Party in this regard is that the Complainant cannot maintain the complaint, as he was not an aggrieved party and he has not averred whether he has been authorized to file the complaint. Further contended that surgery underwent by the Complainant’s wife was excluded under Clause No.4.6 of the terms and conditions of the Policy and therefore the Complainant is not entitled for reimbursement as claimed in the Complaint. Hence there was no deficiency in service, unfair trade practice on the part of the 1^st Opposite Party.

On foregoing discussions and in the facts and circumstances of the case, as per Ex.A-1 the subject Mediclaim policy was taken and insured by the Complainant, for himself, his wife and two children and hence the complaint filed for reimbursement claim made for the surgery underwent by his wife, by the Complainant is maintainable. Accordingly Point No.1 is answered. 

Further, the very filing of the complaint is for, that the Opposite Parties had failed to communicate about the status of the reimbursement claim submitted by the Complainant, when that is so, it is clear that the Opposite Parties had not informed about the said status till the date of filing of the Complaint, is proved, though the 1^st Opposite Party had contended that the Complainant is not entitled for reimbursement under Exclusions Clause No.4.6 of the terms and conditions of the policy, had failed to produce any documentary evidence to show that they had communicated the same to the Complainant, in spite of having acknowledged the receipt of the claim form as found in Ex.A-4. The Opposite Parties having failed to communicate about the status of the reimbursement claim, without following the guidelines of IRDA in fulfilling the norms regarding settlement of claims, has to necessarily reimburse the claim submitted by the Complainant without going into the technicalities. Hence, we hold that the act of the Opposite Parties by not communicating on the reimbursement claim submitted by the Complainant amounts to gross negligence on the part of the Opposite Parties. Therefore, we are of the considered view that the Opposite Parties had committed deficiency of service. Accordingly Point No.2 is answered.

The Judgement of Hon’ble Supreme Court passed on 14.08.2019 in Civil Appeal No.6255 of 2019 in Kanwaljit Singh Vs- National Insurance Company Ltd and Order of the Hon’ble National Consumer Disputes Redressal Tribunal reported in I (2019) CPJ 396 (NC), relied upon by the Complainant, would not apply to the case in hand.

Point No.3:-

 As discussed and decided Point Nos.1 and 2 against the Opposite Parties 1 to 3, the Opposite Parties 1 to 3 are jointly and severally liable to reimburse the claim of Rs.15,499.50/- and also to pay a sum of Rs.50,000/- towards deficiency in service and mental agony caused to the Complainant, along with cost of Rs.3,000/-. And the Complainant is not entitled for any other relief/s. Accordingly Point No.3 is answered.

 

In the result the Complaint is allowed in part. The opposite parties 1 to 3 are jointly and severally directed to reimburse the claim of Rs.15,499.50/- (Rupees Fifteen Thousand Four Hundred  Ninety Nine and fifty paise Only) covered vide claim No.CHE0701401 and to pay a sum of Rs.50,000/- (Rupees Fifty Thousand Only) towards deficiency in service and mental agony caused to the Complainant and to pay a sum of Rs.3,000/- (Rupees Three Thousand Only) towards costs, to the Complainant, within 8 weeks from the date of receipt of this order, failing which the above amounts shall carry interest at the rate of 9% p.a from the date of receipt of this order till the date of realisation.

In the result the Complaint is allowed.

Dictated to Steno-Typist, transcribed and typed by her, corrected and pronounced by us in the Open Commission, on 13^th of October 2022. 

 

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                 B.JIJAA

         MEMBER II                       MEMBER I                        PRESIDENT

 

 

List of documents filed on the side of the Complainant:-

 

Ex.A1	25.09.2015 to 24.09.2016	Mediclaim Policy No.500100561510000545
Ex.A2	22.08.2016 to 23.08.2016	Discharge summary and other medical bills with scan report (Xerox)
Ex.A3	2.09.2016	Claim form part-A & Part-B signed by Doctor
Ex.A4	06.09.2016	Reimbursement form along with all original bills and documents submitted vide claim acknowledgement No.CHE0701401
Ex.A5	14.03.2017	Legal notice with acknowledgements

 

List of documents filed on the side of the Opposite Parties:-

 

NIL

 

 

 

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                   B.JIJAA

         MEMBER II                       MEMBER I                         PRESIDENT