Tamil Nadu

South Chennai

CC/415/2016

P.Rajasekaran - Complainant(s)

Versus

The Managing Director, Health India Care Service (TPA) Pvt Ltd - Opp.Party(s)

M.V.Balakrishnan, S.Venkatesan

28 Nov 2018

ORDER

                                                                        Date of Filing  : 01.12.2016

                                                                          Date of Order : 28.11.2018

 

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.415/2016

DATED THIS WEDNESDAY THE 28^TH DAY OF NOVEMBER 2018

                                 

P. Rajasekaran,

S/o. Late P. Parthasarathy,

No.20, Arumugam Pillai Street,

Magazinpuram,

Vyasarpadi,

Chennai – 600 039.                                                        .. Complainant.                                

 

                                                                                                   ..Versus..

 

1. The Managing Director,

Health India Care Service (TPA) Private Ltd.,

No.27, Lakshmi Tower 3^rd Floor,

Dr. Radhakrishnan Salai,

Mylapore,

Chennai – 600 004.   

 

2. The General Manager,

United India Insurance,

Regional Office,

Silingi Building,

No.134, Greams Road,

Thousand Lights,

Chennai – 600 006.

 

3. The Manager,

Apollo Hospital,

Greams Road,

Chennai – 600 006.                                                ..  Opposite parties.

          

Counsel for complainant                 :  M/s. M.V. Balakrishnan &

                                                            another

Counsel for opposite parties 1 & 2 :  Exparte

Counsel for 3^rd opposite party        :  M/s. P. Ravichandran & another

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite parties under section 12 of the Consumer Protection Act, 1986 praying to pay a sum of Rs.2,82,326/- towards the insurance claim amount with interest at the rate of 12% p.a. and to pay a sum of Rs.50,000/- towards compensation for mental agony to the complainant.

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

The complainant submits that he is employed in the Police Department and have the Insurance Policy right from 2012 vide I.D. card No.PSO/01/BP303/NHIS12/2073298 with two family members in number mentioned in the United India Insurance I.D. Card with the complainant’s name and also his mother P. Saratha’s name with their photos and the same was accepted by the opposite parties 1 & 2 earlier.  The complainant submits that on 27.01.2016, the complainant’s mother Mrs. P. Saratha, aged 75 years sustained hip fracture and was taken to the 3^rd opposite party hospital and  admitted as inpatient in an emergency ward.  After due diagnosis, the 3^rd opposite party informed the complainant that a surgery should be conducted.  On 28.01.2016, the complainant informed the opposite parties 1 & 2 informing the admission and the necessity of surgery and requested for cashless treatment under the policy as per the estimation given by the 3^rd opposite party.   The complainant submits that the opposite parties 1 & 2 demanded unmarried certificate of the employee in order to extend the medical facility to his mother.   The complainant also submitted dependency certificate to the 1^st opposite party on 30.01.2016.   But the opposite parties 1 & 2 has not extended the cashless facility of treatment.  The complainant has expended a huge sum of Rs.2,82,326/- towards medical expenses for his mother.   Therefore, the complainant sent letters dated:30.01.2016, 11.03.2016 & 26.03.2016 to the opposite parties 1 & 2 respectively and the opposite parties 1 & 2 sent reply dated:25.02.2016, 15.03.2016 & 18.04.2016.   But the opposite parties 1 & 2 has not come forward to settle the demands of the complainant.   Hence, the complaint is filed. 

2.     Inspite of receipt of notice, the opposite parties 1 & 2 has not chosen to appear before this Forum and hence the opposite parties 1 & 2 were set Exparte.

3.      The brief averments in the written version filed by the  3^rd opposite party is as follows:

The 3^rd opposite party specifically denies each and every allegation made in the complaint and puts the complainant to strict proof of the same.    The 3^rd opposite party states that the complaint against the 3^rd opposite party is not maintainable.   The 3^rd opposite party has given treatment to the complainant’s mother, Mrs. P. Saradha and after due consent on 30.01.2017, the surgery was conducted to the complainant’s mother.  She was discharged from the hospital on 04.02.2016 in a good health condition.  The complainant’s mother was advised to walk with the help of a walker.   The claim of medical expenses with the opposite parties 1 & 2 have nothing to do with the 3^rd opposite party.  The 3^rd opposite party is an unnecessary party.  There is no deficiency in service on the part of the 3^rd opposite party.  The alleged deficiency in service related to the insurance claim is left with the opposite parties 1 & 2 alone.   Hence, the complaint against the 3^rd opposite party is liable to be dismissed.

4.    To prove the averments in the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A19 are marked.  Proof affidavit of the 3^rd opposite party is filed and no document is marked on the side of the 3^rd opposite party. 

5.      The points for consideration is:-

1. Whether the complainant is entitled to sum of Rs.2,82,326/- paid towards medical expenses as prayed for?
2. Whether the complainant is entitled to a sum of Rs.50,000/- towards mental agony with cost as prayed for?

6.      On point:-

The opposite parties 1 & 2 remained Exparte.  Both complainant and the 3^rd opposite party filed their respective  written arguments.   Perused the records namely the complaint, written version, proof affidavits, documents etc.   The complainant pleaded and contended that he is employed in the Police Department and have the Insurance Policy right from 2012 vide I.D. card No.PSO/01/BP303/NHIS12/2073298 as per Ex.A13.  As per the I.D. card and the insurance policy, himself and his mother are entitled for free medical service.  The learned Counsel for the complainant further contended that  on 27.01.2016, the complainant’s mother Mrs. P. Saratha, aged 75 years sustained hip fracture and was taken to the 3^rd opposite party hospital and  admitted as inpatient in an emergency ward.  After due diagnosis, the 3^rd opposite party informed the complainant that a surgery should be conducted.  On 28.01.2016, the complainant informed the opposite parties 1 & 2 about the admission and the necessity of surgery and requested for cashless treatment under the policy as per the estimation given by the 3^rd opposite party as per Ex.A2.   

7.     Further the contention of the complainant is that the opposite parties 1 & 2 demanded unmarried certificate of the employee in order to extend the medical facility to his mother as per Ex.A4.  But on a careful perusal of the ID card issued by the insurance company, the policy was availed for himself and his mother along with photographs.   The complainant also submitted dependency certificate to the 1^st opposite party on 30.01.2016.   But the opposite parties 1 & 2 has not extended the cashless facility of treatment proves the deficiency in service.  The complainant has expended a huge sum of Rs.2,82,326/- towards medical expenses as per Ex.A14 to Ex.A18.   Since the opposite parties 1 & 2 has not taken proper steps for cashless treatment and settle the medical expenses the complainant is constrained to file this case.  

8.     The opposite parties 1 & 2 remained Exparte and has not taken any steps to defend the case.  The contention of the 3^rd opposite party is that the complaint against the 3^rd opposite party is not maintainable since admittedly, the 3^rd opposite party has given treatment to the complainant’s mother, Mrs. P. Saradha.   After due consent on 30.01.2017, the surgery was conducted to the complainant’s mother.  She was discharged from the hospital on 04.02.2016 in a good health condition.  The complainant’s mother was advised to walk with the help of a walker.   The claim of medical expenses with the opposite parties 1 & 2 have nothing to do with the 3^rd opposite party.  The 3^rd opposite party is an unnecessary party.  There is no deficiency in service on the part of the 3^rd opposite party.  The alleged deficiency in service related to the insurance claim is left with the opposite parties 1 & 2 alone.   Considering  the facts and circumstances of the case, this Forum is of the considered view that the opposite parties 1 & 2 are jointly and severally liable shall pay a sum of Rs.2,82,326/- towards medical expenses with interest at the rate of 9% p.a. from the date of complaint (i.e.) 01.12.2016 to till the date of this order with a compensation of Rs.20,000/- and cost of Rs.5,000/-.

In the result, this complaint is allowed in part.   The opposite parties 1 & 2 are jointly and severally liable  to pay a sum of Rs.2,82,326/- (Rupees Two lakhs eighty two thousand three hundred and twenty six only) being medical expenses incurred along with interest at the rate of 9% p.a. from the date of complaint (i.e.) 01.12.2016 to till the date of this order and to pay a sum of Rs.20,000/- (Rupees Twenty thousand only) towards compensation for mental agony with cost of Rs.5,000/- (Rupees Five thousand only) to the complainant.  The complaint against the 3^rd opposite party is hereby dismissed.

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 28^th day of November 2018. 

 

MEMBER –I                                                                      PRESIDENT

COMPLAINANT SIDE DOCUMENTS:

		Copy of letter from the complainant to the 1st opposite party
		Copy of Doctor’s Estimation of Expenses
		Copy of denial of Authorization letter
		Copy of additional document request by the 1st opposite party
		Copy of letter by the complainant to the 1st opposite party
		Copy of letter to furnish Information under Right to Information Act
		Copy of reply by the 1st opposite party
		Copy of letter to the 2nd opposite party
		Copy of reply by the 2nd opposite party
		Copy of letter to the 2nd opposite party
		Copy of reply by the 2nd opposite party
	Dec  2015	Copy of pay slip
		Copy of Identity Card for the Insurance
		Copy of Medical Receipt of the 3rd opposite party
		Copy of Medical Receipt of the 3rd opposite party
		Copy of Medical Receipt of the 3rd opposite party
		Copy of Medical Receipt of the 3rd opposite party
		Copy of Medical Receipt of the 3rd opposite party
		Copy of Death Certificate of P. Saradha

 

3^RD OPPOSITE  PARTY SIDE DOCUMENTS:- NIL

 

 

MEMBER –I                                                                      PRESIDENT