Tamil Nadu

South Chennai

CC/28/2014

S.Chandra - Complainant(s)

Versus

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

R.Dhanalakshmi

22 Nov 2019

ORDER

                                                                             Date of filing      : 23.01.2014

                                                                               Date of Disposal : 22.11.2019

                                                                                  

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (SOUTH)

@ 2^ND Floor, T.N.P.S.C. Road, V.O.C. Nagar, Park Town, Chennai – 3.

 

PRESENT: THIRU. M. MONY, B.Sc., L.L.B, M.L.                    : PRESIDENT

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

 

C.C. No.28/2014

DATED THIS FRIDAY THE 22^ND DAY OF NOVEMBER 2019

                                 

Mrs. S. Chandra,

W/o. Mr. V.R.D. Sivasankaran,

New No.12, Old No.16,

First Main Road Nandanam Extension,

Chennai – 600 035.                                                        .. Complainant.                                                       ..Versus..

 

The Managing Director,

The New India Assurance Co. Ltd.,

No.770-A, Spencer Towers,

III Floor, Anna Salai,

Chennai – 600 002.                                                   ..  Opposite party.

 

Counsel for the complainant    : Ms. R. Dhanalakshmi

Counsel for the opposite party : M/s. K.R.A. Muthukirushnan &            

                                                     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 prays to apologize for all the inconvenience caused to the complainant, to approve the claim amount of Rs.1,83,500/- and to pay a sum of Rs.50,000/- towards compensation for mental agony with cost of Rs.1,000/- to the complainant.

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

The complainant submits that he has availed a Mediclaim Policy (Hospitalisation Benefit) vide policy No.710700/34/13/01/00000116 from the opposite party for an assured sum of Rs.1,00,000/-. On 25.05.2013, the complainant was admitted for MRGFUS treatment in Bharat Scans Hospital, Chennai where in the mediclaim policy was not accepted.   Immediately, the complainant informed the opposite parties’ executive who assured for payment after treatment and submission of claim form with medical bills.  The complainant submits that on 28.07.2013, the complainant submitted the claim form along with medical bills for a sum of Rs.1,83,500/- for due reimbursement through TTK Health Care Service Private Limited.   Even after repeated requests, the opposite parties has not stated anything about the status of the claim caused great mental agony.   The act of the opposite party amounts to deficiency in service and unfair trade practice which caused great mental agony.  Hence, the complaint is filed.

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

The opposite party specifically denies each and every allegation made in the complaint and put the complainant to strict proof of the same.    The opposite party states that the complainant availed medi-claim policy (Hospitalization Benefit) renewed for the period from 23.04.2013 to 22.04.2014 for an assured sum of Rs.1,00,000/-.  The opposite party states that the date of admission was shown as 25.05.2013.  The opposite party states that the treatment procedure does not contain the date of treatment and the manner of treatment. The opposite party states that the complainant submitted her claim for reimbursement is third party administrator repudiated the claim on 13.01.2014.   Therefore, there is no deficiency in service on the part of the opposite party and 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.A5 are marked.  Proof affidavit of the opposite party is filed and documents Ex.B1 & Ex.B2 are marked on the side of the opposite party.

4.      The points for consideration is:-

1. Whether the complainant is entitled to a sum of Rs.1,83,500/- towards the expenses incurred for treatment under the medi-claim policy as prayed for?
2. Whether the complainant is entitled to a sum of Rs.50,000/- towards mental agony with cost of Rs.1,000/- as prayed for?

5.      On point:-

Written argument of the complainant is filed.  The opposite party has not filed any written argument and not turned up to advance oral arguments also.  Heard the complainant’s Counsels 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 (Hospitalisation Benefit) vide policy No.710700/34/13/01/00000116 from the opposite party for an assured sum of Rs.1,00,000/- as per Ex.A1.  On 25.05.2013, the complainant was admitted for MRGFUS treatment in Bharat Scans Hospital, Chennai where in the mediclaim policy was not accepted.   Immediately, the complainant informed the opposite parties’ executive who assured for payment after treatment and on submission of claim form with medical bills as per Ex.A2 (S).  Further the contention of the complainant is that on 28.07.2013, the complainant submitted the claim form along with medical bills for a sum of Rs.1,83,500/- for due reimbursement through TTK Health Care Service Private Limited as per Ex.A3. Even after repeated requests, the opposite parties has not stated anything about the status of the claim.  Further the contention of the complainant is that he wrote a letter to the opposite party as per Ex.A4 and after receiving the same as per Ex.A5, no reply from the opposite party which amounts to deficiency in service.  Hence, the complainant filed this complaint claiming payment of medical expenses and compensation.

6.     The contention of the opposite party is that admittedly, the complainant availed mediclaim policy (Hospitalization Benefit) renewed for the period from 23.04.2013 to 22.04.2014 for an assured sum of Rs.1,00,000/-.  Further the contention of the opposite party is that as per Ex.A2 (S), the date of admission was shown as 25.05.2013.  But on a careful perusal of Ex.A2 (S), it is very clear that the date of registration was 25.05.2013.  Further the contention of the opposite party is that the treatment procedure does not contain the date of treatment and the manner of treatment.   But on a careful perusal of records, Ex.A2, it is very clear that the complainant undergone the treatment procedure for “MRGFUS treatment for UTERINE FIBROID, GELPAD FOR AND ACCESSORIES MRGFUS TREATMENT, SCAR PATCH FOR MRGFUS TREATMENT etc”.   The test report is very clear that the treatment was done on 25.05.2013 and the complainant was discharged on 30.05.2013.  After the treatment procedure the patient was shifted to the room and hence, it shall be treated as inpatient for treatment / investigation.  Further the contention of the opposite party is that the complainant submitted her claim for reimbursement; the third party administrator repudiated the claim on 13.01.2014.  The patient was discharged after 24 hours of observation.  But none of the terms and conditions produced before this Forum to show specifically to show what is 3.2 proves the unfair trade practice. Considering the facts and circumstances of the case, this Forum is of the considered view that the opposite party is directed to pay a sum of Rs.1,00,000/- being the maximum limit / assured sum and to pay a sum of Rs.10,000/- towards compensation for mental agony with cost of Rs.5,000/- to the complainant.

In the result, this complaint is allowed in part.   The opposite party is directed to pay a sum of Rs.1,00,000/- (Rupees One lakh only) being the maximum limit / assured sum 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 22^nd day of November 2019. 

 

MEMBER                                                                               PRESIDENT

 

COMPLAINANT SIDE DOCUMENTS:-

Ex.A1		Copy of mediclaim policy – Annexure I
Ex.A2 (S)		Copy of hospital bills, treatment procedure and Discharge Summary
Ex.A3	15.07.2013	Copy of claim application
Ex.A4	18.12.2013	Copy of letter addressed to the New India Assurance Co. Ltd., Chennai
Ex.A5	19.12.2013	Copy of postal acknowledgement for the receipt of the above letter

 

OPPOSITE PARTY SIDE DOCUMENTS:-  

Ex.B1	25.10.2013	Copy of repudiation letter
Ex.B2	13.01.2014	Copy of reply by the opposite party

 

 

MEMBER                                                                                                                                                                             PRESIDENT