Tamil Nadu

South Chennai

32/2011

D.Juliet Fancy - Complainant(s)

Versus

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

M.A.R.Pragash

20 Jun 2017

ORDER

                                                                        Date of Filing :   14.12.2010

                                                                        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. 32/2011

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.57,778/- towards reimbursement of medical expenses and also to pay a sum of Rs.1,40,000/- 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 No. is 710400/34/07/20/00000589.   Accordingly 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 further state that in the year 1998 the uterus of the complainant was removed at Best Hospital, Kodambakkam, Chennai.  After the period of nine years, the complainant was admitted in the Rigid Hospital on 27.8.2007 for abdominal pain and after investigation it was found that there was Hernia in the incisional of removed uterus.   The complainant was advised to undergo certain treatment and surgery and finally the complainant was discharged from the hospital on 31.8.2007.   During the course of treatment the complainant had spent a sum of Rs.42,000/- for performing the operation and R.15,778/- towards the medicines in all totaling to a sum of Rs.57,778/-.   

2.     Further the complainant state that after the discharge from the Hospital the complainant applied for reimbursement on 16.9.2007 with all requirements along with relevant certificates and forms.    On 16.11.2007 the opposite parties repudiated the claim as if all the diseases are pre-existing.  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 Colum No.7 & 8 of the certificate filled by the doctor shows that the decease is not pre-existing and the duration of ailment also shows “nil”.   On 15.7.2009 the complainant made a representation to the opposite parties to provide all the particulars regarding the rejection of the claim.  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 even according to the complainant she had undergone removal of uterus in the year 1998.  In any event the same was not disclosed to the opposite party at the time of proposal of the policy.    Even according to the complainant she was diagnosed that there was hernia in the incision of removed uterus.    Hence the said treatment and surgery is for a pre existing disease and hence the same is not payable.  

4.     Further the 1^st opposite party state that on the receipt of the intimation form 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.    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 6.11.2007 that the inception of the policy was from 21.8.2005 and complainant was admitted to the hospital on 27.8.2007 for the treatment of  Incisional hernia and umbilical hernia and the treating doctor gave certificate that the complainant had abdominal swelling since the last 10 years and hence the claim has been repudiated under the Exclusion Clauses 4.1. of the medi claim policy. The company shall not be liable to make any payment under this 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.  

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

5.      In order to prove the averments of the complaint, the complainant had filed proof affidavit as her evidence and documents Ex.A1 to Ex.A10 marked.  Proof affidavit of 1^st opposite party  filed and Ex.B1 to Ex.B4  marked on the side of the 1^st opposite party and oral arguments let in.    

6.   The point for the consideration is: 

 

1. Whether the complainant is entitled to a sum of Rs.57,778/- towards reimbursement of medical expenses as per prayed

for ? .

 

2. Whether the complainant is entitled to a sum of Rs.1,40,000/- towards mental agony due to the deficiency of service committed by the opposite parties with cost as prayed for ?

 

 

7.  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 advanced any oral argument for long time; hence it is treated that complainant have no oral arguments.

 

8.     The complainant pleaded in her complaint and stated in the written arguments that she joined the medi claim policy on 21.8.2005 and her policy Number is 710400/34/07/20/00000589.  The complainant paid the premium amount without any break continuously till date.   On 27.8.2007 the complainant was admitted in the Rigid Hospital, due to  abdominal pain.   After due check up doctor diagnosed that the complainant is suffering from Hernia in the incision of removed uterus and advised to undergo treatment of surgery.  The complainant also undergone surgery and was discharged on 31.8.2007.  Ex.A5 is the medical certificate issued by a doctor Medi Assist India Pvt. Limited, Bangalore and the complainant filed claim form for reimbursement of medical expenses incurred on 16.09.2007, the opposite parties repudiated the claim stating that the complainant is suffering from Abdominal swellings since last 10 years.   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 swelling.   As per Ex.A1 the complainant is suffering such Abdominal swellings “nil”.  The allegation that the complainant is suffering from abdominal pain for past 10 years is against true fact.   Since the opposite parties has not come forward to 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.57778/- towards medical expenses and a sum of Rs.1,40,000/- 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 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 till date.   Further the learned counsel for the 1^st opposite party contended that the complainant was suffering from abdominal pain for the 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 reimbursement of the medical expenses and rightly repudiated the claim as per Ex.A5.   But on a careful perusal of Ex.A5 it is very clear that the complainant  undergone incisional hernia of removed uterus and undergone  surgery which is squarely admissible as per the terms and conditions of the 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, who 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.57778/- towards medical expenses is very high and not accepted.   It is solely based on the medical records.  Further the claim towards mental agony is 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.57778/- towards reimbursement of medical expenses and compensation of Rs.20,000/- towards mental agony and also cost of Rs.5,000/-  and 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.57,778/- (Rupees Fifty seven thousand seven hundred and seventy eight 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  amounts 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 Mediclaim Policy Form.

Ex.A2-         - Copy of Medical bills and Prescriptions.

Ex.A3-  31.8.2007 - Copy of Bill and Report.

Ex.A4-  28.8.2007 - Copy of Chart.

Ex.A5-  16.9.2007 - Copy of Claim form with medical certificate.

Ex.A6-  6.11.2007 - Copy of Rejection letter.

Ex.A7-  15.7.2009 - Copy of representation.

Ex.A8-  3.8.2009   - Copy of representation to grievance cell.

Ex.A9-  5.8.2009   - Copy of Ack. Receipt.

Ex.A10- 5.11.2009         - Copy of Rejection order.

Opposite party’s side document: -   

Ex.B1-         -       - Copy of Policy of insurance.

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

Ex.B3- 15.9.2007  - Copy of Medical Certificate.

Ex.B4- 6.11.2007  - Copy of letter given by 2^nd opposite party to complainant.  

 

 

 

MEMBER-I                        MEMBER-II                             PRESIDENT.