Tamil Nadu

South Chennai

CC/406/2014

M/s.Jyothi Suresh - Complainant(s)

Versus

The Manager, The New India Assurance Co Ltd - Opp.Party(s)

Yurendra Kumar

30 Jun 2022

ORDER

Date of Complaint Filed: 07.10.2019

Date of Reservation     : 10.06.2022

Date of Order              : 30.06.2022

 

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. 406/2014

THURSDAY, THE 30^th DAY OF JUNE 2022

Jyothi Suresh,

Flat #: 2/A, Mangalam Apartments,

#:12, Brewary Road Shenoy Nagar,

Chennai – 600 030.                                                                                                                                          ... Complainant             

 

..Vs..

The Manager,

The New India Assurance Co Ltd.,

Mezzanine floor,

EastCoast Chambers,

#:92 G.N. Chetty Road,

T.Nagar, Chennai -17.                                                                                                                                        ...  Opposite Party

 

******

Counsel for the Complainant          : M/s. V. Yurendra Kumar

Counsel for the Opposite Party       : M/s. S. Radha Devi

 

        On perusal of records and after having heard the oral arguments of the Counsel for Complainant and the Counsel for the Opposite Party, we delivered the following:

ORDER

Pronounced by the President Tmt. B. Jijaa, M.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 pay a sum of Rs.96,722/- with interest in terms of mediclaim Policy No.713101/34/13/25/00000895, to pay Rs.25,000/- for the deficiency of service in having repudiated the Policy, to pay Rs.25,000/- for unfair trade practice committed by the Opposite Party and to pay Rs.10,000/- for the resultaint mental agony and pain caused to the Complainant along with cost of Rs.25,000/-.

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

        The Complainant given a grandiose picture of availing medical insurance and  its attendant benefits, by personnel of the Opposite Party. The Complainant, greatly believing such assurances given, decided to avail a Medi Claim Policy for her father R.V.Vaideeswaran and mother Alamelu. The Complainant's parents underwent various medical and other tests under the supervision and instruction of the Opposite Party. The Opposite Party only after completion of the tests and satisfying themselves, issued a Medi Claim Policy. The Medi Claim Policy was in force since January 2000 and was being renewed for the last 14 years to till date without any break and the insured enjoyed no claim bonus. The Opposite Party on 06.01.2014 on renewal gave Medi Claim Policy  #:713101/34/13/25/00000895. The sum insured was Rs.1,25,000/- each for the parents of the Complainant who had paid a premium of Rs.18,021/- for this policy. The policy was for a period from 06.01.2014 to 05.01.2015. On 23.05.2014, the Complainant's mother had an accidental fall in her house, and was taken to Guest Hospital for treatment. The doctors after examination and tests diagnosed Comminuted Distal Radius Fracture Left Side, advised surgery. The Complainants' mother on 24.05.2014, underwent surgery of Orif with locking plate and screws left distal radius by Dr.Sunder Ganesh. The Complainants' mother was discharged on 26.05.2014. As per policy the Complainant gave a claim for Rs 96,722/ enclosing all necessary documents and reports in time. The Complainant was asked to provide further particulars by the Opposite Party letter dated 18.06.2014 which was given. The Complainant was greatly shocked to receive the Opposite Party's letter dated 04.07.2014 making a partial payment of Rs.39,154/- as against the total claim of Rs.96,722/- quoting on account of "superficial injury of the wrist and hand". The Complainant was further agonised by the Opposite Party's reason given as "claimant opted higher room rent than the entitled category”. It is needless to point out that the Opposite Party had made the Complainant and his wife undergo various tests before issuance of the policy and now allegedly opted for higher room rent. The Opposite Party's failure to quote “claimant opted for higher room rent than the entitled category” cannot be a ground for rejecting a rightful claim made. Hence Opposite Party's contention rejecting the legitimate claim under such pretext is unfounded. This goes to show that the Opposite Party confirms that the policy is subsisting and is in force, however maintains the benefit under the policy is not payable. There is no purpose of having insurance cover without payment of benefits from the policy, for what is the purpose of having insurance cover to the insured policyholder. The Opposite Party only to repudiate the genuine claim had chosen to bring such pretext. The undue reasons given for repudiating the justifiable claim made by the Opposite Party amounts to deficiency of service. The Opposite Party had failed to give valid and proper reason for such repudiation. The Complainant is entitled to be compensated for the resultant mental agony and pain as well. Hence the complaint.

3.Written Version Filed by the Opposite Parties in brief is as follows :-

        The Opposite Party respectfully submits that the Complainant has not come to this Hon'ble forum with clean hands and is guilty of suppression of material facts and this Complaint is devoid of merits. The Complainant ought to prove that the Medi Claim Policy was regularly renewed without any break, Claims or default. The Complainant had taken Medi Claim valid from 06.01.2014 to 05.01.2015.The Opposite Party states that in said Medi Claim Policy it was clearly mentioned that Complainant is bound by the terms and conditions of Medi Claim Policy 2012. The Medi Claim Policy along with terms and Conditions of Policy were handed over to the Complainant at the time of taking the Policy and the same had also been filed by the Complainant before this Forum. The Opposite Party can settle the claim only as per the terms and conditions of Medi Claim and after verification of documents submitted by the Complainant. On scrutiny of the Discharge Summary and Bills, Medi Assist India, Third Party Administrator for settlement of claims of the Opposite Party found that the Complainant's mother opted for higher room rent than the entitled category. The Complainant is bound by the terms and Conditions of the Medi Claim Policy 2012. As per clause 3.1 , 3.1(a) , 3.1(b) of the said Policy it is crystal clear that the Complainant's mother is entitled to claim only as per the sum insured towards room rent, investigation & Lab charges, Surgery charges, Consulted charges and Pharmacy & Medicine charges. The  amount claimed by the Complainant is Rs.96,722/. The Medi assist India TPA Pvt Ltd, Claim settlement adviser of the Opposite Party after relating entire bills with Policy Clause assessed the amount payable and amount not payable and the reason for non payable. The total amount payable as per Policy clause is Rs.39,154/-. The Opposite Party settled a sum of Rs.39,154 through NEFT on 04.07.2014. The Date of accidental fall is 23.05.14 and the amount is settled by the Opposite Party on 04.07.14 within two months from the date of accident. The Opposite Party denies that claimant opted for higher room rent cannot be a ground for rejecting a rightful claim. The Opposite Party states that they had not rejected the claim of the Complainant but they had settled the claim as per the Policy clause. The Claim amount made under all the heads are not payable by the Opposite Party as there was no deficiency of service whatsoever on the Part of the Opposite Party and the claim amount was already settled. It is therefore prayed to dismiss the Complaint with cost.

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 Opposite Party submitted his Proof Affidavit and Written Arguments. On the side of Opposite Party  documents Ex.B-1 alone was marked.     

5.     Points for Consideration

1. Whether there is deficiency in service on the part of the Opposite Party?

2. Whether the Complainant is entitled for reliefs claimed?

3. To what other reliefs the Complainant is entitled to?

Point No.1:

The Complainant had availed Medi Claim Policy for her father R.V.Vaideeswaran and mother Alamelu since January 2000, which was renewed every year without break.  As per Ex.A-1 , on 06.01.2014 the Opposite Party  had issued Medi Claim Policy #:713101/34/13/25/00000895 and the sum insured was Rs.1,25,000/- each for her parents  who had paid a premium of Rs.18,021/- for a period from 06.01.2014 to 05.01.2015. On 23.05.2014, the Complainant's mother had an accidental fall in her house and was taken to Guest Hospital, where the doctors diagnosed Comminuted Distal Radius Fracture Left Side and advised surgery. The Complainants' mother on 24.05.2014, underwent surgery of Orif with locking plate and screws left distal radius and was discharged on 26.05.2014. The Complainant made a claim for Rs.96,722/- with the Opposite Party enclosing all necessary documents. However to the shock of the Complainant she received letter dated 04.07.2014 from the Opposite Party for a partial payment of Rs.39,154/- as against the total claim of Rs.96,722/- and the reason given as "claimant opted higher room rent than the entitled category". The Opposite Party had admitted that the Complainant had taken Medi Claim Policy valid from 06.01.2014 to 05.01.2015. The Opposite Party contended that the  Complainant is bound by the terms and conditions of Medi Claim Policy 2012. And they can settle the Medi Claims only as per terms and conditions of Medi Claim Policy. On scrutiny of the Discharge Summary and Bills, Medi Assist India, Third Party administrator for settlement of claims of the Opposite Party found that the Complainant's mother opted for higher room rent than the entitled category. As per clause 3.1 , 3.1(a) , 3.1(b) of the above said Policy  the Complainant's mother is entitled to claim only as per the sum insured towards room rent, investigation  and Lab charges, Surgery charges, Consulted charges and Pharmacy and Medicine charges.  The Medi assist India TPA Pvt Ltd, Claim settlement adviser of the Opposite Party assessed the amount payable as per Policy clause at Rs.39,154/- as against the claim of Rs.96,722/. The Opposite Party settled a sum of Rs.39,154 through NEFT on 04.07.2014. The Opposite Party contended that they had not rejected the claim of the Complainant but they had settled the claim as per the Policy clause.

“The learned Counsel for the Complainant placed reliance on the Order of the National Consumer Disputes Redressal Commission Circuit Bench at Bangalore, in R.P.No.53 of 2006, wherein it was observed that for making false statements in affidavits in a pending proceedings punitive damages are to be imposed has no relevance to the case at hand”.

 Further the Complainant relied on the Order of the National Consumer Disputes Redressal Commission, New Delhi in R.P.No.3258 of 2013, where it was held that “We are of considered view that OP was not justified in making payment of Rs.52,505/- only. Such act of OP appears to be an intentional and technical one, to harass the bonafide customer.  Also, there is no evidence on record to show that condition No.3.1 and the exclusion clause was explained to the Complainant-insured, at the time of submission of the proposal form by him. The customer avails the Mediclaim insurance policy, with the hope that medical treatment expenses will be reimbursed by the Insurer. Therefore, insurer (OP) also has duty to act in good faith, which obliges him to enter into the contract, without concealing the material fact like exclusion clause. We feel that the act of OP is unjust and unfair towards the Complainant, who took the said policy, since 2003 and was renewing it from time to time, since then” and accordingly OP was directed to comply with the impugned order, which is applicable to the Complainant as, in the present case, the Complainant had taken insurance policy since 2000 only on the hope that medical treatment expenses will be reimbursed by the Opposite Party. Further it is not shown that Clause 3.1 , 3.1(a) , 3.1(b) of the above said Policy was explained to the Complainant and she is entitled to claim only as per the sum insured towards room rent.

In the Order dated 04.10.2017 passed by the State Consumer Disputes Redressal Commission, Punjab, Chandigarh in F.A.No.99/2017, Health Services to be provided by the TPA as per the IRDAI ( Third Party Administrators-Health Services) Regulations, 2016 was discussed and observed that TPA can only process the claim and forward the same to the Insurance company and the competent authority of the Insurance Company is to decide the same. Accepting and rejecting the claims at their own by the TPAs is illegal, arbitrary, null and void and is not sustainable in the eyes of law.

It is seen that the claim of the Complainant was partially rejected by Third party Administrator, who have no role to issue such letter as found in Ex.A-5. Hence considering the facts and circumstances of the case, this Commission is of the considered view that the Opposite Party has committed deficiency of service. Point 1 is answered accordingly.

Point No.2 and 3:

As discussed and decided in Point No.1, that the Opposite Party has committed deficiency in service the Opposite Party is liable  to pay a sum of Rs.57,568/- towards reimbursement of balance medical expenses incurred, to pay a sum of Rs.25,000/- towards deficiency in service and resultant mental agony along with cost of Rs.5,000/- to the Complainant. 

In the result the complaint is allowed in part. The Opposite Party is directed to pay a sum of Rs.57,568/- (Rupees Fifty Seven Thousand Five Hundred and Sixty Eight Only) towards reimbursement of balance medical expenses incurred, to pay a sum of Rs.25,000/- (Rupees Twenty Five Thousand Only) towards deficiency in service and resultant mental agony and also cost of Rs.5,000/- (Rupees Five Thousand Only) to the Complainant.

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

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 30^th of June 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	06.01.2014	Policy issued by Opposite Party
Ex.A2		receipt for payment of premium
Ex.A3		Discharge summary
Ex.A4	18.06.2014	Opposite Party’s letter
Ex.A5	04.07.2014	Repudiation letter

 

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

 

Ex.B1

The New India Assurance Company Limited – Medi Claim Policy (2007)

 

 

 

 

 

S. NANDAGOPALAN                                                T.R. SIVAKUMHAR                                                            B.JIJAA

        MEMBER II                                                                MEMBER I                                                               PRESIDENT