Tamil Nadu

North Chennai

CC/107/2015

M/s.K.Nirmal Chand Sethiya - Complainant(s)

Versus

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

M/s.Ramesh Kumar Chopra, M.Vijaykumar

22 Mar 2018

ORDER

 

                                                             Complaint presented on:  17.06.2015

                                                                Order pronounced on:  22.03.2018

 

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

              THIRU. M.UYIRROLI KANNAN B.B.A., B.L.,      MEMBER - I

 

THURSDAY THE 22^nd  DAY OF MARCH 2018

 

C.C.NO. 107/2015

 

 

 

K. Nirmal Chand Sethiya, 60 years

Son of late Kanakmal Sethiya,

C/o. National House of Glasses,

810, Mount Road

(Vummidiars Shopping Centre)

Chennai- 600 002      

                                                                                          ….. Complainant

 

    ..Vs..

 

The Manager, The United India Insurance Co Ltd., Branch Office (010202) II Floor, Ganga Griha, No.6, Nungambakkam High Road, Chennai – 600 034.     T                                                                                                                             .....Opposite Party

Date of complaint                                 : 13.07.2015

Counsel for Complainant                      : M/s. Ramesh Kumar Chopra,

                                                                M.Vijayakumar      

Counsel for Opposite Party                      : Mr.C.S.Vasan

 

O R D E R

 

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

          This complaint is filed by the complainant to direct the opposite party to pay a sum of Rs.44,158/- towards the rejected claim amount and also to pay a sum of Rs.2,00,000/- towards compensation for mental agony with costs of the complaint. u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          The complainant availed health insurance policy for the period 11.06.2014 to 10.06.2015. The sum insured is Rs.5,00,000/-. The complainant was admitted on 03.11.2014 in the Guest Hospital at No.372, Poonamalle High Road, Kilpauk, Chennai-10 for treatment of cystoscopy/ laser vaporization of prostrate and Dr.R.Jayachandran, urologist performed surgery on 04.11.2014 and he was discharged on 07.11.2014. The complainant paid a total sum of Rs.1,87,475/- which includes a sum of Rs.1,79,600/- towards hospital bill and the balance amount paid towards medicines.

          2. The complainant made a claim for a sum of Rs.1,87,475/- from the opposite party within the limits of the policy. However the opposite party has settled only a sum of Rs.1,43,313/- and disallowed the part claim amount of Rs.44,158/- without any reason or justification. The opposite party had not stated on what basis they have arrived that amount. They further invoked clause 3.33 of the policy to restrict the claim. Aggrieved due to restricting the claim, the complainant lodged a complaint with Grievance Cell, but there was no response. The opposite party negligently rejected the part claim and there by committed deficiency in service. Hence the complainant filed this complaint to direct the opposite party to pay a sum of Rs.44,158/- towards the rejected claim amount and also to pay a sum of Rs.2,00,000/- towards compensation for mental agony with costs of the complaint.     

3. WRITTEN VERSION OF THE  OPPOSITE PARTY IN BRIEF

          The opposite party admits that the complainant underwent treatment in the Guest Hospital has incurred bill for Rs.1,87,475/- and they have settled for a sum of Rs.1,43,313/- and has disallowed the balance amount. The dispute is only with regard to quantum of the disallowed amount. The complainant being a party to the contract of the insurance policy, he ought to have referred his grievance about quantum to the arbitration.

4. The opposite party has not repudiated the entire claim. The third party administrator (TPA) processed the claim and they found the bill of the complainant exorbitant and advised the opposite party to pay only Rs.1,43,313/-. The opposite party on their own cannot process the claim of the insured. It has to abide by the policies of IRDA. The complaint is not maintainable for non-joinder of necessary parties. The relief sought in the complaint is unjust and has no merits. Hence the opposite party has not committed any negligence and deficiency in service in deciding the claim of the complainant and prays to dismiss the complaint with costs.

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 admitted facts are that the complainant availed Ex.A1, health insurance policy for the period 11.06.2014 to 10.06.2015 from the opposite party and the sum insured is Rs.5,00,000/-and the complainant was admitted on 03.11.2014 in the Guest Hospital at No.372, Poonamalle High Road, Kilpauk Chennai-10 for treatment of cystoscopy/ laser vaporization of prostrate and Dr. R.Jayachandran, urologist performed surgery on 04.11.2014 and he was discharged on 07.11.2014  and Dr. Jayachandran issued Ex.A3 certificate dated 11.12.2014 and the complainant paid a total sum of Rs.1,87,475/- which includes a sum of Rs.1,79,600/- towards hospital bill and the balance amount paid towards medicines.

          7. The opposite party has not disputed that the complainant incurred a sum of Rs.1,87,475/- towards his medical treatment. The opposite party would contend that the grievance of the complainant is only about the quantum of disallowed amount and as per insurance policy, the complainant ought to have referred such grievance about quantum to the arbitration and further the TPA only processed the claim and arrived the amount and further the complaint is not maintainable for non-joinder of necessary party and therefore the opposite party has not committed any deficiency in service.

          8. The opposite party has not specifically pleaded in his written version who is the necessary party has not been added in the complaint.  The complainant paid premium only to the opposite party/insurance company and they only received the premium and issued receipt to the complainant for accepting the premium. The TPA is only a third party to the contract of insurance between the complainant and opposite party. The TPA is only assisting the insurance company by collecting papers from the Consumer and forward to the insurer. TPA cannot take any decision with regard to award of the claim. Therefore, the TPA is not a necessary party in this complaint. The opposite party who received the premium has to decide independently the consumer claims. The opposite party paid the part claim amount to the complainant as per the advice of the TPA is not legally tenable. Hence, the contention raised by the opposite party that the complaint is not maintainable for non-joinder of necessary party and TPA only processed the claim is rejected.

          9. Though the insurance contract contains clause to refer the matter to the arbitration, section 3 of the Consumer Protection Act 1986 provides the consumers to seek remedy in the Consumer Fora by way of additional remedy. When such a provision enables the consumers to approach this Forum, the complainant did not refer the matter to the arbitration is not sustainable and this objection of the opposite party is also rejected.

          10. The terms and conditions of the policy enclosed in Ex.A1 policy. The clause 3.33 provides reasonable and customary charges for restriction of claim. The opposite party has not stated any reason in the written version how they have deducted or disallowed a sum of Rs.44,158/- in the claim amount. Absolutely, there is no evidence on the part of the opposite party for disallowing the part of the claim amount made by the complainant. Having the opposite party admitted that the complainant incurred the claim amount for his treatment, he should have paid the full claim amount to the complainant and on failure to pay the full claim he has committed deficiency. Further having paid the part claim amount and rejected the balance claim of the complainant proves that the opposite party is liable to pay the claim amount as per the policy issued by them. Therefore, we hold that the opposite party has committed deficiency in service in disallowing a sum of Rs.44,158/- to the complainant.

11. POINT NO:2

          We held above that the opposite party committed deficiency in service in not allowing the full claim amount. Therefore, the complainant is entitled a sum of Rs.44,158/- from the opposite party towards the disallowed portion of the claim amount. Further, due to rejection of the part claim the complainant suffered with mental agony is accepted and for the same it would be appropriate to direct the opposite party to pay a sum of Rs.25,000/- towards compensation, besides 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.44,158/- (Rupees forty four thousand one  hundred and fifty eight only) towards the  disallowed claim amount to the Complainant and also to pay  a sum of Rs. 25,000/- (Rupees twenty five 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 disallowed claim amount and compensation 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 22^nd  day of March 2018.

 

MEMBER – I                                                                PRESIDENT

 

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 11.06.2014                   Insurance Policy

                 to10.06.2015

 

Ex.A2 dated 07.11.2014                   Inpatient bill by Guest Hospital

Ex.A3 dated 11.12.2014                   Certified issued by Dr.Jayachandran of Guest

                                                    Hospital

 

Ex.A4 dated 26.02.2015                   Complaint to Insurance ombudsman

Ex.A5 dated 03.02.2015                   Complaint to United India Insurance Co Ltd.,

                                                    Grievance Cell

 

Ex.A6 dated 07.11.2014                   Discharge Summary

Ex.A7 dated 10.11.2014                   Claim Form

Ex.A8 dated NIL                     Receipt issued by Guest Hospital

Ex.A9 dated NIL                     Award by Ombudsman

LIST OF DOCUMENTS FILED BY THE OPPOSITE PARTY :

 

                                      ……… NIL …….

 

 

 

MEMBER – I                                                               PRESIDENT