Tamil Nadu

South Chennai

847/2009

C.Indumathi - Complainant(s)

Versus

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

N.Subramani

26 Oct 2015

ORDER

                                                                        Date of Filing : 06.08.2009

                                                                        Date of Order : 28.10.2015

 

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, CHENNAI(SOUTH)

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

 

PRESENT: THIRU. B. RAMALINGAM M.A.M.L.,                     : PRESIDENT

                 TMT. K.AMALA, M.A. L.L.B.,                                 : MEMBER I

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

 

C.C.NO.847/2009

       WEDNESDAY THIS  28^TH  DAY OF OCTOBER  2015     

 

Mrs. C. Indumathi,

W/o. Late S.Chandra Babu,

No.17, Ebrahim Sahib Street,

Chennai 600 001.                                                      .. Complainant.                      

             ..Vs..

 

1.  The Oriental Insurance Co. Ltd.,

Divisional Office X,

Dwaraka 2^nd Floor,

No.79, Uttaman Gandhi Road,

Chennai 600 034.

 

2. The Manager,

Medicare TPA Services (P) Ltd.,

No.1, Circular Road,

United India Colony,

Kodambakkam,

Chennai 600 024.                                            ..Opposite parties.

 

 

For the Complainant                    :  M/s. N.Subramani & another  

For the Opposite party-1              :  M/s. Nageswaran & Narichania

For the Opposite party-2              :  M/s. Elveera Ravindran & another

 

        This complaint is being filed by the complainant u/s 12 of the C.P. Act 1986 for a direction to the opposite parties to pay the mediclaim bill amount and also to pay a sum of Rs.2,00,000/- as compensation and Rs.5,000/- towards the cost of the compliant to the complainant.

ORDER

 

THIRU. B. RAMALINGAM PRESIDENT

 

         

1.The case of the complainant is briefly as follows:-

        The complainant obtained Mediclaim policy in No.41200/48/2007/808 on 3.9.2007 from the opposite parties.   He paid the installments regularly to the opposite parties.  On 2.5.2007 the complainant underwent abdominal Histerectomy surgery with Bilateral Salphingo Oopherectomy.  The complainant applied for claim of the above medical expenses on 14.5.2007 and enclosed discharge summary and hospital bills.    But the opposite parties  have rejected complainant’s claim on 13.8.2007 without any proper reason.    She again renewed the policy and has paid the premium installments regularly.  On 29.10.2007 the complainant again made a reminder claiming the medical claim bill amount.    Again she underwent a surgery for Disc Prolapse on 24.9.2007. She again lodged a claim before the opposite parties for the expenses incurred for the above said surgery.   Despite of several demands the opposite parties have not taken any steps to pay the claim amount.      Accordingly the complainant issued a legal notice to the opposite parties on 8.5.2008.   Both the opposite parties received the said notice on 12.5.2008.  But till date they have not paid the claim amount.     As such the act of the opposite parties is amounts to deficiency of service and which caused mental agony and hardship to the complainant.   Hence the above complaint.    

Written version of   1^st  opposite party is  as follows:-

 

2.     It denies all the averments and allegation contained in the complaint except those that are specifically admitted herein.    It is true that the complainant joined a Industrial Mediclaim policy bearing No.412000/48/2008/808.  The policy period is 4.9.2007 to 3.9.2008.  The said policy was issued, subject to the terms and conditions forming part of the policy.   The said two treatments and surgeries undergone by the complainant are pre existing disease on the date of inception of the medi claim policy, as such as per the terms and conditions of the policies, exclusion Clause 4.1, 4.2 and 4.3 the said surgery within the condition mentioned period not covered.  As such the opposite parties have repudiated the said claim made by the complainant are proper.    There is no deficiency of service on the part of the opposite party.    Hence the compliant is liable to be dismissed.

Additional Written version of   1^st  opposite party is  as follows:-

 

3.     It denies all the averments and allegation contained in the complaint except those that are specifically admitted herein. The complainant has filed the complaint for rejection of two claims.  The first claim under the policy No.412000/48/2007/808 from 4.9.2006 to 3.9.2007 was lodged for “Hysterectomy” surgery with Bilateral Salphingo Oopherectomy done on 14.5.2007.  The said claim was repudiated by the 1^st opposite party as hysterectomy is excluded as per policy terms and condition under exclusion No.4.3 (ix) for the first two years, since the claim was lodged under first year of policy the same was not admissible and therefore the claim was repudiated.   The 2^nd claim was lodged with 2^nd opposite party herein, under the renewal policy No.412000/48/2008/882 for the period from 4.9.2007 to 3.9.2008 for surgery of Disc Prolapse L5 Sl.   The 2^nd opposite party considering the MRI Scan report that extensive degenerative change with secondary canal stenosis suggests that disease is long standing and the degeneration process takes years to develop and as this is 2^nd year policy, the claim was repudiated as the disease is pre-existing as per the exclusion 4.1 of the policy conditions.    Moreover, the surgery for Disc prolapsed arising from accident is excluded under the policy exclusion No.4.3 (xx) apart from Ex.No.4.1 pre-existing as quoted by the 2^nd opposite party.  Hence the claim for two surgeries, i.e. hysterectory and disc prolapsed falls under the exclusion No.4.3 (ix) and (xx) respectively.  Hence the compliant is liable to be dismissed.

Written version of  2nd   opposite party is  as follows:-

 

4.     It denies all the averments and allegation contained in the complaint except those that are specifically admitted herein.      At the outset the 2^nd opposite party submit 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 Oriental Insurance Company Limited, the 1^st opposite party herein, who are the insurer and hence there is no privity of contract between the opposite party and the complainant herein and hence the said dispute ought to be dismissed in limine on this ground and the said complaint deserves to be dismissed.

5.   Complainant has filed his Proof affidavit and  Ex.A1 to Ex.A11 were marked on the side of the complainant.   Opposite parties have filed his proof affidavit and Ex.B1 to Ex.B4  marked on the side of the opposite parties. 

6.      The points that arise for consideration are as follows:-

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

 

2. To what relief the complainant is entitled to?  

7.      POINTS 1 & 2 :

         Perused the complaint  filed by the complainant, written version filed by the 1^st & 2^nd opposite parties, and additional written version filed by the 1^st opposite party and  proof affidavit filed by the complainant and the  opposite parties and the documents   Ex.A1 to Ex.A11 filed on the side of the complainant and the documents Ex.B1 to Ex.B4 filed on the side of the opposite parties and considered both side arguments.

8.     There is no dispute that the complainant had taken a medi claim policy from the 1^st opposite party insurance company.   The polices Ex.A1 filed by the complainant which was in force for the period from 4.9.2006 to 3.9.2007 and 4.9.2007 to 3.9.2008 respectively. On 2.5.2007 the complainant underwent abdominal Hysterectomy surgery with Bilateral Salphingo Oopherectomy.   She had made a claim before the 1^st opposite party and same was rejected by the opposite party on 13.8.2007.   The complainant again underwent a surgery for Disc Prolapse on 24.9.2007 she made another claim for the reimbursement of the medical expenses of Rs.81795/- for the said hospitalization from the 1^st opposite party.   The same was also not settled and rejected by the 1^st opposite party.    As such the complainant has filed this complaint against the opposite parties for claiming the settlement of the said amount incurred by her for hospitalization on two occasions and  compensation with litigation expenses to the complainant.

9.     Whereas the opposite parties has raised objection stating that the said two treatments and surgeries undergone by the complainant are pre existing disease on the date of inception of the medi claim policy, as such as per the terms and conditions of the policies, exclusion Clause 4.1, 4.2 and 4.3 the said surgery within the condition mentioned period not covered, as such the opposite parties have repudiated the said claim made by the complainant are proper.  The complaint is to be dismissed.  

10.    The opposite parties has filed the terms and conditions for the said medi claim policies as Ex.B1.  The said 1^st medi claim policy taken by the complainant was 4.9.2006 to 3.9.2007 and which is in force from 4.9.2007 to 3.9.2008.  Whereas the complainant has undergone treatment and surgery for Hysterectomy surgery with Bilateral Salphingo Oopherectomy on 2.5.2007 and claim made by the 2^nd hospitalization by the complainant is for the Disc Prolapse are excluded as per exclusion Clause 4.3 (ix) and 4.3 (xx) by the opposite parties is proper when going through the terms and conditions Ex.B1 filed by the opposite parties for the said medi claim policies.   Therefore we are of the considered view that though the complainant was in possession of the medi claim policies for relevant period the claim made by the complainant during first year of her policies which was an exclusion as per the policy condition 4.3. (ix) i.e. Hysterectomy surgery with Bilateral Salphingo Oopherectomy is not covered within two years of inception of the policy.   The 2^nd claim made by the complainant in the 2^nd year of the said policy where exclusion clause 4.3 (xx) clearly states that “surgery for prolapsed inter vertebral disk unless arising from accident” for two years is not payable.   On the said exclusion of clause of terms and conditions the repudiation / rejection of the said claim made by the complainant by the opposite party is proper and are in order and cannot be said to be unreasonable.   Therefore the said act of repudiation of the claim made by the complainant by the opposite parties will not amount to deficiency of service.  As such the complainant is not entitled for any relief sought for in the complaint  against opposite parties and the complaint is liable to be dismissed.  Considering the facts and circumstances parties have to bear their own cost of litigation and as such the points 1 & 2 are decided accordingly.

        In the result this complaint is dismissed. No cost.    

Dictated to the steno-typist transcribed and typed by her corrected and pronounced by us on this the 26^th    day of October   2015.

 

MEMBER-I                        MEMBER-II                             PRESIDENT.

Complainant’s side documents :

Ex.A1- 23.4.2007      - Copy of Insurance policies.

Ex.A2- 14.5.2007      - Copy of letter from Complainant to 1^st  opposite party.

Ex.A3- 13.8.2007      - Copy of letter from 1^st opposite party to complainant.

Ex.A4-         -       - Copy of payment receipts.

Ex.A5-          -       - Copy of discharge summary.

Ex.A6- 29.10.2007    - Copy of letter from complainant to 1^st opposite party.

Ex.A7- 31.10.2007   – Copy of letter from 1^st opposite party to complainant.

Ex.A8- 2.11.2007      - Copy of letter from complainant to 2^nd opposite party.

Ex.A9- 7.11.2007      - Copy of letter from 2^nd opposite party to complainant.

Ex.A10- 8.5.2008      - Copy of legal notice by complainant.

Ex.A11-         -       - Copy of Acknowledgment.

 

Opposite parties’ side  documents:  

 

Ex.B1-          -       - Copy of Medi claim Insurance policy.

Ex.B2- 13.8.2007      - Copy of Scan Report.

Ex.B3- 5.8.2008       - Copy of claim repudiation letter.

Ex.B4- 17.12.2007     - Copy of letter sent by 2^nd opposite party.

 

 

 

MEMBER-I                        MEMBER-II                             PRESIDENT.