Tamil Nadu

South Chennai

CC/293/2013

V.Ramesh - Complainant(s)

Versus

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

N.Pappiah

13 Dec 2018

ORDER

                                                                        Date of Filing  : 11.09.2013

                                                                          Date of Order : 13.12.2018

 

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

TR. R. BASKARKUMARAVEL, B.Sc., L.L.M., BPT., PGDCLP., : MEMBER-II

 

C.C. No.293/2013

DATED THIS THURSDAY THE 13^TH DAY OF DECEMBER 2018

                                 

V. Ramesh,

No.9/1, Valmiki Street,

East Tambaram,

Chennai – 600 059.                                                      .. Complainant.                                                    

 

      ..Versus..

 

1. The Chairman,

New India Assurance Company Ltd.,

New India Assurance Bldg.,

No.87, M.G. Road,

Fort,

Mumbai – 400 001.

 

2. The Divisional Manager,

The New India Assurance Co. Ltd.,

Alwarpet D.O.,

Ratna Buildings,

No.231, T.T.K. Road,

Alwarpet,

Chennai – 600 018.

 

3. Medi Assist India TPA Pvt. Ltd.,

Rep. by its Managing Director,

‘Sri Krishna Arcade’,

No.47/1, 9^th Cross,

1^st Main Road, Sarakki Industrial Layout,

3^rd Phase, J.P. Nagar,

Bangalore – 560 078.

 

4.  Omega Global Logistics,

No.201/204, Prestige Point,

2^nd Floor, No.47/16, Old No.33,

Haddows Road,

Nungambakkam,

Chennai – 600 006.                                                 ..  Opposite parties.

          

Counsel for complainant                    :  Dr. P. S. Vijayakumar

Counsel for opposite parties 1 to 3   :  M/s. S. Radha Devi & others

Counsel for 3^rd opposite party           :  M/s. P. R. Krishnaraj & others

 

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 compensation of Rs.1,00,000/- (including the reimbursement of of Rs.41,712/- and compensation for mental agony to the tune of Rs.59,000/-) to the complainant.

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

The complainant submits that the complainant is a member of group Insurance Policy through the 4^th opposite party M/s. Omega Global Logistics Pvt. Ltd. and insurance through the 3^rd opposite party M/s. Medi Assist India TPA Pvt. Ltd. and the insurance company is New India Assurance Company Ltd., Mumbai under insurance policy No.710802/34/11/02/00000004 and the Policy is continuous and every year is renewed and Policy No. is 01260248100500000340.  The complainant submits that the group insurance was availed only for the purpose of Health Services to the employees of the 4^th opposite party by New India Assurance Co. Ltd., the opposite parties 1 & 2 through its agency M/s. Medi Assist TPA Pvt. Ltd.   The complainant submits that he had undergone treatment for Hepatitis and was admitted in Aashiana Hospital on 18.02.2012 and discharged on 03.03.2012.  The complainant expended a huge sum of Rs.41,712/- towards medical treatment.   The complainant also submitted claim form during April 2012 enclosing all the details of treatment and diagnostic reports.   The complainant submits that the 3^rd opposite party sent a letter stating that the alleged disease of the complainant is not coming under the purview of the mediclaim policy and the claim amount cannot be reimbursed.  Hence, the complainant issued legal notice dated:09.03.2013 for which, the 3^rd opposite party issued reply notice dated:22.04.2013 and has not settled the demands of the complainant.  The act of the opposite parties caused great mental agony.   Hence the complaint is filed.

2.      The brief averments in the written version filed by the  opposite parties 1 to 3 is as follows:

The opposite parties 1 to 3 specifically deny each and every allegations made in the complaint and puts the complainant to strict proof of the same.    The opposite parties 1 to 3 state that the complainant is a member of the group insurance availed by the 4^th opposite party and the policy is subsisting.   The complainant has no rights to file any complaint individually.    The opposite parties state that the complainant has suppressed the material facts and approached this Forum without clean hands.   The opposite parties can settle the claim only after verification of documents submitted by the complainant.  On scrutiny of the documents, the opposite parties found that the complainant had been admitted with the diagnosis of Hepatitis.   The opposite parties state that on perusal of medical records, the opposite parties noticed that the Hospital had taken Liver Function Tests but they have not given any reports for the same.   The opposite parties 1 to 3 state that in any Hepatitis it is customary to do viral Serology/Diagnostic tests to rule out viral hepatitis.   But this test was not done for the complainant.  Further it was also found that the complainant underwent for GGTP Test (Gamma-Glutamyl Tralspeptidase) this test being done in the absence of other viral Serological studies implies that the complainant is probably had alcoholic liver disease rather than viral Hepatitis.  The drugs used during the treatment are for alcohol withdrawal.  

3.     The opposite parties further state that after verifying the medical records, the Medical Experts also opined through the letter dated:25.01.2013 that the complainant had been admitted for Alcoholic Dependency treatment / Psychiatric treatment related to the same and treatment of Liver disease related to alcoholism.    Besides the said findings, the Medical Expert also stated that the drugs prescribed to the complainant on the day of Discharge are suggestive that the patient had been admitted for Alcoholic Dependence and psychiatric treatment.  The 3^rd opposite party had sent request letter dated:26.11.2012 to the complainant to submit all the investigation records to substantiate the complainant’s ailment as Hepatitis for which, he had taken treatment.  But the complainant failed to submit the same to the 3^rd opposite party.    Thereafter, the 3^rd opposite party referred the matter to internal Investigator.  The said Investigator requested the Hospital to furnish indoor case papers and other supportive medical records.  But the Hospital management declined to share any documents as the complainant did not give permission to the hospital to furnish the case papers.   The opposite parties further state that as per investigator reports, the Aashiana Hospital is an exclusive centre for Psychiatric care and rehabilitation and all treating doctors is consultant Psychiatrists.   The opposite parties further state that the claim of the complainant is repudiated under Policy Permanent exclusion clause 4.46 of the Mediclaim Policy which reads as follows:

“Convalescene, general debility Run-down condition or rest cure, obesity treatment and its complications, congenital external disease/ defects or anomalies, treatment, relating to all psychiatric and psychosomatic disorders, infertility, sterility, use of intoxicating drugs/ alcohol, use of tobacco leading to cancer”.

Therefore, there is no deficiency in service on the part of the opposite parties 1 to 3 and hence, the complaint is liable to be dismissed.

4.      The brief averments in the written version filed by the 4^th opposite party is as follows:

The 4^th opposite party specifically denies each and every allegation made in the complaint and puts the complainant to strict proof of the same.   The 4^th opposite party states that the complainant has never paid any amount from his pocket and the 4^th opposite party has never collected or deducted money from the complainant as his employer.  As a good gesture and to avoid defaults, the 4^th opposite party has paid the premium amount for its employees.  But it is not a statutory obligation on the part of the 4^th opposite party.  The complainant is a Senior Executive working under the 4^th opposite party.  The privity of contract is between the Insurance Company and the insured.  The 4^th opposite party does not intervene in the affairs between the contracting parties.  The terms and conditions of the contract is between the insurance company or others has nothing to do with the 4^th opposite party as there is no claim against the employer.  Therefore there is no deficiency in service on the part of the 4^th opposite party and the complaint against the 4^th opposite party is liable to be dismissed.

5.    To prove the averments in the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A13 are marked.  Proof affidavit of the opposite parties 1 to 3 is filed and documents Ex.B1 & Ex.B2 are marked on the side of the opposite parties 1 to 3. Proof affidavit of the 4^th opposite party is filed and no documents filed and marked on the side of the 4^th opposite party. 

6.      The points for consideration is:-

1. Whether the complainant entitled to a sum of Rs.41,712/- towards reimbursement of medical expenses as prayed for?
2. Whether the complainant is entitled to a sum of Rs.59,000/- towards compensation for deficiency in service and mental agony etc with cost as prayed for?

7.      On point:-

Both parties filed their respective written arguments.   Heard the respective Counsels also.  Perused the records namely the complaint, written version, proof affidavits and documents.  The learned Counsel for the complainant would contend that the complainant is a member of group Insurance Policy through the 4^th opposite party M/s. Omega Global Logistics Pvt. Ltd. and the policy is subsisting; is admitted.   Further the contention of the complainant is that the group insurance was availed only for the purpose of Health Services to the employees of the 4^th opposite party by New India Assurance Co. Ltd., the opposite parties 1 & 2 through its agency M/s. Medi Assist TPA Pvt. Ltd. is also admitted.   As per the policy, the maximum amount of Rs.1,00,000/- can be reimbursed towards medical expenses.  The complainant’s name is cited as member No.51 in the group containing 185 persons as per Ex.A5.  The policy also having the details of pre-existing disease; which is not applicable.  As per Ex.A3 policy conditions 4.1 which reads as follows:

Pre-existing diseases / condition:  All diseases / injuries/ conditions, which are pre-existing when the cover incepts for the first time (except as shown hereunder).  Any complication arising from pre-existing disease /ailment / injury will be considered as a part of pre-existing condition.  This exclusion will be deleted after four consecutive claim free policy year provided there was no hospitalisation for the pre-existing disease/ailment/condition/injury during the said four years of insurance with our Company.

8.     Further the complainant contended that he had undergone treatment for Hepatitis and was admitted in Aashiana Hospital on 18.02.2012 and discharged on 03.03.2012.  Ex.A7 is the Discharge summary.  The complainant expended a huge sum of Rs.41,712/- towards medical treatment  as per Ex.A1 & Ex.A2, bills.   The complainant also submitted claim form as per Ex.A2 enclosing all the details of treatment and diagnostic reports.   Further the contention of the complainant is that the 3^rd opposite party sent a letter stating that the alleged disease of the complainant is not coming under the purview of the mediclaim policy and the claim amount cannot be reimbursed without substantial reason which amounts to deficiency in service.  Hence, the complainant was constrained to issue lawyer notice dated:09.03.2013 as per Ex.A8 for which, the 3^rd opposite party issued reply with untenable contention as per Ex.A9.  Hence, the complainant was constrained to file this case for reimbursement of medical expenses and compensation.

9.     The contention of the opposite parties is that admittedly, the complainant is a member of the group insurance availed by the 4^th opposite party and the policy is subsisting.   The complainant has no rights to file any complaint individually.  But it is apparent that in the absence of taking suitable action by the employer, the affected employee can take suitable steps for claiming compensation.  Further the contention of the opposite parties is that the complainant has suppressed the material facts and approached this Forum without clean hands.   The complainant after availing treatment submitted the claim form as per Ex.A2, was duly verified by the opposite parties. On a careful scrutiny of the documents, it is found that the complainant was admitted for diagnosis of Hepatitis.  The complainant also had taken liver function test.  But no report submitted either to the opposite parties or before this Forum.  In the case of Hepatitis, it is mandatory that viral Serology/ Diagnostic test to rule out viral hepatitis.  Nowhere, it is stated in the complaint that the complainant has taken such test.  Equally, the complainant has not produced any report related to GGTP Test (Asmma – Glutamyl Tralspeptidase).  In the absence of such test, it can be confirmed that the complainant probably had alcoholic disease rather than viral hepatitis.  The drugs used in the course of treatment are also for alcohol withdrawal. 

10.    Further the contention of the opposite parties is that the complainant has not produced any document to prove the administration of drugs for hepatitis.  The medical experts stated that the drugs prescribed to the complainant namely Naltima, Etilaam, Liofen, Nova SR, Disulfiram etc are only for Alcoholic Dependence and Psychiatric treatment which is excluded as per the exclusion clause 4.4.6 of the Medi claim Policy proves that there is no deficiency in service.   Further the contention of the opposite parties is that the investigator appointed by the opposite party submitted his report that the Aashiana Hospital is an exclusive centre for Psychiatric care and rehabilitation and all treating doctors are the consultant Psychiatrists also proved from the document filed by the complainant in Ex.A7, Discharge Summary which reads as follows:

Investigations done:

1. Liver Function Test

2. Complete Blood Count

3. Blood Sugar (Report enclosed). 

Considering the facts and circumstances of the case this Forum is of the considered view that the complainant availed treatment only for alcoholic dependence and Psychiatrists treatment which is excluded as per the Exclusion clause of the policy.   Hence, the complainant is not entitled to any compensation and the compliant has to be dismissed.

In the result, this complaint is dismissed.  No costs.

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 13^th day of December 2018. 

 

MEMBER-I                           MEMBER-II                     PRESIDENT

 

COMPLAINANT SIDE DOCUMENTS:-

Ex.A1		Copy of bill for a sum of Rs.41,712/-
Ex.A2	04/2012	Copy of Claim Form
Ex.A3		Copy of Group Mediclaim Policy (2007)
Ex.A4		Copy of Policy for the period from 28.11.2011 to 27.11.2012
Ex.A5	06.12.2012	Copy of Policy schedule
Ex.A6	12.12.2012	Copy of letter
Ex.A7	03.03.2012	Copy of Discharge Summary
Ex.A8	09.03.2013	Copy of notice
Ex.A9	22.04.2013	Copy of reply notice
Ex.A10	13.03.2013	Copy of acknowledgment card
Ex.A11		Copy of acknowledgment card
Ex.A12		Copy of acknowledgment card
Ex.A13		Copy of Policy Schedule of the Standard Group Mediclaim Policy, 2007 (Hospitalisation Benefit Policy)

 

OPPOSITE  PARTIES 1 TO 3 SIDE DOCUMENTS:-

Ex.B1	25.01.2013	Copy of repudiation letter
Ex.B2	06.04.2013	Copy of Medical Expert Opinion

 

4^TH OPPOSITE  PARTY SIDE DOCUMENTS:-  NIL

 

 

MEMBER-I                           MEMBER-II                     PRESIDENT