Tamil Nadu

North Chennai

168/2014

Mrs.S.Panjavarnam,W/o.Thiru.S.Srinivasa nadar, - Complainant(s)

Versus

The Oriental Insurance Co., Ltd,Rep by its manager, - Opp.Party(s)

M/s.R.Dhanalakshmi

25 Jan 2017

ORDER

                                                            Complaint presented on:  05.08.2014

                                                                Order pronounced on:  25.01.2017

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (NORTH)

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

 

PRESENT: THIRU.K.JAYABALAN, B.Sc., B.L.,        PRESIDENT

                    TMT.T.KALAIYARASI, B.A.B.L.,           MEMBER II

 

WEDNESDAY THE 25^th DAY OF JANUARY 2017

 

C.C.NO.168/2014

 

Mrs.S.Panjavarnam,

W/o. Thiru.S.Srinivasa Nadar,

No.103, Angalamman Koil Street,

Choolai, Chennai – 600 112.

                                                                                    ….. Complainant

 

..Vs.

1.The Oriental Insurance Co., Limited,

Rep. by its Manager,

Divisional Office – IV Lukman Manzil,

258, Third Floor,

Angappa Naicken Street,

Chennai – 600 001.

 

2. MD India Health Care Service TPA (P) Ltd.,

Rep. by its Manager,

3^rd Floor, Mount casa Blanea Building,

Anna Salai, Chennai – 600 040.

.....Opposite Parties

Date of complaint                                 : 26.08.2014

Counsel for Complainant                      : Ms.R.Dhanalakshmi

Counsel for 1st Opposite Party                : N.Vijayaraghavan,

 

Counsel for 2nd Opposite Party              : Ex - parte

                                       

                                                          

O R D E R

 

BY PRESIDENT THIRU. K.JAYABALAN B.Sc., B.L.,

          This complaint is filed by the complainant u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          The Complainant has taken a Medi-Claim Policy with the 1^st Opposite Party and was regular in payment of yearly premium. She is very regular in renewal of her policy and lastly she renewed on 20.01.2011. The policy covers hospitalization, treatment and costs of medicines to an extent of Rs.2,00,000/-. The Complainant states that 1^st Opposite Party assigned a policy bearing ref. No.411400/48/11/00955 for the period 05/02/2011 to 04/02/2012. The Complainant all of a sudden she fell ill during the month of August 2011. She got high fever and related serious sickness due to a benign neoplasm developed in her ovary side. On account of her deteriorating health condition and on the advice of her doctor, she got admitted in Apollo Hospital at Greams Road, Chennai on 26.08.2011 and was discharged from the hospital only on 31.08.2011 after full medical treatment.  The Complainant for the medical expenses suffered by her on account of the above said sickness amounting to Rs.1,23,966/-.  She had made a Medi Claim on 31.08.2011 but was repudiated and denied by the 2^nd Opposite Party who is acting on behalf of the first of you on 28.09.2011 under clause 4.10 and 5.4 of the policy issued to her by its letter dated 28.09.2011. The Complainant was shocked on account of the improper repudiation of 2^nd Opposite Party and therefore she was put in much mental agony. The Opposite Parties jointly and severally committed the Deficiency in Service. Having received the payment the Opposite Party did not consider the legitimate amount which was incurred by her at the time of the treatment. Inspite of all the documents submitted as per their requisition, the Opposite Parties denied the medical expenses which is unfair trade practice. The counsel sent the Legal Notice dated 11^th September 2012 which was received by the Opposite Party 1. Thus within a period of two years this Complaint is presented before this Hon’ble Forum. Therefore, it is humbly prayed that this Hon’ble Forum may be pleased to direct the Opposite Party to return the consideration paid a sum of Rs.1,23,966/- with and also for compensation for the mental agony and sufferings caused to the Complainant due to Deficiency in Service committed by the Opposite Party with costs of the Complaint.

2. WRITTEN VERSION OF THE 1^st OPPOSITE PARTY IN BRIEF:

          The Opposite Party admits that the Complainant was insured under Mediclaim Policy for the period from 05.02.2011 to 04.02.2012. The coverage under the policy is subject to specific terms and conditions. Any claim is payable only if falling within the scope of cover. The Opposite Party further submits that in respect of hospitalization policy requires immediate intimation prior to at least at the time of admission to enable the 2^nd Opposite Party to verify the medical records in order to determine the nature of ailment, proposed treatment etc. The Complainant submitted a claim for the expenses incurred at Apollo Hospital for the period from 26.08.2011 to 31.08.2011. The claim was dealt with by the 2^nd Opposite Party which is licensed by the Insurance Regulatory & Development Authority to act as “Third party Administrator” to process mediclaims. The 2^nd Opposite Party on intimation of hospitalization of Complainant perused all necessary records and documents and found that the claim was not admissible. The Complainant had failed to intimate the treatment as required by the policy but only submitted the claim after completing the treatment and discharge from the Hospital on 31.08.2011. During the period of treatment, or prior to admission the Complainant could have easily reported the same to the 2^nd Opposite Party through the Hospital itself for which adequate facilities have been provided. It is a breach of policy condition No.5.4.The course in hospital was found to be largely   evolution in nature without any significant treatment of any serious ailment. Such Expenses for hospitalization are excluded under the policy as per clause 4.10. The Opposite Party has taken the decision on the claim was taken as per terms of the policy and in the circumstances presented by the claim itself. The Opposite Party has not committed any deficiency and it cannot be accused of deficiency for having acted as per terms of the policy and the Complaint is liable to be dismissed with costs.        

3. POINTS FOR CONSIDERATION:

          1. Whether there is deficiency in service on the part of the opposite parties?

          2. Whether the complainant is entitled to any relief? If so to what extent?

4. POINT NO :1 

          The Complainant is the Mediclaim Policy Holder of the 1^st Opposite Party for the periods 05.02.2011 to 04.02.2012.  The Complainant was assigned policy No.411400/48/11/00955. The terms and condition of the policy issued by the 1^st Opposite Party is marked as Ex.A2 with policies for different years.  The Complainant suddenly fell with heavy fever during August 2011 and hence she was admitted  in the Apollo Hospital, Greams Road, Chennai on 26.08.2011 and she was discharged on  31.08.2011 and the said hospital issued Ex.A1 Discharge Summary to her. The Complainant made  a mediclaim on 31.08.2011, but the same was repudiated by the 2^nd Opposite Party on behalf of the 1^st Opposite Party under Ex.A3 dated 28.09.2011,  that in view of clauses.4.10 & 5.4 of the policy.

          5. The Complainant contended that he made the claim on the date of discharge for an amount of Rs.1,23,966/- spent  for her  treatment at Apollo Hospital and the same was rejected under Ex.A3 is not sustainable and therefore the Complainant is entitled for the claim made by her.

          6. The Opposite Party contended that as per the terms and conditions the policy clauses 4.10 & 5.4  that  the expenses incurred by the Complainant only for evaluation purpose  and the claim should have been made with prior notice within 48 hours of admission or  before discharge from the hospital  and due to above exclusion clauses the claim was repudiated and therefore the Complaint is not maintainable  and liable for dismissal.

          7. It is relevant to extract the policy condition clauses 4.10 & 5.4 below for better appreciation

         Clause 4.10: Expenses incurred at Hospital or Nursing Home primarily for evaluation/diagnostic purposes which is not followed by active treatment for the ailment during the hospitalized period.

         Clause 5.4:  Notice of Claim: Immediate notice of claim with particulars relating of Policy Number, ID Card No., Name of insured person in respect of whom claim is made, Nature of disease/illness/injury and Name and Address of the attending medical practitioner/Hospital/Nursing Home etc. should be given to the Company/ TPA while taking treatment in the Hospital/Nursing Home by Fax, E-mail. Such notice should be given within 48 hours of admission or before discharge from Hospital/Nursing Home, unless waived in writing.

As per clause 5.4 the insured shall issue notice to the insured within 48 hours of admission or before discharge from the hospital. The Complainant would state that he gave claim on 31.08.2011 on the date of discharge. However, nowhere she had stated that  before discharge she had given intimation that she was admitted in the hospital to the Opposite Parties and for the same no proof filed by the Complainant.

          8. Further as per clause 4.10 if the treatment is only for evaluation for diagnostic purposes the expenses incurred for that purpose will be excluded. Ex.A1 is the discharge summary issued by the Apollo Hospital where the Complainant undergone treatment as inpatient for the period 26.08.2011 to 31.08.2011. In the said discharge summary it has been clearly stated that the Complainant was admitted for the evaluation of fever for one week.  Therefore, the Complainant was admitted only for the purpose of evaluation and undergone treatment on the above said period and she had also not intimated  in time to the Opposite Parties to make claim and hence the contention of the Opposite Parties that the claim made by the Complainant was repudiated under the Exclusion Clause is accepted.  In view of such conclusion the claim made by the Complainant was repudiated under Ex.A3 is sustainable and therefore, it is held that the Opposite Parties have not committed any deficiency in service.

 

 

 

09. POINT NO:2

Since the Opposite Parties have not committed any deficiency in service, the complainant is not entitled for any relief as prayed and the complaint is liable to be dismissed.

          In the result the complaint is dismissed. No costs.

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 25^th day of January 2017.

 

MEMBER – II                                                               PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 31.08.2011                   Complainant’s discharge summary

Ex.A2  various dates               Policies of different years with terms and condition

                                                    issued by 1^st Opposite Party

 

Ex.A3  dated 28.09.2011                  Pre-repudiation statement by Opposite Party

Ex.A4 dated 11.09.2012                   Legal notice by Complainant

Ex.A5 dated 01.10.2012                   Reply sent by Opposite Party

LIST OF DOCUMENTS FILED BY THE  1^st  OPPOSITE PARTY :

                                                ……. NIL ……..

 

MEMBER – II                                                               PRESIDENT