Tamil Nadu

South Chennai

478/2005

T.Sivarambabu - Complainant(s)

Versus

The New india Assurance Company limited - Opp.Party(s)

A.R.Balaji

21 Dec 2016

ORDER

                                                                        Date of Filing :   18.08.2005

                                                                        Date of Order :   21.12.2016

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, CHENNAI (SOUTH)

     2^nd Floor, Frazer Bridge Road, V.O.C. Nagar, Park Town, Chennai-3

 

PRESENT: THIRU. S. PANDIAN, B.Sc., L.L.M.                       : PRESIDENT 

                 TMT. K.AMALA, M.A. L.L.B.,                                  : MEMBER I           

                DR. T.PAUL RAJASEKARAN, M.A ,D.Min.PGDHRDI, AIII,BCS : MEMBER II

 

C.C.NO. 478/2005

WEDNESDAY THIS  21^ST DAY OF DECEMBER 2016

 

T. Sivarambabu,

S/o. V.B. Thirupuresh,

Flat No.Subhanu Flats,

No.25, Cheyyur,

Parthasrathy Street,

Perambur, Chennai -11.                                            ..Complainant

             

                                        ..Vs..

 

1.  The New India Assurance

Company Limited,

Reg. and Head Office

New India Insurance Building,

No.87, M.G.Road,

Mumbai 400 001.

 

2. The Divisional Manager,

New India Assurance Company Ltd.,

Door No.74, G.S.T. Road,

Guindy, Chennai 600 032.                                         ..Opposite parties

 

 

Counsel for the Complainant           :  M/s. A.R. Balaji & V.V.Ravichandran

Counsel for the opposite parties      : M/s. Nageswaran & Narichania

ORDER

THIRU.   T.PAUL RAJASEKARAN ::    MEMBER-II      

 

1.The case of the complainant is briefly as follows

        The complainant submits that he was a medical policy holder of the opposite parties for the past five years and was paying yearly premium well before the due dates under policy No.712403/48/01/00976 he insured for sum of Rs.25,000/- and lodged a claim.   Accordingly, on prior occasions due to a minor accident he underwent treatment and incurred Medical expense of  Rs.3,800/- which was sanctioned and paid by the opposite parties to the complainant  from the sum assured Rs.25,000/- and a balance sum of Rs.21,200/- is still available to his credit. 

2.     The complainant submits that he approached his family doctor Mr.G.V. Reddy who in turn referred to the Dr.K.Raghuram of the Best Hospital, Chennai and the  Dr.Raghuram asked the complainant to take to various investigations to find the root cause, for the drop in the level of hemoglobin and in the report Hemoglobin was shown as 10.00 mg.  The minimum level required is 13.00 mg.  The reduction of Hemoglobin will automatically affect the kidney and the movement.   To find out the root cause, his doctor advised him to take Endoscopy and colonoscopy.  The above said investigation will not come under the hospitalization.   Based on the reports he was advised to admit as inpatient as a precautionary reason.  The complainant was admitted on 6.5.2004 and the investigation test was taken on 7.5.2004 and he was discharged on 7.5.2004 and time of admission and discharge was not given to substantiate his stay exceeds 24 hours.  The  complainant  also  submits  that since he was a medi-claim  policy  holder,  based   on   the   discharge  summary given to his reference by the hospital, he had applied for reimbursement on 18.5.2004.   The 2^nd opposite party recklessly without going through the reports of the hospital, and  failed to reimburse the claim amount.  

3.     Hence the complainant sent a legal notice  through his counsel on 24.8.2004, though it was acknowledged no reply was received by the complainant till date.    As such the attitude of the opposite parties amount to deficiency in service on the part of the opposite party which caused mental agony and torture.  Hence the complaint.

4.      Written version opposite parties are as follows:

    The opposite parties deny all the averments and allegation contained in the complaint except those that are specifically admitted herein.   It is true that the complainant obtained medi-claim policy from the opposite parties for a maximum  sum of Rs.25,000/-.  The said mediclaim policy was issued subject to the terms and conditions forming part of the said policy.   It is true that a claim from the complainant was received by the opposite parties.   At the outset the opposite parties submit that there is no deficiency of service on their part at any stage i.e. at the time of accepting the proposal, issuance of policy and finally when the claim lodged by the complainant was repudiated on 6.7.2004.   Under this policy the complainant is entitled for reimbursement of the expenses on hospitalization for any illness or any bodily injury through accident and hospitalization expenses for medical treatment.   A claim for reimbursement of expenses incurred for taking treatment for diagnosis.   This itself establishes that the claim is not payable as per the policy condition.  The penal Doctor  has certified that the claim is not acceptable on account of the expenses incurred by the complainant is only for investigation and treatment for anemia which are not payable under the policy terms and conditions.  

5.     Based on the Panel Doctor’s opinion, the claim of the complainant was repudiated by the opposite parties, vide their letter dated 67.2004 stating that as per the exclusion No.4.8 of the policy, the expenses incurred for the treatment is excluded under the policy.   Exclusion No.4.8 read as follows:

        “Convalescence, general debility, ‘run down’ condition or test cure, congenital external disease or defects or anomalies, sterility, general disease, intentional self-injury and use  of “intoxicating drugs/alcohol” .

The claim was repudiated by the opposite parties, vide letter dated 6.7.2004, which is only after due application of mind after careful consideration of all facts and as per the terms and conditions of the policy.  Hence there is no deficiency in service on the part of the opposite parties and the complaint is liable to be dismissed.

6.     In order to prove the averments of the complaint, the complainant has filed proof affidavit along with his evidence and documents Ex.A1 to Ex.A4 marked.  Proof affidavit of opposite parties field and Ex.B1 to Ex.B7  marked on the side of the opposite parties.   

7.   At this juncture, the point for the consideration before this

        Forum is:  

 

 

1. Whether there is any deficiency of service on the part of the 

    Opposite parties as alleged in the complaint?

 

2.  Whether the complainant is entitled to any relief as prayed for?

8. Point No.1

          The complainant was a policy holder of the opposite party-2 (Division at office and opposite party-1 is Head office) where he had a medical insurance stating he was in possession of medical insurance for the past five years.  The complainant lodged a claim under policy No.712403/48/01/000976 and had a policy for a sum of Rs.25,000/-.  Under para-4 of the complaint he had stated he availed a claim of Rs.3,800/- and left over sum assured is Rs.21,200/-.  The complainant sought a reimbursement of Rs.7,061/- with the opposite party-2 on 18.5.2004 by submitting his claim form and the break-up figures of medical expenses incurred.   It was stated that he was admitted on 6.5.2004 and discharged on 7.5.2004 at the Best Hospital Pvt. Ltd. Chennai-24. (Ex.A1).   The said claim was repudiated by the opposite party-2 on 7.8.2004 (Ex.A2) on account of “Due to run-down conditions, General check up no ailment specified except anemia”.  

9.     The learned counsel of the complainant had served a legal notice to the opposite party-2 on 1.10.2004 seeking the reimbursement of hospital charges incurred by the complainant. (Ex.A3).  Since there is no proper reply from the opposite party the complainant filed a complaint in this forum on 18.8.2005 and taken for filing on 16.9.2005.   The complainant prayer is to get back the medical reimbursement claim by him to the tune of Rs.7,061/- plus interest at the rate of 18% from 18.5.2004 to 30.6.2004 and to pay compensation of Rs.90,000/- for mental agony and the cost of legal notice Rs.500/- totaling Rs.98,947.60.

10.    The learned counsel of the opposite parties had submitted their written version, proof affidavit, documents consisting of policy conditions, claim form submitted by the complainant, discharge summary, letter of the opposite party to the Penal Doctor for this opinion, claim note and the repudiation letter excluding the policy document.     

11.    The complainant / complainant’s counsel had not submitted a primary document i.e. the policy document which elicits the name of the insured, the period of insurance, the sum assured, the cumulative bonus accrued and attached policy conditions.  He had submitted only the claim form along with the statement of expenses (Ex.A1), repudiation letter Ex.A2, legal notice Ex.A3, and the postal acknowledgment Ex.A4.  

 

12.    The opposite parties contention in para-4 of the proof affidavit, under the policy the complainant is entitled for reimbursement of the expenses on hospitalization for any illness or bodily injury through accident and hospitalization for the medical treatment.   The claim lodged by the complainant shows that the expenses incurred purely for diagnosis and not for hospitalization.   Ex.B3 reveals that the complainant “a regular blood Donor had donated five units of blood earlier and found to be anemia during one such blood transfusion”.  The investigation taken by the complainant revealed the HB count was shown as 9.1 and in order to improve this he undertook other investigations colonoscopy, UGI scopy outside the hospital which was revealed in the discharge summary (Ex.B3).   

13.    Ex.B6 reveals as per Clause No.4.8. and 4.10 of the within mentioned policy the said claim is not admissible as per the terms and conditions described in  the policy and hence the opposite parties counsel prays to dismiss the case.  

 

14.    Pursuant on the complaint, written version, proof affidavit, and documents filed by both the parties to the disputes it is observed neither the complainant nor the opposite parties had produced  the policy document where the dispute lies in, to substantiate their claim and the existence of the said policy.    The complainant had not submitted the relevant documents to substantiate   his claim to get reimbursement.    Though the opposite party had not produced the policy document but he had produced Ex.B1 to Ex.B7 and explained through their learned counsel and what circumstances the claim was repudiated.  

 

15.    The policy condition No.4.8 describes

   “Convalescence, general debility, run-down condition or rest cure, congenital external disease or defects or anomalies, sterility, general disease, intentional self injury and use of intoxicating drugs/alcohol”. 

The policy condition No.4.10 describes

“ charges incurred at hospital or nursing home primarily for diagnosis x-ray or laboratory examination not consistent with or incidental  tour to diagnosis and treatment of the positive existence or presence of any ailment”. 

 

16.    Based on the conditions furnished above and on hearing both the learned counsels arguments we are of the considered view that the claim lodged by the complainant false within the conditions 4.8 and 4.10 of the within mentioned policy and the denial of the claim of the opposite parties seems to be in order on the side of the opposite parties.  Since the complainant had failed to substantiate his claim through proper documentation, and as per the policy condition we are not inclined to grant compensation and the reimbursement of medical expenses incurred by the complainant which is against the policy condition.    Thus the point No.1 is answered accordingly.

 

 

17. Point No.2

          As per the view concluded in point No.1, the complainant is not entitled for any relief as prayed for in the complaint.  Thus the point No.2 is answered accordingly.

In the result, the complaint is dismissed.  No cost.

        Dictated by the President to the Assistant, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the  21st   day  of  December   2016.

 

MEMBER-I                        MEMBER-II                             PRESIDENT.

 

Complainant’s side documents:

Ex.A1- 18.5.2004 - Copy of Claim-form with expense incurred list.

Ex.A2- 6.7.2004    - Copy of rejection letter from the 2^nd opposite party.

Ex.A3- 1.10.2004  - Copy of legal notice issued by the complainant counsel.

Ex.A4- 4.10.2004  - Copy of Ack. card of the legal notice.

Opposite parties’ side documents:   

Ex.B1-         -       - Copy of Policy terms and conditions.

Ex.B2- 18.5.2004  - Copy of claim form.

Ex.B3- 7.5.2004    - Copy of Discharge summary with enclosures.

Ex.B4- 8.7.2004    - Copy of letter to Panel doctor by opposite party.

Ex.B5- 28.7.2004  - Copy of Doctor’s opinion.

Ex.B6- 31.7.2004  - Copy of Claim note.

Ex.B7- 6.7.2004    - Copy of repudiation letter.

 

MEMBER-I                        MEMBER-II                             PRESIDENT.