Tamil Nadu

South Chennai

CC/2/2015

M/s.M.Palani S/o.Muthu - Complainant(s)

Versus

The Manager, The United India Insurance Co Ltd., - Opp.Party(s)

M/s.P.S.Prasanth

16 Nov 2018

ORDER

                                                                        Date of Filing  : 17.112014

                                                                          Date of Order : 16.11.2018

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (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

 

C.C. No.02/2015

DATED THIS FRIDAY THE 16^TH DAY OF NOVEMBER 2018

                                 

M. Palani,

S/o. Mr. Muthu,

No.21, Old No.153,

Vellala Street,

Ambattur,

Chennai – 600 058.                                                        .. Complainant.                                                 

 

      ..Versus..

 

The Manager,

M/s. United India Insurance Co. Ltd.,

No.39, Greams Road,

Silingi Buildings,

Chennai – 600 006.                                                    ..  Opposite party.

          

Counsel for complainant     :  Mr. P.S. Prasanth

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 praying to pay a sum of Rs.42,616/- being expended towards medical treatment with interest at the rate of 24% p.a. and to pay a sum of Rs.52,848/- towards compensation for mental agony with cost to the complainant.

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

The complainant submits that he has availed a Mediclaim Policy viz No.010702/48/12/06/00001018 from the opposite party on 26.11.2012 which is valid from 26.11.2012 to 25.11.2013.   When the Policy was in force, the complainant met with a minor accident involving his feet.  Immediately, he was admitted in Dr. Ravindran’s Health Care Centre Pvt. Ltd., Ambattur wherein the complainant undergone treatment from 24.07.2013 to 26.07.2013 and continued treatment at the New Hope Hospital at Arumbakkam and he was cured completely.   The complainant submits that as per the above said policy the opposite parties is bound to bear the expenses of the above said medical treatment of the complainant.  The complainant made claim to the opposite party for the amount spent by him for the above said treatment of Rs.42,616/-.   But the opposite party did not come forward to bear the said costs of the medical treatment.   Hence, the complainant issued legal notice dated:07.07.2014 to the opposite party but did not come forward to settle the demands of the complainant.    Thereafter, this complaint is filed.

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

The opposite party specifically denies each and every allegation made in the complaint and puts the complainant to strict proof of the same.   The opposite party states that the complainant has obtained a Medicare Policy from 26.11.2012 to 25.11.2013.  The opposite party states that the complainant made a claim for hospitalization at Dr. Rabindran’s Health Care Centre from 24.07.2013 to 26.07.2013 and submitted Hospital Bills for Rs.17,316/-.   Hence, the complaint in respect of treatment in New Hope Hospital subsequently is not maintainable as it was neither reported to the opposite party nor any claim was submitted for the same.   The opposite party states that the said Medicare policy was issued to the complainant in good faith on the basis of information provided in the proposal form.  The complainant was duty bound to disclose all the facts since the coverage of policy was subject to terms and conditions and exclusions specified in the policy.   As per the terms of the policy, the complainant is bound to inform about hospitalization immediately to the Third Party Administrator and submit claim within 15 days of discharge as per Condition No.5.3 and 5.4 of the policy.   In the Discharge Summary, it is  mentioned that the complainant was suffering from diabetes Mellitus for a few years, which was not disclosed in the Proposal Form and the Policy had been obtained by suppression of material facts.  The opposite party states that the complainant has not given due intimation immediately after hospitalization.   There is no deficiency in service on the part of the opposite party.  Hence the complaint is liable to be dismissed.

3.    To prove the averments in the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A9 are marked.  Proof affidavit of the opposite party is filed and documents Ex.B1 to Ex.B7 are marked on the side of the opposite party. 

4.      The points for consideration before the Forum is:-

1. Whether the complainant is entitled to a sum of Rs.42,616/- spent towards medical treatment with interest as prayed for?

 2. Whether the complainant is entitled to a sum of Rs.52,848/- towards compensation for mental agony with cost as prayed for?

5.      On point:-

Both parties filed their respective written arguments.  Heard the complainant’s Counsel also.  Perused the records namely the complaint, written version, proof affidavits and documents.   The complainant pleaded and contended that he has availed a Mediclaim Policy from the opposite party on 26.11.2012 as per Ex.A1, Mediclaim Policy.   When the Policy was in force, the complainant met with a minor accident involving his feet.  Immediately, he was admitted in Dr. Ravindran’s Health Care Centre Pvt. Ltd., Ambattur wherein the complainant undergone treatment from 24.07.2013 to 26.07.2013 and continued treatment at the New Hope Hospital at Arumbakkam.  Ex.A2 is the Discharge Summary by Dr. Ravindran’s Health Care Centre Pvt. Ltd., Ambattur.   Ex.A3 is the Discharge Summary by New Hope Hospital at Arumbakkam.  The complainant has expended a sum of Rs.42,616/- for the treatment.  The opposite party is duty bound to reimburse the amount.   The complainant duly submitted Ex.B3, claim form.  Ex.A8 Series are the medical bills for a sum of Rs.24,300/- expended towards treatment in the New Hope Hospital at Arumbakkam. Ex.B5 is the medical bill for a sum of Rs.17,316/- expended towards treatment in  Dr. Ravindran’s Health Care Centre Pvt. Ltd., Ambattur.   The opposite party repudiated the claim on the ground of pre-existing disease. But as per Ex.A9, Dr. B. Cheran issued reply notice stating that “The statement of known case of DM for past few years on regular treatment” is such a fact written by the Doctor as told to him by the patient.   

6.    As per the cited decisions reported in

II (2006) CPJ 357

RAJASTHAN STATE CONSUMER DISPUTES REDRESSAL

COMMISSION, JAIPUR

SHANTI DEVI

..Vs..

LIFE INSURANCE CORPORATION OF INDIA & ANR.

 

Held that

From the above, diabetes cannot be classified with a particular name of disease.  It is a general term for diseases characterized by excessive urination. Mellitus is a chronic disorder of carbohydrate metabolism, characterized by hyperglycemia and glycosuria and resulting from inadequate production or utilization of insulin”.

I (2017) CPJ 498 (NC)

RAVINDER SINGH BINDRA

..Vs..

NATIONAL INSURANCE COMPANY LIMITED & ORS.

 

Held that

Based on the above, learned Counsel claimed that no concealment is proved from the record as proposal form is not available on the record.  Also suppression of any pre-existing disease does not arise because the expenses in question relate to heart disease which was definitely and admittedly not pre-existing as no proof has been placed on record by the Insurance Company.  Even if hypertension is considered to be a pre-existing disease, its concealment is not proved on record due to non-availability of the proposal form.”  … 

..” The main question is that even if there were ailments, counsel for the petitioner cannot produce the proposal form, filled up by the deceased … There is no evidence on the record that the complainant Sh.Rajider Kumar Goel had made the false statement or suppressed any fact before the authorities of insurance company.

“ The proposal form is not traceable its benefit will also go to the LRs of the deceased.  There is certainly suppression of fact/document not by the complainant but by the respondent Insurance Company”

 

Without proper proof by the opposite party raising such contention can be treated as deficiency in service.   The complainant is claiming a sum of Rs.42,616/- towards medical expenses.  But on a careful perusal of records, the complainant has expended a total sum of Rs.41,616/-.  The opposite party without looking into the antecedents and necessarily repudiated the claim proves the deficiency in service.

7.     The contention of the opposite party is that admittedly the complainant obtained a Medicare Policy from 26.11.2012 to 25.11.2013.  Ex.B1 is the proposal form.   Ex.B2 is the copy of the policy with term and conditions.  Further the contention of the opposite party is that the said Medicare policy was issued to the complainant in good faith on the basis of information provided in the proposal form.  The complainant was duty bound to disclose all the facts since the coverage of policy was subject to terms and conditions and exclusions specified in the policy.  As per Ex.B2 policy, the coverage is only for hospitalization expenses incurred as an inpatient when the hospital was medically necessary.   In this case, while administering the complainant sustained a previous wound on his leg for which, neither hospitalization nor inpatient treatment required.  But the opposite party has not produced any Medical Literature to prove the same.  On the other hand, as per Ex.A2 & Ex.A3 Discharge Summaries will speak its own volume for the necessity and treatment as inpatient.   Further the contention of the opposite party is that the policy did not cover pre-existing as per exclusion clause No.4.1.  The complainant had previous ailment for Diabetic Mellitus is not entitled to reimburse any amount since such fact has been totally suppressed.  But as per Ex.A9, the reply notice, it is very clear that the complainant had no such pre-existing disease of diabetics.  Equally, the law is well settled that it cannot be a ground for repudiation of the claim. 

8.     Further the contention of the opposite party is that the complainant has not given due intimation immediately after hospitalization.  Hence the 3^rd party administrator as per condition No.5.3 & 5.4 not entertained the claim.   But the opposite parties has not denied the actual expenditure 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.42,616/- being medical expenses incurred along with interest at the rate of 9% p.a. from the date of complaint (i.e.) 17.11.2014 to till the date of this order and to pay a sum of Rs.10,000/- towards compensation for mental agony with cost of Rs.5,000/-.

  In the result, this complaint is allowed in part.   The opposite party is  directed to pay a sum of Rs.42,616/- (Rupees Forty two thousand six hundred and sixteen only) being medical expenses incurred along with interest at the rate of 9% p.a. from the date of complaint (i.e.) 17.11.2014 to till the date of this order and to pay a sum of Rs.10,000/- (Rupees Ten thousand only) towards compensation for mental agony with cost of Rs.5,000/- (Rupees Five thousand only) to the complainant.

The aboveamounts shall be payablewithin 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 Steno-typist, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 16^th day of November 2018. 

 

MEMBER –I                                                                      PRESIDENT

COMPLAINANT SIDE DOCUMENTS:

		Copy of Medical Policy
		Copy of Discharge Summary by Dr. Rabindran’s Health Care Centre
		Copy of Discharge Summary by New Hope
		Copy of letter issued by the opposite party
		Copy of Certificate issued by Dr.A.A. Arunachalam
		Copy of legal notice of the complainant to the opposite party
		Copy of proof of acknowledgement / India Post
		Copy of medical bills of New Hope Indian speciality Hospitals
		Copy of reply legal notice of the opposite party’s Counsel to thecomplainant

 

OPPOSITE  PARTY SIDE DOCUMENTS:-

Ex.B1		Copy of Proposal Form
Ex.B2	26.11.2012	Copy of Family Medicare Insurance Policy with terms and conditions
Ex.B3		Copy of Claim form
Ex.B4		Copy of Consent letter from the complainant to the Hospital
Ex.B5		Copy of the bill issued by Dr. Rabindran Health Care Centre Pvt. Ltd. for Rs.17,316/-
Ex.B6	13.08.2013	Copy of letter of the Third Party Administrator to the complainant
Ex.B7	03.10.2013	Copy of letter of the Third Party Administrator to the complainant

 

 

 

MEMBER –I                                                                      PRESIDENT