Tamil Nadu

South Chennai

CC/14/2013

M.Arunachalam, - Complainant(s)

Versus

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

Mrs. Thenmozhi Shiva Perumal

13 Nov 2018

ORDER

                                                                        Date of Filing  : 08.01.2013

                                                                          Date of Order : 13.11.2018

 

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.14/2013

DATED THIS TUEDAY THE 13^TH DAY OF NOVEMBER 2018

                                 

Mr. M. Arunachalam,

S/o. Mr. AR. Muthuraman,

No.34, Rajaji Avenue,

Opposite Nilgiris,

Valasaravakkam,

Chennai – 600 087.                                                         .. Complainant.                                                      ..Versus..

 

1. The Divisional Manager,

The New India Assurance Co.,

Do:710700 Macmillan House, II Floor,

No.21, Patulous Road,

Chennai – 600 002.  

 

2. The Managing Director,

The New India Assurance Company Limited,

Casino Division,

No.21, Patulous Road, 2^nd Floor,

Chennai – 600 002.                                                 ..  Opposite parties.

          

Counsel for complainant                  :  Mrs. Thenmozhi Shiva Perumal 

                                                             s& another

Counsel for opposite parties 1 & 2  :  M/s. S. Radha Devi & 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 refund a sum of Rs.30,000/- which has been paid by the complainant to the Hospital and to pay a sum of Rs.1,50,000/- towards compensation for mental agony, unfair trade practices and deficiency in service  with cost of Rs.50,000/- to the complainant.

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

The complainant submits that he availed Hospitalization and Domiciliary Hospitalization Benefit Policy of the opposite party from 15.10.2001 and is renewed continuously without any break.  The complainant further submits that on 14.10.2010, one of the policy holder namely Mrs. Valli Deivanai, W/o complainant was admitted in Vijaya Health Centre, Vadapalani for Hemolytic Anemia as inpatient and undergone treatment and further discharged on 16.10.2010.   The complainant has expended a sum of Rs.29,658/- towards such treatment.  The complainant stated that he was shocked as he had received a letter from the TTK HC on 12.11.2010 stating that the claim is unable to entertain as the ailment is pre-existing for 2 years and so that it is not payable.  The complainant submits that he sent a detailed letter as reply to the opposite parties on 24.11.2010 stating that the reasons given for denial of the claim as it is a pre-existing one and discontinuation of the policy – both are false.  Further, the complainant submits that even after repeated requests and demands, after submission of the claim form, the opposite party repudiated the claim stating that some documents to be submitted and the complainant submitted the same at their office by then on 16.09.2011 and received an acknowledgement from the same office.  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  & 2 is as follows:

The opposite parties 1 & 2 specifically deny each and every allegations made in the complaint and puts the complainant to strict proof of the same.   The opposite parties 1 & 2 state that the complainant is having the subsistence of Medi Claim policy.  Mrs. Valli Deivanai was admitted only for Hemolytic Anemia and after treatment she was advised to take injections and tablets.   The opposite parties state that the complainant had spent only Rs.12,449.84/- and he had not spent Rs.29,658/-.  The opposite parties further state that in the final bill itself Laboratory, Pharmacy, Endoscope and Blood was included and total was arrived for Rs.12,449.84/-. Further the opposite parties state that the complainant’s wife was treated for Hemolytic Anaemia in Vijaya Health Center, Vadapalani, Chennai from 14.10.2010 to 16.10.2010.  The opposite parties further state that Hemolytic Anaemia is not a disease but it is only deficiency of iron and which can be treated with iron.  But as per the Medi claim Policy terms and conditions Medi Claim can be availed only for disease which has to be cured and which requires hospitalization.  Therefore, the opposite parties are not liable to pay compensation to the complainant as it was repudiated as per the terms and conditions of the Policy and there is no deficiency in service and 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.A20 are marked.  Proof affidavit of the opposite parties 1 & 2 is filed and no document is marked on the side of the opposite parties 1 & 2. 

4.      The points for consideration is:-

1. Whether the complainant is entitled to a sum of Rs.30,000/- paid towards hospital expenses as prayed for?
2. Whether the complainant entitled to a sum of Rs.1,50,000/- towards deficiency in service and mental agony and unfair trade practice with cost of Rs.50,000/- as prayed for?

5.      On point:-

Both parties filed their respective written arguments.  Perused the records namely the complaint, written version, proof affidavits and documents. The complainant availed Hospitalization and Domiciliary Hospitalization Benefit Policy of the opposite parties from 15.10.2001 and is renewed continuously without any break as per Ex.A1 to Ex.A10.  The complainant further contended that on 14.10.2010, one of the policy holder namely Mrs. Valli Deivanai, W/o complainant was admitted in Vijaya Health Centre, Vadapalani for Hemolytic Anemia as inpatient and undergone treatment and further discharged on 16.10.2010.  Ex.A12 is the Discharge Summary.  The complainant has expended a sum of Rs.29,658/- towards such treatment as per Ex.A11, bills.   But on a careful perusal of Ex.A11, it is seen that the total bill amount is Rs.12,449.84 less drug returned for Rs.351.70 and advance paid for a sum of Rs.7,500/-.   Thereby, the complainant has expended a sum of Rs.12,449.84.   Further, the contention of the complainant is that evenafter repeated requests and demands, after submission of the claim form as per Ex.A13, the opposite party repudiated the claim stating that Mrs. Valli Deivanai had pre-existing disease and is not entitled to any claim amount.  But admittedly, the complainant had the policy of insurance right from 14.10.2010 till 16.10.2010.  The said repudiation of claim is against the terms and conditions of the policy proves the deficiency in service.

6.     The learned Counsel for the opposite parties 1 & 2 contended that admittedly, the complainant is having the subsistence of Medi Claim policy.  Mrs. Valli Deivanai was admitted only for Hemolytic Anemia and after treatment she was advised to take injections and tablets.  But the opposite parties has not produced any medical literature or guidelines for such conservative treatment not covered under the policy.  Further the contention of the opposite parties is that Mrs. Valli Deivanai had the Anaemia problem quite long back and undergone treatment previously which was suppressed and the policy was availed.  But on a careful perusal of Ex.A1 to Ex.A10 pre-existing nature of disease cannot be a bar in claiming the medical expenses for treatment.  Further the contention of the opposite party is that the complainant is claiming a sum of Rs.1,80,000/- towards reimbursement of medical expenses.   But it is seen from the records that the complainant has expended only a sum of Rs.12,449.84 towards medical expenses.  Considering the facts and circumstances of the case, this Forum is of the considered view that the opposite parties shall pay a sum of Rs.12,450/- being amount spent towards medical expenses and a sum of Rs.10,000/- towards compensation for mental agony with a 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.12,450/- (Rupees Twelve thousand four hundred and fifty only) being amount spent towards medical expenses 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 13^th day of November 2018. 

 

MEMBER –I                                                                      PRESIDENT

 

COMPLAINANT SIDE DOCUMENTS:

		Copy of the Insurance policy
		Copy of the Insurance policy
		Copy of the Insurance policy
		Copy of the Insurance policy
		Copy of the Insurance policy
		Copy of the Insurance policy
		Copy of the Insurance policy
		Copy of the Insurance policy
		Copy of the Insurance policy
		Copy of the Insurance policy
		Copy of the bills
		Copy of Discharge Summary
		Copy of the claim form
		Copy of the reply given by the opposite party
		Copy of the letter by the complainant
		Copy of letter given by the opposite party
		Copy of the reply letter given by the complainant
		Copy of the Insurance Policy
		Copy of letter given to the complainant with AD
		Copy of the Insurance Policy

 

OPPOSITE  PARTIES SIDE DOCUMENTS:- NIL

 

 

MEMBER –I                                                                      PRESIDENT