Tamil Nadu

North Chennai

CC/112/2016

Mr.A.Venkatraman - Complainant(s)

Versus

The Oriental Insurance co.Ltd - Opp.Party(s)

P.B.Sampathkumar

29 Nov 2017

ORDER

 

                                                            Complaint presented on:  15.06.2016

                                                                Order pronounced on:  29.11.2017

 

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

              THIRU. M.UYIRROLI KANNAN B.B.A., B.L.,      MEMBER - I

WEDNESDAY THE 29^th   DAY OF NOVEMBER 2017

 

C.C.NO.112/2016

 

Mr.A.Venkatraman,

S/o.Arul,

No.7, Angalamman Koil Street,

Pungampedu,

Minjur Post,Ponneri T.K.,

Tiruvallur District – 602 107.

 

                                                                                    ….. Complainant

 

..Vs..

 

1.The Oriental Insurance Company Limited,

Rep. by its Authorized Signatory,

Oriental House, 1^st Floor,

No.215/115 Prakasam Salai,

Broadway,

Chennai – 600 108.

 

2.The Manager,

M/s. MD India Healthcare Services (TPA) Pvt. Ltd.,

No.260/16, 3^rd Floor,

Mount Road Cass Blanca,

Near Raj Video Vision,

Anna Salai, Chennai – 600 006.

.....Opposite Parties

Date of complaint                                 : 15.07.2016

Counsel for Complainant                      : M/s.P.B.Sampathkumar, D.Gopinathan

Counsel for 1^st Opposite Party                 : M/s. Nageswaran & Narichania

Counsel for 2^nd 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 to pay the balance amount of Rs.96,099/- towards medical expenses and also compensation for deficiency in service and mental agony with cost of the complaint u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          The complainant took mediclaim policy under “Happy Family Floater Policy” dated 16.04.2015 for the period 20.04.2015 to 19.04.2016.  The complainant paid a premium of Rs.9,966/- and the sum assured was Rs.3,00,000/- and personal accident cover for Rs.13,00,000/-  This policy has a deduction of 10% as per agreement of policy which amount will be deducted from the available sum insured.

          2. The complainant’s mother Mrs.A.Ruby had no complaints at the time of inception of the policy. However, she complained of abdominal pain in January 2016. She was admitted in the Apollo Hospital, Tondiarpet and was diagnosed that she was suffering from Fibroid Uterus Umbilical Hernia.  The doctor advised for surgery. The complainant applied for pre approval on 11.02.2016 to the opposite party for surgery. After 12 days they sanctioned the pre approval for Rs.1,00,000/-. After deducting 10%, the opposite party authorized an amount of Rs.90,000/- as per the authorization letter dated 22.02.2016. After getting this approval the doctor conductor surgery on 24.02.2016 and billed for an amount of Rs.1,41,099/- for surgery. 

          3. The opposite party issued another authorization letter dated 02.03.2016 after the surgery cancelling the earlier amount of Rs.90,000/- and further approved only for an amount of Rs.45,000/-.  The sum assured in the policy was Rs.3,00,000/- and the complainant is entitled for the such assured amount. However, the opposite parties sanctioned a sum of Rs.90,000/-  and subsequently reduced the said sum to a sum Rs.45,000/- is a clear case of deficiency on the part of the opposite parties. The complainant was previously holding mediclaim policy continuously for several years.  Failure to sanction the assured amount, the complainant suffered with mental agony is accepted. Hence the complainant filed this complaint to pay the balance amount of Rs.96,099/- towards medical expenses and also compensation for deficiency in service and mental agony with cost of the complaint.

          4. The 2^nd opposite party is called absent and he was set ex-parte.

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

           The 2^nd opposite party is the 3^rd party administrator of the 1^st opposite party. The 1^st opposite party admits that the complainant availed a “Happy Family Floater Policy” for the period 20.04.2015 to 19.04.2016 and his mother was admitted in the Apollo Hospital for treatment and at his request they sanctioned a sum of Rs.90,000/- as initial pre-authorization and subsequently the said amount was reduced to Rs.45,000/- based on the medical history of the patient.

          6. The complainant had mediclaim policy with the United India Insurance Company for the period 2012 – 2013 & 2013 – 2014 for a sum insured of Rs.50,000/-. The insurance cover was raised to Rs.1,00,000/- for the period 2014 – 2015. Subsequently the said sum was further raised to Rs.3,00,000/-  with the 1^st opposite party for the year 2015 – 2016.

          7. As per the terms and condition of the policy under clause 4.3 there are exclusion for the expenses on treatment for ailment/surgeries during the current policy.  The surgery for hernia is not payable under the current policy for two years from the inception of the policy i.e under the current policy period of 2015/2016. Therefore, the insurance cover for the period 2013/2014 was taken into consideration and applying the sum insured of Rs.50,000/- the claim was evaluated. The third administrator made payment and issued a claim payment statement for payment of Rs.45,000/- amount less 10% and final payment of Rs.40,500/- based on the policy cover for the year 2013/2014 as the treatment taken by the mother of the insured was not covered under the current policy issued by the first opposite party.

          8. The treatment/operation for umbilical hernia is clearly excluded for initial two years under the current insurance cover and for an enhanced sum insured. Thus, the claim is beyond the scope of coverage of insurance under the policy issued by the first opposite party. Therefore this opposite party has not committed any negligence or deficiency in service and prays to dismiss the complaint with costs.

9. 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?

10. POINT NO :1

          The admitted facts are that the  complainant took mediclaim policy under “Happy Family Floater Policy” dated 16.04.2015 for the period 20.04.2015 to 19.04.2016 which is marked as Ex.A2 and the complainant paid a premium of Rs.9,966/-  and the sum assured was Rs.3,00,000/- and the personal accident cover for Rs.13,00,000/-and  this policy has a deduction of 10% as per agreement of policy which amount will be deducted from the available sum insured  and the  complainant mother Mrs.A.Ruby had complained of abdominal pain in January 2016 and she was admitted in the Apollo Hospital, Tondiarpet and was diagnosed that she was suffering from Fibroid Uterus Umbilical Hernia and the doctor advised for surgery and  the complainant applied  under Ex.A8  request for pre authorization  on 11.02.2016 to the opposite parties  for surgery and  after 12 days they sanctioned the pre approval for Rs.1,00,000/- and after deducting 10%, the opposite party authorized amount of Rs.90,000/- under Ex.A12   authorization letter dated 22.02.2016 and after getting this approval the doctor conductor surgery on 24.02.2016 and billed Ex.A15  for an amount of Rs.1,41,099/- for surgery and she was issued Ex.A16 discharge summary.

          11. The complainant filed Ex.A1 & Ex.A19 copy of medi claim policies for the period 2006 to 2015 with United India Insurance Company Limited. He took “Happy Family Floater Policy” dated 16.04.2015 for the period 20.04.2015 to 19.04.2016 which is marked as Ex.A2. The complainant mother admitted in the Apollo Hospital for Hernia Surgery and he had applied for pre authorization based on Ex.A2 policy. The opposite parties initially sanctioned a sum   of Rs.1,00,000/- less 10% for a sum of Rs.90,000/- and the said sum was again reduced to Rs.45,000/- less 10%.  However, in the policy in force, the sum assured was Rs.3,00,000/-.

          12. The opposite parties would contend that as per the policy terms and conditions, under clause 4.3 there are exclusion for the expenses on treatment ailment or surgeries for specific periods not payable if the diseases contracted during the current period of the policy.  Admittedly the complainant mother suffered hernia during the current period policy of “Happy Family Floater Policy” dated 16.04.2015.        For the said exclusion clause the opposite party referred Ex.B1 terms and conditions of the medi claim insurance policy from pages 8 to 19.  At page 13 of the said documents the exclusion clause 4.3 says that the surgery of hernia is excluded for a period of two years. However, the said terms and conditions relates to individual policy as mentioned at page 8 of the document. Whereas in the case in hand the policy is “Happy Family Floater Policy” and this policy has separate terms and conditions along with policy is available in Ex.B1 itself form pages 1 to 7. In that conditions of the “Happy Family Floater Policy” nowhere, it is stated that for the current policy the pre authorization is not entitled. Therefore, the opposite parties referred the terms and conditions of the medi claim insurance policy for the individual is not applicable to this case and on the other hand the complainant is entitled as per the “Happy Family Floater Policy” for the pre authorization requested by him.  Hence, the opposite parties initially sanctioned 90,000/- and subsequently reduced of Rs.45,000/- as per the policies taken in the year  2012 – 2013 & 2013 – 2014   is not sustainable and it is held that the opposite parties have committed deficiency in service to the complainant.

 

13. POINT NO:2

As per Ex.A2 policy the complainant is entitled for the sum assured of Rs.3,00,000/-. However, he had filed Ex.A15 bill only for a sum of Rs.1,41,099/- towards medical expenses and for such amount he is entitled from the opposite parties. The complainant claimed a sum of Rs.96,099/- towards balance medical expenses in this complaint after deducting already received a sum of Rs.45,000/-. Therefore, the opposite parties can be directed to pay a sum of Rs.96,099/- towards medical expenses. Failure to grant pre–authorization, inspite of that the complainant was assured a sum of Rs.3,00,000/-, the complainant suffered with mental agony is accepted. Hence, it would be appropriate to order a sum of Rs.50,000/- towards compensation for deficiency in service and mental agony would meet ends of justice, besides a sum of Rs.5,000/- towards litigation expenses.

          In the result the Complaint is partly allowed. The Opposite Parties 1 & 2 are jointly or severally   are ordered to pay a sum of Rs.96,099/- (Rupees ninety six thousand  and ninety nine only) towards the medical expenses  to the Complainant and also to pay  a sum of Rs. 50,000/- (Rupees fifty  thousand only) towards compensation for deficiency in service and mental agony, besides a sum of Rs. 5,000/- (Rupees five thousand only)  towards litigation expenses.

The above amount shall be paid to the complainant within 6 weeks from the date of receipt of the copy of this order failing which the above said amount shall carry 9% interest till the date of payment.

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 29^th  day of November 2017.

 

MEMBER – I                                                                PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 2006 to 2015      Individual Medi-claim policy with United India

                                                    Insurance Company Limited

 

Ex.A2 dated 16.04.2015                   Happy Family Floater Policy with the opposite

                                                    parties

 

Ex.A3 dated 28.09.2015                   Sugam Hospital – Heal Check up medical report of

                                                   A.Ruby

 

Ex.A4 dated 05.10.2015                   Billroth Hospital – Admission order form

 

Ex.A5 dated 07.11.2015                   Sugam Hospital – Heal Check up medical report of

1. Ruby

 

Ex.A6 dated 08.02.2016                   Sugam Hospital – Heal Check up medical report of

1. Ruby

 

Ex.A7 dated 11.02..2016                  Apollo Hospitals –Heal Check up medical report

                                                   of A.Ruby

 

Ex.A8 dated 11.02.2016                   Request for cashless Hospitalization sent by the

                                                     Apollo Hospital

 

Ex.A9 dated 11.02.2016                   SMS sent by the opposite parties

To 22.02.2016

 

Ex.A10 dated 13.02.2016                 Apollo Hospitals –Heal Check up medical report

                                                 of A.Ruby

 

Ex.A11 dated 15.02.2016                 Apollo Hospitals – Medical Prescription

 

Ex.A12 dated 22.02.2016                 Pre Approval Authorization Letter (AL-1)

                                                    sanctioned by the 1^st opposite party to the Apollo

                                                 Hospitals

 

Ex.A13 dated 22.02.2016                 Apollo Hospital – op cash Bill

 

Ex.A14 dated 02.03.2016                 Authorization Letter (AL)

Ex.A15 dated 04.03.2016                 IP Bill

 

Ex.A16 dated NIL                             Apollo Hospital – Discharge Summary of A.Ruby

 

Ex.A17 dated 18.04.2016                 Pre – Legal Notice to the opposite parties with AD

                                                    Cards

 

Ex.A18 dated 29.05.2016                 Reply Legal Notice

 

Ex.A19 dated 2010 to 2011    Individual Medi-claim policy with United India

                                                    Insurance Company Limited        

 

Ex.A20 dated NIL                             Individual Medi-claim policy’s terms conditions

                                                    issued by United India Insurance

 

LIST OF DOCUMENTS FILED BY THE OPPOSITE PARTY :

 

Ex.B1 dated 16.04.2015                   Insurance Policy along with Terms and Conditions

 

Ex.B2 dated 05.08.2016                   E-mail copy

 

 

 

MEMBER – I                                                               PRESIDENT