Complaint taken on file:20.12.2017

     Order delivered on: 14.10.2022

BEFORE THE HON´BLE DISTRICT CONSUMER DISPUTES REDRESSALCOMMISSION, ARIYALUR

      PRESENT:

Dr.V.Ramaraj M.A., M.L: President

Mr.N.Balu B.A, B.L : Member - I

Mrs.V.Lavanya B.A., B.L :Member - II

Consumer Complaint (RBT) No.215/2022

Friday, the fourteenth day of October, 2022

S.Senthamil Selvi, W/o. E.P.Srinivasan

No.44, 3nd Cross, Sakthi Nagar,

Thindal Post, Erode – 638 012                                         ...            Complainant

-Vs-

1.The New India Assurance Co. Ltd.,

  Rep. by its Branch Manager,

  Divisional Office-720800,

  Amman Complex, 1^st Floor,

  1360, E.V.N Road, Erode-638 011

2.M/s.Vidal Health TPA Pvt Ltd.,

146, Sri Saibaba Towers, Raju Naidu Road,

Tatabad, Coimbatore – 641 012             

3.M/s.Appollo Hospitals (Insurance Section)

  21, Greams Lane, Off Greams Road,                     

  Chennai – 600 006                                                                       ...         Opposite Parties

Counsel for Complainant: M/s.S.Vijayakumar

Counsel for 1st Opposite Party: Mr.A.S.Subramanian

2^nd and 3^rd Opposite Parties were set exparte on 25.01.2018

On perusal of records in this case, we delivered the following

ORDER

Pronounced by Mr.N.Balu: Member-I

Adopted by Dr.V.Ramaraj: President and Mrs.V.Lavanya: Member-II

1.     The Complainant has filed this case as against the Opposite Parties claiming a reimbursement of Rs.2,81,319/- with interest till date towards mediclaim, Rs.10,00,000/- as damages for deficiency in their service and the cost of this case from the 1^st and 2^nd Opposite Parties. The 3^rd opposite party is a formal party.

The facts of complaint in brief:

2.     The complainant has taken a Mediclaim policy from the 1^st opposite party in 2013 for her whole family consisting 3 members and extended the policy on 31.05.2016 vide Policy No.72080034162800000013 with customer id No.ME01839154 for the period from 12.06.2016 to 11.06.2017 with a coverage up to Rs.8,00,000/-. The complainant had a problem on the Rectal Prolapse Hypothyroidism and consequently she consulted the 3^rd opposite party, was examined by a specialist and was advised to go for a surgery. Prior to the surgery, the 3^rd opposite party approached the 2^nd opposite party who is the authorized agent of the 1^st opposite party. The 2^nd opposite party gave the preauthorization letter for admission and for surgery and discharged Rs.1,00,000/- as pre-approved amount.

3.         The surgery was performed on 19.04.2017 and the complainant was discharged on 22.04.2017. The 3^rd opposite party issued the bill for Rs.3,81,319/-. After adjusting the pre-approved amount of Rs.1,00,000/-, the third opposite party asked the complainant to pay the balance amount of Rs.2,81,319/-. When the complainant approached the 2^nd opposite party, they said that only Rs.1,00,000/- is approved for “Rectal prolapse for lap combined ventral rectopexy with Sacro hysteropexy H/O hemorrhoidectomy 8 years back and sent a mail also the complainant. The complainant on 24.04.2017 received a certificate from the 3^rd opposite party’s doctor Venkatesh Munikrishnan who performed the surgery and submitted it directly to the 2^nd opposite party on 25.04.2017.

4.         The 2^nd opposite party sent a mail to the complainant on 25.04.2017 stating that another Rs.1,00,000/- towards cashless treatment has been approved. When the complainant insisted the 2^nd opposite party to pay the total outstanding balance of Rs.2,81,319/-, they did not agree to it but said that they can pay only Rs.1,00,000/- in addition to the paid pre-approved payment off Rs.1,00,000/- on 18.04.2017. The complainant rejected the partial sanction of Rs.1,00,000/- offered by the 2^nd opposite party and mobilized the balance amount of Rs.2,81,319/- with great difficulty and paid the amount and got discharged from the 3^rd opposite party hospital.

5.         The complainant sent a legal notice on 05.05.2017 to the 1^st and 2^nd opposite parties calling upon them to settle the claim. In spite of submission of all necessary documents, the 2^nd opposite party in the capacity of authorized agent of the 1^st opposite party refused to process and discharge the claim of the complainant. The complainant has been regularly paying the premiums of the mediclaim policy to the 1^st opposite party and as such the 1^st opposite party should have settled the reasonable claim of the complainant without any delay but the 1^st opposite party has failed to settle the claim of the complainant. Hence, the 1^st and 2^nd opposite parties may be ordered to pay Rs.2,81,319/- with interest towards the balance amount of the claim that was paid by the complainant at the time of discharge to the 3^rd opposite party with great difficulty and Rs.1,00,000/- towards damages for the mental agony and physical hardships caused to the complainant because of the deficiency in the services of the 1^st and 2^nd opposite parties and the costs of this litigation.

The facts of written version of 1st Opposite Party:

6.         The 1^st opposite party states that the husband of the complainant paid the premiums for the policy, there was no privity of contract between the complainant and the 1^st opposite party, the complainant is not at all a beneficiary under the policy and hence the complaint has to be dismissed with cost. The complainant was originally covered in her husband’s “New Mediclaim 2012” policy bearing No: 72080034142500000043 for the period 10.06.2014 to 09.06.2015 with a coverage of Rs.3,00,000/- to complainant’s husband, Rs.2,00,000/- to complainant and Rs.1,00,000/- to their son. The husband of complainant renewed it with a gap of 2 days for the period 12.06.2015 to 11.06.2016 under a new scheme namely “New India Floater Mediclaim” with a coverage of Rs.8,00,000/- for all the 3 persons put together on floater basis and renewed it as Policy No. 72080034162800000013 for the period from 12.06.2016 to 11.06.2017.

7.         The terms and conditions differ from New Mediclaim 2012 to New India Floater Mediclaim policy. In paragraph 8 of the written version, the 1^st opposite party says that the 2^nd opposite party gave pre-approval for Rs.1,00,000/- on 22.04.2017. The 3^rd opposite party should have obtained approval for enhancement of further expenses. Neither the complainant not the 3^rd opposite party approached the 2^nd opposite party seeking enhancement approval. In paragraph 9, the 1^st opposite party says that as per policy condition, the 2^nd opposite party sent a mail to the complainant’s husband on 22.04.2017 stating that they were ready to pay Rs.1,00,000/- in addition for which there was no response from the side of the complainant’s husband. Even now the 1^st respondent is ready to pay the same Rs.1,00,000/- towards the claim of the complainant. Therefore the 1^st opposite party also says that the complainant had a break of 2 days in renewal of their policy in 2015. In paragraph 14, the 1^st opposite party says that as the complainant failed to submit the receipts regarding their further expenditure to the 2^nd opposite party, they were unable to process the claim.

8.         The 1^st opposite party has stated in paragraph 16 that the 2^nd opposite party has offered the complainant her legitimate claim of Rs.2,00,000/- as per her eligibility. In paragraph 20, the 1^st opposite party has expressed their willingness to transfer Rs.1,00,000/- as she is legally entitled to get it whenever the complainant provides her bank account details. They also say that clauses 5.11, 4.1, 4.2 and 4.3 are applicable to the claim of the complainant and accordingly her claim is rejected. Hence, they pray to dismiss the complaint with cost.

9.  Points to be considered:

1). Has the Opposite Party committed deficiency in their service as alleged by the complainant? If yes, what is the relief the complainant is entitled to?

2). Whether compensation can be awarded to the complainant?

3). What are the other reliefs the complainant is entitled to?

Points 1 and 2:

10.       The 2^nd opposite party in the capacity of representative of the 1^st opposite party gave the preauthorization letter for admission of the complainant in the 3^rd opposite party hospital for surgery and discharged Rs.1,00,000/- on 18.04.2017 as pre-approved amount. The 1^st opposite party has admitted that the complainant was originally covered in her husband’s “New Mediclaim 2012” policy bearing No: 72080034142500000043 for the period 10.06.2014 to 09.06.2015 with a coverage of Rs.3,00,000/- to complainant’s husband, Rs.2,00,000/- to complainant and Rs.1,00,000/- to their son. The husband of complainant renewed it for the period 12.06.2015 to 11.06.2016 under a new scheme namely “New India Floater Mediclaim” with a coverage of Rs.8,00,000/- for all the 3 persons put together on floater basis and renewed it as Policy No. 72080034162800000013 for the period from 12.06.2016 to 11.06.2017. We can find out that all the 3 persons covered under such policy are eligible for sum assurance of Rs.8,00,000/- put together.

11.       As per the terms of the policy, the complainant as soon she received the bill from the 3^rd opposite party approached the 2^nd opposite party seeking the balance amount of Rs.2,81,319/-, they said that only Rs.1,00,000/- is approved for “Rectal prolapse for lap combined ventral rectopexy with Sacro hysteropexy H/O hemorrhoidectomy 8 years back and sent a mail also the complainant. The complainant has received a certificate from the 3^rd opposite party’s doctor Venkatesh Munikrishnan who performed the surgery and submitted it directly to the 2^nd opposite party on 25.04.2017 seeking their assistance to pay the bill. As per the terms of the policy, all the 3 persons are covered with a total coverage of Rs.8,00,000/- put together.

12.       The 1^st opposite party says that the 2^nd opposite party gave pre-approval for Rs.1,00,000/- on 22.04.2017 before performing surgery on the complainant. The stand of the 1^st opposite party that the 3^rd opposite party hospital should have obtained prior approval for enhancement of further expenses is not acceptable. They further contend that neither the complainant not the 3^rd opposite party approached the 2^nd opposite party seeking enhancement approval before the surgery. In paragraph 9 of their written version, the 1^st opposite party says that as per policy condition, the 2^nd opposite party sent a mail to the complainant’s husband on 22.04.2017 stating that they were ready to pay Rs.1,00,000/- in addition for which there was no response from the side of the complainant’s husband. Here we have to note that they have not mentioned anything in their mail like the complainant or the 3^rd opposite party did not get seek our prior approval for further enhancement of claim. They have straight away given approval for further Rs.1,00,000/- which was not accepted by the complainant.

13.       The 1^st opposite party’s stand that the husband of the complainant renewed their previous policy with a gap of 2 days for the further period from 12.06.2015 to 11.06.2016 under a new scheme namely “New India Floater Mediclaim” with a coverage of Rs.8,00,000/- for all the 3 persons. The stand of the 1^st opposite party that floater coverage of Rs.8,00,000/- to all 3 persons will be applicable only if the complainant had renewed it without any gap is rejected as it has no merit. Their contention in paragraph 5 (iv) of their proof affidavit that as per their policy (Ex.B-3) condition No.2.7, in case of change in sum assured during uninterrupted coverage, the lowest sum assured would be considered for any claim is unacceptable and unethical. The 2^nd opposite party who is the agent of 1^st opposite party has not stated anything while discharging the 1^st installment of Rs.1,00,000/-. This itself is a serious violation of insurance rules.

14.       The 1^st opposite party has stated in paragraph 5 of their proof affidavit that as per conditions No.4.1, 4.2 and 4.3 of the policy (Ex.B-3) some diseases will attract coverage only if the policy holder is having a continuous coverage of such insured person for a particular period like 24 months, 48 months, etc. They further contend that some diseases will not get coverage even after 24 months if it arises from a pre-existing disease or pre-existing body condition of the insured. These contentions of the 1^st opposite party are not acceptable. Because the opposite parties do not totally deny the claim of the complainant. They have partially accepted and have given Rs.1,00,000/- and are still willing to give another Rs.1,00,000/- to the complainant any moment. At the time of renewal, the 1^st opposite party has assured to the complainant that as per the new policy namely “New India Floater Mediclaim” policy, all the family members get a coverage of up to Rs.8,00,000/- altogether instead of separate/specific coverage to each person.

15.       Therefore, it is concluded that the 1^st opposite party has deputed 2^nd opposite party to act in its place. The 1^st opposite party and 2^nd opposite party have committed deficiency in their service to the complainant. The 3^rd opposite party is only a formal party. The 1^st and 2^nd opposite parties have denied the complainant’s lawful claim of Rs.2,81,319/- and are jointly liable to pay the same to the complainant with interest. This commission comes to the conclusion that a compensation of Rs.2,00,000/- would be sufficient to the complainant for the mental agony and physical hardships caused to her. Hence, points No. 1 and 2 are answered accordingly.

Point No.3:

16.       The complainant has proved her case. She is eligible for compensation. This commission comes to the conclusion that Rs.10,000/- can be awarded as the cost of this litigation payable to the complainant by the 1^st and 2^nd opposite parties.

As result this Commission passes the following ORDER:

(i).        The 1^st and 2^nd opposite parties are directed to pay to the complainant a sum of Rs.2,81,319/- with interest at the rate of 9% per annum from the date of this complaint till the date of payment towards the balance amount of the insurance claim.

(ii).       The 1^st and 2^nd opposite parties are directed to pay to the complainant a sum of Rs.2,00,000/- towards compensation for the mental agony.

(iii).      The 1^st and 2^nd opposite parties are directed to pay to the complainant a sum of Rs10,000/- towards cost of this litigation.

            The 1^st and 2^nd opposite parties should pay all these amounts within a period of 2 months from the date of this order.

This Order was dictated by me to the steno today the fourteenth day of October, 2022, was taken notes in short-hand and then typed in computer and corrected by him and was pronounced by us in the open court today.

                                                                                                            President

                                                                                                            Member - I

                                                                                                            Member -II

Witness examined by the Complainant: S.Senthamil Selvi (Complainant)

Witness examined by 1st Opposite Party: B.A.Belson (Regional Manager of 1^st O.P)

2^nd and 3^rd Opposite Parties were set exparte on 25.01.2018

Exhibits marked by the Complainant:

Exhibits marked by the Opposite Party:

                                                                                                            President

                                                                                                            Member - I

                                                                                                            Member -II