Tamil Nadu

North Chennai

CC/186/2016

Koshi Philip,S/o.Mr.Philp - Complainant(s)

Versus

The Manager The National Insurance co.Ltd - Opp.Party(s)

Joshua Chelliah

10 Mar 2017

ORDER

 

 

                                                            Complaint presented on:  08.11.2016

                                                                Order pronounced on:  10.03.2017

 

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.,        PRESIDENT

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

 

FRIDAY THE 10^th DAY OF MARCH 2017

 

C.C.NO.186/2016

 

 

 

Koshi Philip,

S/o.Mr.Philip,

3A, Anugraha Apartment,

Seethanagar 2^nd Cross Street,

Nungambakkam,

Chennai – 600 034.

                                                                                            ..... Complainant

 

..Vs..

	The Manager, The National Insurance Co. Ltd., No.29, Pulla Avenue, Shenoy Nagar, Chennai – 600 030.
	.....Opposite Party

Date of complaint                                  16.12.2016

Counsel for Complainant                      : Mr.Joshua Chelliah

Counsel for opposite party                       : Ex - parte

O R D E R

 

BY PRESIDENT THIRU. K.JAYABALAN B.Sc., B.L.,

          This complaint is filed by the complainant  to pay the claim  amount of Rs.2,35,200/- to him and compensation for mental agony with cost of the Complaint  u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IS IN BRIEF:

          The Complainant had a heart attack on 05.06.2015 and rushed to Dr.Mehta Hospital, Chetpet. His condition became worse than he was rushed to Madras Medical Mission Hospital. The Complainant was taken emergency open Heart Surgery and was revived. Later he was advised to have a pacemaker and this procedure was also done to him. The Complainant incurred a total sum of Rs.3,32,702/- for his treatment including medicines. The Complainant made a claim to the Opposite Party as he had insurance with him for the above said amount. However, the Opposite Party settled only a sum of Rs.94,800/-. No reason was given by the Opposite Party for rejecting the balance claim amount. The Complainant made an e-mail correspondence to the Opposite Party and he gave evasive replies. The Complainant also registered a Complaint with ombudsman for the claim, he had not redressed grievances. Hence the Complainant filed this Complaint against the Opposite Party to pay balance claim of amount of Rs.2,35,200/- to him with compensation for mental agony and hardship caused to him and  with cost of the Complaint.

2. Though the Opposite Party received notice, he did not appear on 19.01.2017 and hence the Opposite Party called absent and set Ex-parte.

          3. The Complainant had filed his proof affidavit and documents Ex.A1 to Ex.A30 were marked on the side of the Complainant.

          4. The Complainant had also come forward with written argument and oral argument of the Complainant was heard.

5. POINTS FOR CONSIDERATION

          1. Whether there is deficiency in service on the part of the opposite party?

          2. Whether the complainant is entitled to any relief? If so to what extent ?

6. POINT NO :1

            The Complainant had a heart attack on 05.06.2015 and he was admitted in the Madras Medical Mission Hospital on the same day and underwent heart surgery and was discharged on 10.06.2015. Ex.A16 is the discharge summary issued by the Madras Medical Mission Hospital for treating the Complainant for his heart disease. Ex.A2, Ex.A3 is out patient bill issued by the Mehta Hospital for initial treatment and Ex.A4 issued by the Madras Medical Mission Hospital.  Ex.A1 is the Insurance Policy issued by the Opposite Party for the period 24.07.2014 to 23.07.2015, the Complainant underwent the treatment at Madras Medical Mission Hospital  was well covered under Ex.A1 policy. Even before this policy from year 2004 to till date the Complainant regularly revived his medical policy with the Opposite Party through Ex.A18 to Ex.A30. Ex.A17 is the Proposal of Medi Claim Policy.

          7. As the Complainant had policy coverage issued by the Opposite Party during the relevant period, the Complainant made a claim of Rs.3,32,702/- which was incurred by him in the Mehta Hospital and Madras Medical Mission Hospital towards his heart treatment. However the Opposite Party made a settlement to the Complainant only for a sum of Rs.94,800/- to the Complainant and the balance amount was not paid to the Complainant, no reason was stated by the Opposite Party for nonpayment of the balance claim of Rs.2,35,200/- to the Complainant. Having, a part claim amount of Complainant was settled to him and failed to pay the balance claim of Rs.2,35,200/-  to the Complainant without any reason proves that the Opposite Party have committed deficiency on his part and therefore we hold that the Opposite Party has committed Deficiency in Service.

 8. POINT NO: 2

          Ex.A2, Ex.A3, Ex.A4, Ex.A7  are  the bills for the payment of outpatient as well as inpatient treatment incurred by the Complainant. Having the Opposite Party failed to pay the balance claim amount, the Complainant is entitled for the same and the Opposite Party can be directed to pay a sum of Rs.2,35,200/- towards the balance claim to the Complainant. Failure to pay the part claim by the Opposite Party the Complainant suffered with mental agony is accepted and for the same. It would be appropriate  to order the Opposite Party  to pay a sum of Rs.50,000/- towards compensation for mental agony and apart from that a sum of Rs.5,000/- towards litigation expenses.

          In the result the Complaint is partly allowed. The Opposite Party is ordered to pay a sum of Rs.2,35,200/- (Rupees two lakhs thirty five  thousand and two hundred only)  towards the balance claim amount to the Complainant and also to pay a sum of  Rs.50,000/- (Rupees fifty thousand only) towards compensation for   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 10^th   day of March 2017.

 

MEMBER – II                                                               PRESIDENT

 

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 11.07.2014                   Insurance policy

Ex.A2 dated 05.06.2015                   Out Door Patient Bill (Metha Hospital)

Ex.A3 dated  05.06.2015                  Out Door Patient Bill (Metha’s Clinical Laboratory

                                                   Hospital)

 

Ex.A4 dated 10.06.2015                   Out Patient Pharmacy (Madras Medical Mission)

 

Ex.A5 dated 05.06.2015                   Discharge Summary (Madras Medical Mission)

 

Ex.A6 dated 06.09.2015                   Medical Discharge (Madras Medical Mission)

 

Ex.A7 dated 13.06.2015                   In-Patient-Cash Bill (MMM)

 

Ex.A8 dated 15.06.2015                   Claim Form

 

Ex.A9 dated 12.08.2015                   E-mail from Complainant to Insurance

 

Ex.A10 dated 08.12.2015                 E-mail from Insurance to  Complainant

 

Ex.A11 dated 09.02.2015                 E-mail from Insurance to  Complainant

 

Ex.A12 dated 30.12.2015                 E-mail from Insurance to  Complainant

 

Ex.A13 dated 30.12.2015                 E-mail from Complainant to Insurance

 

Ex.A14 dated 27.01.2016                 E-mail from Complainant to Insurance

 

Ex.A15 dated 27.01.2016                 E-mail from Complainant to Insurance

 

Ex.A16 dated 10.06.2015                 Discharge Summary from Madras Medical

                                                    Mission

 

Ex.A17 dated 23.07.2004                 Proposal for Medi Claim Policy

 

Ex.A18 dated 23.07.2004                 Medi Claim Policy period from 23.07.2004 to mid

                                                    night of 22.07.2005

 

Ex.A19 dated 24.07.2005                 Medi Claim Policy period from 23.07.2005 to mid

                                                    night of 22.07.2006

 

Ex.A20 dated 21.07.2006                 Medi Claim Policy period from 23.07.2006 to mid

                                                    night of 22.07.2007

 

Ex.A21 dated 24.07.2007                 Medi Claim Policy period from 24.07.2007 to mid

                                                     night of 23.07.2008

 

Ex.A22 dated 24.07.2008                 Medi Claim Policy period from 24.07.2008 to mid

                                                    night of 23.07.2009

 

Ex.A23 dated 24.07.2009                 Medi Claim Policy period from 24.07.2009 to mid

                                                    night of 23.07.2010

 

Ex.A24 dated 24.07.2010                 Medi Claim Policy period from 24.07.2010 to mid

                                                    night of 23.07.2011

 

Ex.A25 dated 24.07.2011                 Medi Claim Policy period from 24.07.2011 to mid

                                                    night of 23.07.2012

 

Ex.A26 dated 24.07.2012                 Medi Claim Policy period from 24.07.2012 to mid

                                                    night of 23.07.2013

 

Ex.A27 dated 24.07.2013                 Medi Claim Policy period from 24.07.2013 to mid

                                                    night of 23.07.2014

 

Ex.A28 dated 24.07.2014                 Medi Claim Policy period from 24.07.2014 to mid

                                                    night of 23.07.2015

 

Ex.A29 dated 13.07.2015                 Medi Claim Policy period from 24.07.2015 to mid

                                                   night of 23.07.2016

 

Ex.A30 dated 05.07.2016                 Medi Claim Policy period from 24.07.2016 to mid

                                                    night of 23.07.2017

 

 

                  

 

MEMBER – II                                                               PRESIDENT