Tamil Nadu

South Chennai

372/2010

D.Juliet Fancy - Complainant(s)

Versus

The New India Assurance Company Ltd., & another - Opp.Party(s)

M.A.R.Pragash

20 Jun 2017

ORDER

                                                                        Date of Filing :   17.09.2010

                                                                        Date of Order :   20.06.2017

DISTRICT CONSUMER DISPUTE 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

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

C.C.NO. 372/2010

TUESDAY THIS  20^TH   DAY OF JUNE 2017

D. Juliet Fancy,

W/o. P. Nelson,

No.29, Dr. Ambedkar Street,

Villivakkam,

Chennai -19.                                               .. Complainant

 

                                        ..Vs..

1.  The New India Assurance Company Ltd.,

Rep. by its Manager,

New No.453, Old No.312 Annasalai,

SIET, Teynampet,

Chennai -18.

 

2. Medi Assist India TPA Pvt. Ltd.,

Rep. by its Manager,

No.1, Lakshmi Ammal Street,

Ayyavu Naidu Colony First Floor,

Razak Garden Main Road,

Amanjikarai,

Chennai – 20.

 

3. Medi Assist India TPA Pvt. Ltd.,

Rep. by its Manager,

No.49, Shilpa Viday Building, I Main,

Sarakki Industrial Layout, 3^rd Phase,

J.P. Nagar, Bangalore 560 078.               .. Opposite parties.

 

Counsel for Complainant         :    M/s. M.A.R. Pragash & another    

Counsel for opposite party-1    :    M/s. Elveera Ravindran & another

For opposite parties 2 & 3       :    Exparte.

 

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 seeking direction to pay a sum of Rs.1,00,779/- towards reimbursement of medical expenses and also to pay a sum of Rs.90,000/- towards physical and mental agony to the complainant.

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

         The complainant submit that she joined the medi-claim policy on 21.8.2005.  Her Policy Number is 710400/34/09/11/00000507.  The complainant has been paying the premium amount without any break till date and hence the complainant is covered under insurance policy and entitled for medical reimbursement.   The complainant was admitted in the City Tower Hospital on 5.8.2009 for abdominal pain and she was advised to undergo certain treatment and surgery and finally the complainant was discharged from the hospital on 10.8.2010.    After the discharge from the Hospital the complainant applied for reimbursement on 7.9.2009 with all requirements along with relevant certificate and forms.  The same was acknowledged by the opposite party.    

2.     Further the complainant state that on 13.10.2009 the opposite party repudiated the claim as if all the disease are pre-existing when the policy was incepted by the complainant.  Further in the rejection form it is stated that the complainant was suffering from abdominal swellings since last 10 years.   It is pertinent to note that the certificate filled by the doctor as well as the complainant show that the complainant had  the abdominal pain only prior to three months.   As such the act of the opposite parties clearly amounts to gross deficiency in service which caused mental agony and hardship to the complainant.  Hence the complaint is filed.

3. The brief averments in the Written Version of  the 1^st opposite party   are as follows:

        The 1^st opposite party denies all the allegations made in the complaint  except those that are specifically admitted herein and puts the complainant to strict proof of all the allegations made therein.    The 1^st opposite party submit that the complainant was admitted for abdominal pain on 5.8.2009 and she had to undergo treatment and surgery and was discharged from hospital on 10.8.2009.    The  1^st opposite party also submit that she had applied for reimbursement on 7.9.2009 and that she had filed all the necessary details and documents with the opposite party and that the same was registered.    The 1^st opposite party further submit that on the receipt of the intimation from the complainant, as per the rules laid down by the IRDA for the speedy and effective disposal of claims, sent the papers to the 2^nd opposite party,  the third party administrators for processing the same.  

 4.    The 2^nd opposite party had on the application of mind to the documents available and the facts and circumstances of the case, intimated to the complainant vide their letter dated 13.10.2009 that the complainant was admitted to the hospital on 5.8.2009 for the treatment of obstructed umbilical hernia and the treating doctor certified that the complainant was suffering from abdominal swelling since the last 10 years and that the claim has been repudiated under the Exclusion Clause 4.1. of the medi claim policy.    The company shall not be liable to make any payment under the policy in respect of 4.1. Pre existing diseases All diseases / injuries / conditions which are pre-existing when the cover incepts for the first time.  Any complication arising from pre-existing disease / ailment / injury will be considered as a part of pre-existing condition.    Hence there is no deficiency in service on the opposite party and therefore this complaint is liable to be dismissed.  

5.     Inspite of service of notice the opposite parties 2 & 3 were called absent and set exparte.

6.      In order to prove the averments of the complaint, the complainant had filed proof affidavit as his evidence and documents Ex.A1 to Ex.A9 marked.  Proof affidavit of 1^st opposite party  filed and Ex.B1 to Ex.B5  marked on the side of the 1^st opposite party and oral arguments let in.    

7.   The point for the consideration is: 

 

1. Whether the complainant is entitled to a sum of Rs.1,00,779/- towards reimbursement of medical expenses as per prayed for ? .

 

2. Whether the complainant is entitled to a sum of Rs.90,000/- towards mental agony due to the deficiency of service committed by the opposite parties with cost as prayed for ?

 

 

 

8.  POINTS 1 & 2 :-

 

Both parties filed their respective written arguments.  The 1^st opposite party counsel advanced his oral arguments also.   The complainant’s counsel had not been ready for any oral argument for long time; hence it is treated that complainant have no oral argument.

         The complainant pleaded in his complaint and  stated in the written arguments that she joined the medi claim policy on 21.8.2005 and her policy Number is 710400/34/09/11/00000507.  The complainant paid the premium amount without any break continuously for four years  (i.e.) till 2010.   On 5.8.2009 the complainant was admitted in the City Tower Hospital, Chennai due to  sudden abdominal pain.   After due check up doctor told and diagnosed that the complainant is suffering from Obstructed Umbilical Hernia and advised to undergo treatment of surgery.  The complainant also undergone surgery resulting the linear incision skin flap raised umbilical hernia  and was discharged on 10.8.2009.  Ex.A5 is the discharge summary.  Ex.A6 is the medical certificate issued by the  doctor City Tower Hospital, Chennai.  The complainant filed Ex.A7 claim form for reimbursement of medical expenses incurred on 13.10.2009, the opposite parties repudiated the claim stating that the complainant is suffering from Abdominal swellings for the past 10 years and sent letter Ex.A9.  Hence the complainant is constrained to file this claim.  The complainant further pleaded and stated in the written arguments that as per Ex.A1 the complainant is entitled to reimbursement of medical expenses for abdominal pain.   As per Ex.A6 the complainant is suffering from such pain for the past three months.  The allegation that the complainant is suffering from abdominal pain for past 10 years is against true fact and also since the opposite parties has not come forward for reimbursement of medical expenses incurred by the complainant and repudiated the claim. The complainant sustained severe mental agony. The complainant is claiming a sum of Rs.1,00,779/- towards medical expenses and a sum of Rs.90,000/- towards mental agony. 

9.     The learned counsel for the 1^st opposite party would contend that the medical claim policy availed by the complainant is admitted.  The complainant’s husband took the policy for his family.  The complainant wantonly omitted to add her husband as a party.   But it is seen from Ex.A1 to Ex.A4 that the complainant and her whole family having separate assured amount towards medical expenses and paid the premium without any break or default from 21.8.2005 to 2010.   Further the learned counsel for the 1^st opposite party contended that the complainant was suffering from abdominal pain for past 10 years and as per clause 4.1. of the terms and conditions of the policy Ex.A1 the complainant is not entitled to reimburse the medical expenses and rightly repudiated the claim as per Ex.A9.   But on a careful perusal of Ex.A5 & Ex.A6 it is very clear that the complainant  undergone umbilical hernia  surgery which is admissible as per the terms and conditions of policy.  Further it is also very clear that the complainant has not undergone any surgery towards Abdominal swellings.  Hence the repudiation by the opposite party is imaginary and cannot be accepted.     As per the  terms  and  conditions 4.3, the complainant also  crossed the waiting period of two years.   Further it is seen that the claim was rejected by 3^rd party administrator, they have no role to issue such repudiation letter.    The  insurance company alone is entitled to issue such repudiation letter after due report from the medical officers.  Further the learned counsel for the opposite party contended that the claim of Rs.1,00,779/- towards medical expenses is very high; is not acceptable because it is solely based on the medical records.   Further the claim towards mental agony is  baseless exorbitant and imaginary.  Considering the facts and circumstances of the case, this forum is of the considered view that the complainant is entitled to a sum of Rs. 1,00,779/- towards reimbursement of medical expenses and compensation of Rs.20,000/- towards mental agony and also cost of Rs.5,000/- and the points 1 & 2 are answered accordingly.  

 

In the result, the complaint is  allowed in part.   The  opposite parties 1 to 3 are jointly and severally liable  to pay a sum of Rs.1,00,779/- (Rupees One lakh seven hundred and seventy nine only)  towards reimbursement of medical expenses and  compensation of Rs.20,000/- (Rupees twenty thousand only)  towards mental agony and also cost of Rs.5,000/- (Rupees Five thousand only) to the complainant

The above  amount shall be payable within six weeks from the date of receipt of the copy of the 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 Assistant, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the  20^th   day  of  June 2017.  

 

MEMBER-I                        MEMBER-II                             PRESIDENT.

Complainants” side documents:

Ex.A1-         -     - Copy of Medi claim Policy. 

Ex.A2- 21.8.2006  - Copy of Policy receipt.

Ex.A3- 19.8.2008  - Copy of Policy receipt.

Ex.A4- 18.8.2009  - Copy of Policy receipt.

Ex.A5- 10.8.2009  - Copy of Discharge Summary.

Ex.A6- 27.8.2009  - Copy of Medical certificate.

Ex.A7- 7.9.2009    - Copy of Claim Form.

Ex.A8- 10.9.2009  - Copy of Ack. Receipt.

Ex.A9- 13.10.2009         - Copy of Rejection letter.

Opposite parties’ side document: -   

Ex.B1-         -      - Copy of Policy of Insurance.

Ex.B2-         -       - Copy of terms and conditions of policy.

Ex.B3- 13.10.2009         - Copy of letter sent by 2^nd opposite party to complainant.

Ex.B4-         -       - Copy of letter from doctor.

 

 

MEMBER-I                        MEMBER-II                             PRESIDENT.