Tamil Nadu

South Chennai

313/2009

E.A.Radhakrishnan - Complainant(s)

Versus

The Oriental Insurance Co.Ltd..& others - Opp.Party(s)

B.Naveen Raja

05 Jul 2018

ORDER

                                                                        Date of Filing  : 14.11.2008

                                                                          Date of Order : 05.07.2018

 

DISTRICT CONSUMER DISPUTES 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

 

C.C. No.313/2009

DATED THIS THURSDAY THE 05^TH DAY OF JULY 2018

                                 

Mr. E.A. Radhakrishnan,

S/o. Mr. E. Aravamuthu,

Old No.92, New No.69,

Rajeswari Illam – G1,

Thulasingam IInd Street,

Perambur,

Chennai – 600 011.                                               .. Complainant.                                           

 

     ..Versus..

1. The Oriental Insurance Co. Ltd.,

CBO XI,

Rep. by its Senior Branch Manager,

No.251, 1^st Floor, Arcot Road,

Vadapalani,

Chennai – 600 026.

 

2.  Medicare TPA Services India Pvt. Ltd.,

Rep. by its Regional Manager,

No.1, Circular Road,

United India Colony,

Kodambakkam,

Chennai – 600 024.                                         ..  Opposite parties.

          

Counsel for complainant            :  Mr. B. Naveen Raja

Counsel for 1^st opposite party   :  Mr. N. Maheswaraiah

Counsel for 2^nd opposite party  :  M/s. Elveera Ravindran & 

                                                       another

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 praying to pay a sum of Rs.83,673/- towards the expenses incurred by the complainant for his hospitalization and to pay a sum of Rs.1,00,000/- towards compensation for mental agony, physical hardship and strain suffered by the complainant  with cost of the complaint.

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

The complainant submits that the 1^st opposite party is the Insurance Company issued Mediclaim policy to the complainant.  The 2^nd opposite party is the 3^rd party Administrator appointed for the speedy and effective processing of the claim by the customers of the 1^st opposite party.  The policy availed by the complainant can be used to reimburse the medical expenses incurred for any disease or suffer from any illness or bodily injury through accident treated by a duly qualified Medical Practitioner as inpatient.   The 1^st opposite party after receiving premium issued policy No.412001/48/2007/636 dated:17.05.2006 covering the period from 12.05.2006 to 11.05.2007 for a sum of Rs.1,00,000/-.  The complainant renewed the policy for the period from 12.05.2007 to 11.05.2008.  On 05.09.2007, the complainant had some breathing difficulty and was admitted at Life Line Rigid Hospital and was diagnosed as Epigastric Discomfort (GERD), Diabetes Mellitus, Hypertension, Bronchial Asthma and Ischemic Heart Disease. The complainant undergone a Laparoscopic Fundoplication Surgery and was discharged on 13.09.2007.  The complainant duly informed the opposite parties with regard to the ailments and treatment and submitted claim form claiming a sum of Rs.83,673/-.  But the opposite parties even after inordinate delay repudiated the claim on 05.10.2007 as the disease of the complainant is one of pre-existing nature.  Hence the complainant issued notice dated:03.05.2008 to the opposite parties.  But the opposite parties has not come forward to settle the complainant’s claim.   The act of the opposite parties caused great mental agony to the complainant.  Thereafter, the complaint is filed.

2.     The brief averments in the written version filed by the  1^st opposite party is as follows:

The 1^st opposite party specifically denies each and every allegation made in the complaint and puts the complainant to strict proof of the same.   The contention of the 1^st opposite party is that the complainant availed Medi claim Insurance Policy for the period from 12.05.2006 to 11.05.2007 covering himself and his wife for a sum of Rs.1,00,000/- each.  The policy was subsequently renewed from 12.05.2007 to 11.05.2008.   The policy excludes pre-existing condition under clause 4.1.  The treatment and expenses which are bound to occur or there is substantial possibility of the same is excluded.  There cannot be any liability of pre-existing condition of the insured which is specifically excluded.   The claim made by the complainant under the policy for hospitalization on 05.09.2007 and Laparoscopic Fundoplication Surgery performed on 11.09.2007 is excluded because in the discharge summary dated:13.09.2007, the complainant was diagnosed as follows:

“GERD + DM + HT + 13A + IHD GASTRO ESOPHAGEAL REFLEX DISEASE + DIABETES MELLITUS + HYPERTENSION + BRONCHIAL ASTHAMA + ISCHEMIC HEART DISEASES" 

The 2^nd opposite party who is the Medical Expert for 3^rd party claim dealt with the claim categorically opined that the aforesaid physical condition of the patient which warranted surgery was such that the disease process (GED 99%) is likely to be pre-existing in nature.   The disease was found to be clearly pre-existing on the basis of the physical condition reflected by the medical records.  The 1^st opposite party had considered the claim carefully on the basis of available records and medical opinion, in accordance with policy conditions.  There was no negligence or deficiency in service on the part of the 1^st opposite party.  Therefore, the complaint is liable to be dismissed.

3.     The brief averments in the written version filed by the 2^nd opposite party is as follows:

The 2^nd opposite party specifically denies each and every allegation made in the complaint and puts the complainant to strict proof of the same.   The 2^nd opposite party submits that they are merely third party administrators who have been assigned the task of mitigating the time spent by the respective insurance companies to process claims that are submitted to the insurance companies and as such they are only rendering a beneficial service as they receive the claim papers from the respective insurance company and scrutinize the same for the speedy settlement and effective disbursement of legitimate claims being bound by the rules of the IRDA.  Hence the 2^nd opposite party submits that the policy of insurance under which the complainant was filing his claim was issued by the 1^st opposite party who are the insurer and hence there is no privity of contract been the 2^nd opposite party and the complainant and hence the complaint to be dismissed in limine on that ground.  The insurance company is the final authority in deciding the fact of each claim, based on the recommendation sent to them and in no way is the insurance company bound to accept the recommendation so sent to them by the 2^nd opposite party.  Therefore, there is no deficiency in service on the part of the 2^nd opposite party.   Hence the complaint is liable to be dismissed.

4.   In spite of sufficient time is given, the complainant and the 2^nd opposite party have not come forward to file their respective proof affidavits in order to prove the averments made in the complaint and written version.   Hence the evidences on the side of the complainant and 2^nd opposite party are closed on 11.11.2010.   Proof affidavit of the 1^st opposite party is filed and document Ex.B1 is filed and marked on the side of the 1^st opposite party.

5.     The points for consideration is:-

1. Whether the complainant is entitled to a sum of 83,673/- expended towards hospitalization as prayed for?
2. Whether the complainant is entitled to a sum of Rs.1,00,000/- towards compensation for mental agony, physical hardship and strain etc with cost as prayed for?

6.     On point:-

The complainant after filing of the complaint has not turned up and filed proof affidavit to prove the contentions in the complaint.   The complainant has not turned up to advance any argument also.  Heard the opposite parties’ Counsel.  Perused the records namely the complaint, written versions, proof affidavit and written arguments of the 1^st opposite party.  The complainant eventhough filed several documents along with the complaint, has not come forward to mark the documents through proof affidavit in this summary proceedings.  The law is well settled that unmarked documents cannot be looked into.  The complainant pleaded in the complaint that the 1^st opposite party is the Insurance Company issued Mediclaim policy to the complainant.  The 2^nd opposite party is the 3^rd party Administrator appointed for the speedy and effective processing of the claim by the customers of the 1^st opposite party.  The policy availed by the complainant can be used to reimburse the medical expenses incurred for any disease or suffer from any illness or bodily injury through accident treated by a duly qualified Medical Practitioner as inpatient.   The 1^st opposite party after receiving premium issued policy No.412001/48/2007/636 dated:17.05.2006 covering the period from 12.05.2006 to 11.05.2007 for a sum of Rs.1,00,000/-.  The complainant renewed the policy for the period from 12.05.2007 to 11.05.2008.  On 05.09.2007, the complainant had some breathing difficulty and was admitted at Life Line Rigid Hospital and was diagnosed as Epigastric Discomfort (GERD), Diabetes Mellitus, Hypertension, Bronchial Asthma and Ischemic Heart Disease. The complainant undergone Laparoscopic Fundoplication Surgery and was discharged on 13.09.2007.  The complainant duly informed the opposite parties with regard to the ailments and treatment and submitted claim form claiming a sum of Rs.83,673/-.  But the opposite parties evenafter inordinate delay repudiated the claim on 05.10.2007 as the disease of the complainant is one of pre-existing nature.  Hence the complainant issued notice and filed this complaint.  Eventhough the complainant filed several documents along with the complaint has not come forward to mark the documents with proper proof affidavit of evidence.   

7.     The contention of the opposite party is that admittedly, the complainant availed Medi claim insurance for the period from 12.05.2006 to 11.05.2007 covering himself and his wife for a sum of Rs.1,00,000/- each.  The policy was subsequently renewed from 12.05.2007 to 11.05.2008.   The policy excludes pre-existing condition under clause 4.1.  The treatment and expenses which are bound to occur or there is substantial possibility of the same is excluded.  There cannot be any liability of pre-existing condition of the insured which is specifically excluded.   The claim made by the complainant under the policy for hospitalization on 05.09.2007 and Laparoscopic Fundoplication Surgery performed on 11.09.2007 is excluded because the discharge summary dated:13.09.2007 shows that the complainant was diagnosed as follows:

“GERD + DM + HT + 13A + IHD GASTRO ESOPHAGEAL REFLEX DISEASE + DIABETES MELLITUS + HYPERTENSION + BRONCHIAL ASTHAMA + ISCHEMIC HEART DISEASES" 

The 2^nd opposite party who is the Medical Expert for 3^rd party claim dealt with the claim categorically opined that the aforesaid physical condition of the patient which warranted surgery was such that the disease process (GED 99%) is likely to be pre-existing in nature.   Considering the policy duration is of 16 months only and  hence the opposite parties rightly repudiated the claim.  Further the contention of the opposite parties is that there was no negligence or deficiency in service on the part of the opposite party and the complainant is not entitled to any compensation.  Considering the facts and circumstances of the case this Forum is of the considered view that the compliant has to be dismissed.

In the result, this complaint is dismissed.  No costs.

Dictated  by the President to the Steno-typist, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 05^th day of July 2018. 

 

MEMBER –I                                                                      PRESIDENT

COMPLAINANT SIDE DOCUMENTS:  EVIDENCE CLOSED

1^ST OPPOSITE  PARTY SIDE DOCUMENTS:  

Ex.B1

02.11.2009

Medical Opinion by a Doctor - Original

 

2^ND OPPOSITE  PARTY SIDE DOCUMENTS:  EVIDENCE CLOSED

 

MEMBER –I                                                                      PRESIDENT