Filed On: 31.5.2013
Disposed On:23.06.2015
DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, THIRUVALLUR
PRESENT: THIRU. S. PANDIAN, B.Sc., L.L.M., : PRESIDENT
TMT. S. SUJATHA, B.SC., : MEMBER-I
THIRU. V. VENKATESAN, M.A.B.Ed., MBA. M.PHIL.B.L., : MEMBER-II
Tuesday, the Day of 23rd June-2015
CC. No. 24/2013
C. Baskar
S/o. C. Chanda Bose
Salesman, Sri Lakshmi Agro Foods Ltd.,
New No. 6,T.H. Road, Toll Gate
Chennai – 500 019. …Complainant
-Vs-
The New India Assurance Company Ltd.,
Thiruvottiyur Branch (710203)
No. 251, T.H. Road, Thiruvvottiyur,
Chennai – 600 019. …Opposite Party
Counsel For the Complainant : Party –in-Person
Counsel For the Opposite Party : M/s. T.V. Suresh
ORDER
PRONOUNCED BY THIRU. S. PANDIAN, PRESIDENT,
District Consumer Disputes Redressal Forum, Thiruvallur District.
This complaint has been filed by the complainant under section 12(1) of the Consumer Protection Act 1986, against the Opposite party for seeking direction to pay a sum of Rs.60,000/- (Rupees Six Thousand only) for the mental agony and to pay back the balance amount of Rs. 60,000/- (Rupees Six Thousand only) towards the surgery to the management. Out of the huge amount of Rs.1,10,000/-
The brief facts of the complaint are as follows:
1. The complainant has taken Medi Claim Policy with New India Assurance Company, Thiruvottiyur Branch (710203) at 251, T.H. Road, Thiruvottiyur, Chennai- 600 019 for (hospitalization) benefit Policy No. 71020334 / 001/ 00203306 Rs.1,00,000/- since 2006 no previous claims. So Far, the complainant is eligible for ‘Bonus’ benefit also. The complainant submitted the claim form on 3.10.2011, though Medi Assist, India Ltd., as per company’s arrangement for a total sum of Rs.1,09,210/- but to his great shock and surprise, he received a cheque for Rs.43,216/- only by stating the reason that surgical charges or Rs. 70,000/- not paid through the hospital and so it can allow only Rs. 10,000/- as against Rs. 70,000/- paid. The surgeon has given computerized bill for Rs. 70,000/-.
2. The real fact is that conditions in the Insurance Policy as ‘Annexure’ has not been ‘Attached’ with the policy as expected. The Insurance agent also did not inform me the, said condition while paying the surgical charges. The factor involved and the ‘confusion’ and ‘Anxiety’ prevalent then, the complainant could not make any enquiry as to how payments to be made. The surgeon ‘warned’ the necessity of making immediate operation for this type of thyroid operation as life saving measure but for it his life would have been in danger. The Complainant paid the fees as but for it demanded before admission and he arranged for immediate admission in to Prasanth Multi Policy Hospital, Chetpet, Chennai, where the surgeon is specialist consultant for this type thyroid operation. The Hospital has given its own bill for Rs. 28,951/- so the complainant submitted the complaint with the Insurance Ombudsman, Chennai on 30.4.2012, against the award of the opposite party herein. However, by its Award dated 08.8.2012 ‘Dismissed’ the complaint. Hence, this complaint filed.
The averments of the Written Version of the Opposite parties are as brief as follows:
3. The alleged claim pertains to the treatment of the complainant for multi nodular Goiter at Prashanth Multispeciality Hospitals, Chetpet, Chennai-600 031 from 30.7.2011 to 02.08.2011 and the total claim was made for Rs. 1,09,2010/- and the opposite party settled the claim for Rs. 43,216/- during August 2011. Hence there was no deficiency of service. The Complainant by his letter dated. 30.09.2011 made a representation to Grievance Department and The Regional Manager of the Grievance Department upheld the decision of the TPA and replied by insurer letter dated.17.10.2011 that as per the policy terms and conditions 2.3 and 2.4, The applicable and eligible surgical fee was only Rs. 10,000/- . The complainant not satisfied with the reply of the Regional Manager, Grievance Department of Insurer (Opposite party), made a representation to Insurance Ombudsman and the Hon’ble Insurance Ombudsman Categorically discussed all the points and upheld the decision of TPA that the claim was settled as per the terms and conditions of the policy and the doctor’s fee of Rs. 10.000/- as against the claim of Rs. 70,000/- was allowed as per the terms and conditions of the policy. Therefore, there is no deficiency of service or short payment of claim amount to the complainant. The complainant’s claim was settled by M/s. Medi Assist who is the TPA of the opposite party as per the terms and conditions of the policy as per the schedule condition No. 2.0, 2.3, 2.4 and note 2. Hence, this complaint is liable to the dismissed.
4. On the side of the complainant, the proof of affidavit is filed for his evidence along with the documents Ex.A1 to Ex.A13. Similarly, on the side of the opposite party, the proof affidavit to filed as evidence and Ex.B1 to B2 marked.
At the Juncture, the vital point for considerations is:
- Whether there is any deficiency of service on the part of the Opposite party as narrated with complaint?
- Whether the complainant is entitled for any relief as prayed for?
5. Written Arguments filed on both sides and the copy of the same is furnished to either side. In condition with, oral arguments adduced on both sides.
6. Point No. (1) According to the case of the complainant is that the complainant has taken the Medi Claim Policy with the Opposite party’s Insurance Company for a Amount of Rs. 1,00,000/- since 2006 and it has been periodically renewal and then he made a claim for the Medical Expenses including the Hospitalization, Pharmacy, Surgery and Anesthetist for a sum of Rs. 1,09,210/- on 03.10.2011 but initially Rs.43,216/- only passed and subsequently it has been allowed only of Rs. 10,000/- as against Rs. 70.000/- paid for surgery and the remaining amount is not applicable under the terms and conditions of the Insurance Company which is highly arbitrary and the complainant is entitled to claim and get the whole amount of Rs. 70,000/- spent for surgery. While, the opposite party fully denied the allegation made in the complaint and the opposite party has acted upon as per rules and regulations of the Insurance Company and therefore the opposite party has rightly paid by cash of the restricted amount of Rs. 10,000/- and therefore, there is no deficiency of service and also there is no cause of action on the complaint.
7. At the outset, on careful perusal of the rival submissions put forth on either side, the taking of Medi Claim Policy for a sum of Rs. 1,00,000/- by the complainant, taking treatment by hospitalization due to underwent of operation of the complainant’s son and the payment of the Bills are all admitted by the opposite party. But the only contention on the side of the Opposite party is that as per policy clause 2.3, surgeon, Anesthetist, Medical Practitioner, Consultant, Specialist fee should be included with Hospital main Bill and as per the policy terms and conditions of 2.3 and 2.4, the applicable and eligible surgical fee was only 10,000/- as against the claim of the 70,000/- was allowed and paid in cash and also settled the claim of Rs. 43,216/- for hospitalization of the complainant from 30.07.2011 to 2.8.2011 at Prashanth Multi Speciality Hospital, Chetpet, Chennai and therefore there is no deficiency of service.
8. At the Juncture, on going through the proof affidavit of the complainant, it is seen that the details of the sufferings of the Thyroid disease and the hospitalization due to the surgery of the said disease which was taken place in the Multi Speciality Hospital, Chetpet, Chennai have been furnished. In order to prove the same Ex.A2 to Ex.A3, Ex.A7 to A10 are marked. It is further stated that the Insurance Policy taken by the complainant for a sum amount of Rs. 1,00,000/- for himself is marked as Ex.A6 and the claim form is marked as Ex.A1. It is further seen from the affidavit that the complainant received the cheque for Rs. 43,216/- for settlement of claim through Medi Assist. India Private Ltd., which is marked as ExA5. It is further stated in the proof affidavit that, on dissatisfaction of the settlement of claim by the opposite party, the complainant write a letter to the opposite party and to the effect reply received from the Medi Assist. is marked as Ex.A4 and the rejection letter from the Insurance Company is marked as Ex.A11 and Ex.A12 is the Insurance Ombudsman award and Ex.A13 is the extract of the Rule of 9 of the Insurance Ombudsman scheme by Quoting that an ombudsman’s award is not binding on the complainant, So If the vadict does not uphold his claim the party still have the option of approaching a court of law or a Consumer Forum and therefore, the complainant filed this complaint for the compensation.
9. While being so, the opposite party averred in their proof affidavit that the Policy schedule condition No. 2.0, 2.3 will clearly throw is the light relating to surgeon’s fee which is not a part of the Hospitalization bill, if paid by cash separately is restricted to Rs. 10,000/- which is rightly followed in the present case and the same was rightly allowed by the TPA reiterated by the grievance department of the opposite party and upheld by the Hon’ble Ombudsman and to prove the same ExB1 to B2 marked and hence there is no deficiency of service.
From the foregoing among other facts, it is crystal clear that except the claim amount of surgeon fee of Rs. 70,000/- other facts are all admitted by the opposite party. At the outset, it is an admitted fact that they Rs. 10,000/- awarded as against Rs. 70,000/- towards surgeon fee and the same was paid in cash to the complainant.
10. At this point of time, this forum has to consider as to whether the complainant is entitled for the claim of compensation of remaining surgeon fees of Rs.60,000/-. Regarding this point, on careful perusal of the Ex.A6, the Insurance Policy which is produced on the side of the complainant is not disputed by the opposite party. On bare seeing the Ex.A6 through naked eye it is learnt though there is a mentioning about the clause attached but it is actually not attached with the Ex.A6 and the same is not disputed by the opposite party at any point of time before the forum through proper evidence. So the arguments of the complainant that the real fact is that condition for passing claim amount purported to be contained in the Insurance Policy (ExA6) as Annexure has not been attached with the policy as expected and the Insurance agent also had not informed the said condition to the complainant while paying the surgical charges and the same was agreed by the opposite party during cross examination before the Ombudsman cannot be easily thrown act.
Furthermore, this Forum has to keep in mind that the Hon’ble Apex Court held in many cases that, in the policies, conditional claim only in English that too illegible nature is unreadable’, small letter even if educated and not included Regional Language Readable and understand by even an ordinary layman not educated enough and if the Insurance company insists upon such conditional clause while passing claim is not maintainable in law. Similarly, Entitlements cannot be scuttled by mere Technicalities and strict rule of proof cannot be insisted while considering any claim.
11. At the outset, this Forum wish to say that more technicalities found in the condition claim of note 2, under 2.3, the necessary surgeon fee and Anesthetist, fee should be reimbursed limited to the maximum of 25% of sum assured, provided the insured pays such fee through crossed cheque and if it is paid by cash may be entertained against a limit of Rs. 10,000/- only, provided the surgeon / Anesthetist provides a numbered bill, cannot be a valid ground to reject the claim of the complainant in toto.
In such circumstances, on seeing the Ex.A2 Bill, no doubt, that it is a numbered computerized bill furnished by the Hospital authority. Though there is an objection on the side of the opposite party, the said bill amount paid by cash not by cross cheque, but the complainant has explained the circumstances by which it was paid by cash. It is quite acceptable since every human being would always think of their life which they are in danger and hence the payment was made by cash on urgency for immediate operation. Whatever the mode of payment, the ultimate aim is the immediate payment for surgery has to be taken into consideration. Moreover, the source of collecting money is in many ways and hence, the mode of payment is only by crossed cheque cannot be expected. Since, there is no logic. Hence, the plea taken by the opposite party is hereby rejected.
12. In the light of the above facts, and circumstances, this Forum has without any hesitation to hold that the complainant has proved his case factually and legally and therefore he is entitled to get the balance amount of the sum assured of Rs.10,000/- deducting the amount already paid by the Opposite party in total Rs. 53,216/- and (Rs. 43,216/- + 10,000/-) therefore the opposite party has to pay of Rs. 46,784/- for the deficiency of service on the side of the Opposite party. Thus the point No. 1 is answered accordingly.
13. Point No. 2 In view of the decision arrived in point No.1, the complainant is entitled to get reasonable Compensation for the deficiency of service of the opposite party. Thus, this point No. 1 is answered accordingly.
In the Result, this complaint is allowed in part and accordingly the opposite party is directed to pay a sum of Rs.46,784/- (Rupees Forty Six Thousand Seven Hundred and Eighty Four Only) towards the surgery fees and Rs. 2,000/- (Two Thousand Only) towards compensation for mental agony.
The above amount shall be payable within one month from the date of the receipt of the copy of the order, failing which the said amount shall carry interest at the rate of 9% P.A. till the date of payment.
Dictated directly by the President to the Steno-typist, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 23rd day of June – 2015.
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MEMBER –I MEMBER-II PRESIDENT
List of Complainant Documents:
Ex.A1. - - - Xerox copy of Claim Form
Ex.A2. - 29.07.2011 - Xerox copy of Surgical fee of Rs. 70,000/- received by
the surgeon –by computerized Bill
Ex.A3. - 18.08.2011 - Xerox Copy of Details of Rs. 70,000/- bill
Ex.A4 - 29.10.2011 - Xerox Copy of Medi Assist Letter
Ex.A5. - 08.09.2011 - Xerox Copy of Axis Bank Cheque for Rs. 43,216/-
Ex.A6 - 25.02.2011 - Xerox Copy of Insurance Policy Schedule
Ex. A7. - 02.08.2011 - Xerox Copy Discharge Summary
Ex.A8. - 02.08.2011 - Xerox Copy of Pathology Report
Ex. A9. - 04.08.2011 - Xerox Copy of HPE Report (Apollo Report)
Ex.A10. - 02.08.2011 - Xerox Copy of Prashanth Hospital Bill for Rs. 28,951/-
Ex.A11. - 17.10.2011 - Xerox Copy of Insurance Company’s grievance cell
Rejection letter
Ex.A12. - 08.08.2012 - Xerox Copy of Insurance Ombudsman Award
Ex.A13 - 07.08.2012 - Xerox Copy of Extract of Rule 9 of Insurance
Ombudsman scheme
List Of Opposite Party Document:
Ex.B1. - 29.10.2011 - Xerox Copy of Medi Assist Letter
Ex.B2. - - - Xerox Copy of The New India Assurance Company
Medi claim Policy (2007)
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MEMBER – I MEMBER –II PRESIDENT
