Tamil Nadu

South Chennai

810/2009

V.Rajasekaran - Complainant(s)

Versus

The Manager Royalm Sundaram Alliance Insurance Company Ltd., - Opp.Party(s)

N.Subramani

20 Feb 2018

ORDER

                                                                                                                           Date of Filing  : 06.08.2009

                                                                          Date of Order : 20.02.2018

DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, CHENNA (SOUTH)

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

PRESENT: THIRU. M. MONY, B.Sc., L.L.B, M.L,                    : PRESIDENT

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

        DR. T.PAUL RAJASEKARAN, M.A ,D.Min.PGDHRDI, AIII,BCS : MEMBER II     

           CC. NO.810 /2009

TUESDAY THE 20^TH DAY OF FEBRUARY 2018

                                              

Mr.v. Rajasekaran,

No.6, 2^nd Floor,

Strahans Road,

Pattalam, Chennai 600 012.                                                .. Complainant

 

                                      ..Vs..

 

The Manager,

Royal Sundaram Alliance

Insurance Company Ltd.,

Corporate Claims Department,

“Sundaram Towers,

NO.45  & 46 Whites Road,

Chennai 600 014.                                     ..  Opposite party.

 

 

Counsel for complainant         :  M/s. N.Subramani & another   

Counsel for opposite party     :  M/s. M.B.Gopalan & others    

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite party under section  12 of the Consumer Protection Act 1986 seeking direction to pay the Health Insurance Policy amount and also to pay a sum of Rs.1,00,000/- towards compensation for deficiency in service and Rs.5,000/- towards cost of the complaint. 

1. The averments of the complaint in brief are as follows:

          The complainant submit that he availed Health Insurance Policy bearing No.HLSTCB 0017 with certificate number HE00013162000104 for himself and his family members from the opposite party on payment of Rs.8620/- towards premium.  The complainant further state that the period of insurance is from 11.8.2008 to 10.8.2009.   On 17.2.2009  the complainant was suffered from severe fever and was admitted in the Apollo Hospital, Chennai as patient for five days due to joint pain, body ache, swelling of both ankles, vomiting etc.  due to Chickun Quniya and was discharged on 18.2.2009.  The complainant applied for medi claim on 1.4.2009 for the above said medical expenses incurred during 17.2.2009 and subsequent dates.   The opposite party without any reason rejected the claim.   Therefore the complainant sent a notice through his counsel on 3.6.2009 to the opposite party.  But till date the opposite party has not paid the claim amount.    As such the act of the opposite party amounts to deficiency in service which caused mental agony and hardship to the complainant.  

2. The brief averments in the written version filed by the  opposite party is as follows:

The  opposite party deny each and every allegations except those that are specifically admitted herein.  The opposite party state that the complainant availed Health Shield Premium Insurance Policy for the period from 11.8.2008 to 10.8.2009.   The  opposite party state that the policy was intended for covering hospitalization expenses necessarily incurred for the purpose of treatment of any disease or injury.  The Hospitalization must be necessary which is the crucial basis and intention of the policy.  It is pertinent to mention that the policy does not cover outpatient treatment.  To avoid the same, if a day’s hospitalization is undergone on that basis claim for tests cannot be fastened upon the insurer.  On verification of the discharge summary and medical records he was found have suffered from Viral fever arising out of common symptoms of joint pain and body ache.   The claim in fact was reported initially to M/s. Medicare TPA services Ltd., who declined Cashless facility as there was no serious ailment requiring hospitalization was found.   After due consideration of the facts and circumstances the opposite party had rejected the claim for valid and justifiable reason.  Hence there is no deficiency in service on the part of the opposite  parties and the complaint is liable to be dismissed.

3.   In order to prove the averments of the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A7 marked.  Proof affidavit of the opposite party filed and Ex.B1 to Ex.B4  marked on the side of the  opposite party.

4.      The points for consideration is :

1. Whether the complainant is entitled to a sum of Rs.39,255/- towards medical expenses as prayed for ?

2. Whether the complainant is entitled to a sum of Rs.1,00,000/- towards mental agony with cost of Rs.5000/- as prayed for ?

5. POINTS:  1 & 2:

          Both parties filed their respective written arguments.   Heard the opposite party also.  Perused the records (viz) complaint, written version, proof affidavits and documents.  Admittedly the complainant availed Health Insurance Policy bearing No.HLSTCB 0017 with certificate number HE00013162000104 for himself and his family members from the opposite party on payment of Rs.8620/- towards premium as per Ex.A1 & Ex.A2.  the complainant pleaded and contended that during the 2^nd week of February 2009 while the policy was subsisting the complainant was suffered from severe fever and was admitted in the Apollo Hospital, Chennai as in patient for five days due to joint pain, body ache, swelling of both ankles, vomiting etc.  due to Chickun Quniya and was discharged on 18.2.2009.  Ex.A2 is the discharge summary.    Ex.A4 is the lab report.  The complainant applied for medi claim on 1.4.2009 for the above said medical expenses incurred during the hospitalization period from 17.2.2009 and subsequent dates as per Ex.A3.   The opposite party without any reason rejected the claim as per A5 & Ex.B4 stating that “ Chickun Quniya is a viral fever only” and not coming under the purview of Hospitalization and treatment.  Hence the complainant issued legal notice Ex.A6 dated 3.6.2009.   As per the terms and conditions of the policy Ex.A2 the complainant  is eligible for claim as he was admitted in hospital and stayed for more than 24 hours for the sole purpose of receiving treatment.   As per the policy even 24 hours hospitalization is not required for cataract, Tonsillectomy, Eye surgery, Lithoripsy and D & C treatments.   Hence the complainant is entitled to claim pre-hospitalization expenses.  The complainant has expensed  a sum of Rs.39,255/-.  The opposite party even after admitting the treatment, and the hospitalization and investigation report deliberately repudiated the claim.   Hence the complainant was constrained to file this case for deficiency in service of the opposite party.

6.   Learned counsel for the opposite party contended that admittedly the complainant availed Health Shield Premium Insurance Policy for the period from 11.8.2008 to 10.8.2009.   The contention of the opposite party is that the policy was intended for covering hospitalization expenses necessarily incurred for the purpose of treatment of any disease or injury.  The Hospitalization must be necessary which is the crucial basis and intention of the policy.  It is pertinent to mention that the policy does not cover outpatient treatment.  To avoid the same, if a day’s hospitalization is undergone on that basis claim for tests cannot be fastened upon the insurer.    In this case the complainant made a claim for Rs.41,155.61 towards hospitalization expenses for a single days hospitalization at Apollo Hospital.   Further the contention of the opposite party is that as per the medical record the only sickness mentioned was Viral Fever and the expenses were all for the purpose of various tests.  No ailment or any significant treatment was found to have been disclosed in the discharge summary.  But it is apparently seen from   the records that the complainant suffered severe fever,  joint pain, body ache, swelling of both ankles, vomiting etc for five days.  Further the contention of the opposite party is that the policy is intended to cover hospitalization that is necessary for the treatment  of an ailment positively  diagnosed.  The hospitalization for ailments of the complainant did not require hospitalization but the hospital in which the complainant undergone treatment  admitted the complainant  as in patient and has given suitable treatment alone the complainant has not enjoyed the pleasant days during the hospitalization period as a special guest having no ailment.   Further the contention of the opposite party is that as per the terms and conditions of the  policy, it clearly covers only “reasonable and customary expenses” alone shall be considered.  The medical expenses claimed by the complainant  for Viral fever or Chickun Quniya is not reasonable or customary. But the opposite party has not produced any document for such a reasonable and customary expenses related to medical treatment proves the deficiency in service.     Considering the facts and circumstances of the case this forum is of the considered view that the opposite party shall  pay a sum of Rs.39,255/- towards medical expenses   and also shall pay compensation of Rs.10,000/- towards mental agony with cost of Rs.5,000/-  to the complainant. 

 

In the result the complaint is allowed in part.   The opposite party shall  pay a sum of Rs.39,255/- (Rupees Thirty Nine thousand two hundred and fifty five only)  towards medical expenses   and also shall pay compensation of Rs.10,000/- (Rupees ten thousand only) for mental agony with cost of Rs.5,000/- (Rupees five thousand only) to the complainant. 

The above  amounts shall be payable within six weeks from the date of receipt of the copy of this order, failing which, the said amounts shall carry interest at the rate of 9% p.a to till the date of payment.

         Dictated  by the President to the Assistant, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 20^th  day of February 2018. 

MEMBER –I                       MEMBER-II                              PRESIDENT.

COMPLAINANT SIDE DOCUMENTS:

Ex.A1- 12.8.2008 - Copy of letter from the Insurance Company.

Ex.A2-           - Copy of Health Shield Insurance.

Ex.A3- 1.4.2009  - Copy of letter from the complainant to opp. party.

Ex.A4-             - Copy of Lab report.

Ex.A5- 15.5.2009 - Copy of letter from the Insurance company.

Ex.A6- 3.6.2009  - Copy of legal notice.

Ex.A7- 12.6.2009 - Copy of Ack.

OPPOSITE  PARTY SIDE DOCUMENTS:  

Ex.B1-           - Copy of insurance policy.

Ex.B2-             - Copy of Claim Form.

Ex.B3- 18.2.2009- Copy of Discharge summary.

Ex.B4- 15.5.2009- Copy of Repudiation letter.

 

MEMBER –I                       MEMBER-II                              PRESIDENT.