Tamil Nadu

North Chennai

CC/18/2016

M/s.Surendra S.Jain - Complainant(s)

Versus

The Oriental Insurance Company Ltd., - Opp.Party(s)

K.P.Kiran Rao

30 Jun 2017

ORDER

                                                            Complaint presented on:  29.12.2016

                                                                Order pronounced on:  30.06.2017

 

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

 

FRIDAY THE 30^th DAY OF JUNE 2017

 

C.C.NO.18/2016

 

 

Surendra S.Jain,

Flat No.303A, 3^rd Floor,

Prince Garden,

No.40, Thamu Swamy Road,

Kellys, Chennai – 600010.

                                                                                    ….. Complainant

 

..Vs..

1. The Oriental Insurance Company Limited,

Rep. by its Branch Manager,

(BO Royapuram – 411 401)

No.10, Appavoo Towers,

New No.46, Old No. 69,

West Madha Church Street,

Royapuram, Chennai – 600 013.

 

2. MD India Health Care Services (TPA) Pvt. Ltd.,

Rep. by its Director,

260/16, 3^rd Floor, Mount Casa Blanca,

Anna Salai, Chennai – 600 006.

 

.....Opposite Parties

Date of complaint                                 : 24.02.2016

Counsel for Complainant                      : M/s.K.P.Kiran Rao

Counsel for 1^st Opposite Party                : M.B.Gopalan Associates,

                                                                    N.Vijayaraghavan, M.B.Raghavan

 

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 direct the Opposite Party to pay the claim amount of Rs.1,44,274.10/- together with 15% interest from 01.01.2015 and also compensation for mental agony with cost of the Complaint u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          The Complainant is holding a mediclaim policy bearing No.411401/48/15/01603 dated 01.08.2014 for the period from 16.09.2014 to 15.09.2015, issued by the first Opposite Party, by paying annual premium of Rs.17,576/-. The Complainant was subscribing to the mediclaim policy of the first Opposite Party for the past several years.  The Complainant was hospitalized during the period 18.12.2014 to 22.12.2014 and underwent treatment for Odontogenic Kerotocyst at Dr.Mehta’s Multi Specialty Hospital,No.2, MC Nichols Road, Chetpet, Chennai – 600 031.

          2. He had incurred total expenditure of Rs.1,44,374/- towards the treatment and he had submitted the claim form with necessary documents to the second Opposite Party. The TPA for the second Opposite Party repudiated the claim on 13.01.2015 stating that the treatment undergone by the Complainant was excluded from the scope of the policy and hence the claim was not payable. The second Opposite Party again vide letter 24.03.2015 repudiated the claim stating that the claim is excluded under clause 4.7 of the mediclaim policy, followed by their email dated 30.03.2015. The Complainant wrote letters dated 25.03.2015 and 30.03.2015, explaining that the treatment undergone by him is not dental treatment and it was a disease that required hospitalization as evidenced by the Doctor’s Certificate, but in vain.

3. The repudiation of the claim has caused great mental agony and suffering to the Complainant and the Opposite Parties are liable to compensate him for the same.   Hence the Complainant has filed this Complaint to direct the Opposite Party to pay the claim amount of Rs.1,44,274.10/- together with 15% interest from 01.01.2015 and also compensation for mental agony with cost of the Complaint. 

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

          The Opposite Party admits that the Complainant availed mediclaim policy bearing No.411401/48/15/01603 for the period 01.08.2014 subject to the terms and conditions. The Complainant submitted claim for treatment of Odontogenic Keratocyst of mandible. On careful examination of papers by medical experts of the 2^nd Opposite Party which is the Third Party Administrator had found that the same was not payable in as much as the policy did not cover.

1. Any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure, filling of cavity, root canal including wear and tear etc unless arising from disease or injury and which requires hospitalization for treatment,
2. As per clause 4.7 of the policy,
3. The treatment was for external congenital disease/defect which is excluded from the scope of policy and
4. The Complainant had undergone dental treatment without any hospitalization and without any disease or injury which is not covered by the policy.

The Opposite Party has no liability for the claim. It has dealt with the claim without delay and in the absence of any loss/damage due to an insured peril; the claim has been duly repudiated and intimated without delay to the Complainant. The repudiation of claim in such circumstances cannot be construed as deficiency in service and prays to dismiss the Complaint with costs.

5. 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?

6. POINT NO :1 

          The admitted facts are that the  Complainant has availed Medi Claim  Ex.A1 policy  dated 01.08.2014 for the period  16.09.2014 to 15.09.2015 by paying annual premium of Rs.17,576/- from the 1^st Opposite Party  and even prior to this policy the Complainant was having policies regularly from 16.09.2003 to 15.09.2014 which is evidenced under policies Ex.A16 to Ex.A26 and the Complainant  was admitted at the Mehta’s Hospital Private Limited on 18.12.2014 and he was diagnosed with Odontogenic Keratocyst  disease and having mandible cyst and surgery was done for the same on 18.12.2014 and after four days he was discharged on 22.12.2014  as per Ex.A4 discharge summary and the Complainant made pre-authorization claim under Ex.A7 during that period and however the same was rejected by the 2^nd Opposite Party under Ex.A8 as treatment for an external Congenital disease which is excluded from the scope of the policy and after discharge the Complainant made claim and that was also repudiated by the 2^nd Opposite Party under Ex.A9  dated 24.03.2015 and Ex.B1 that the  Odontogenic Keratocyst  is a genetic disorder and congenital disease and  the expenses incurred for the said disease are not payable under policy exclusion clauses 4.1 & 4.7 and against the said repudiation the Complainant had filed this Complaint.

          7. The Complainant contended that  the treatment given to the Complainant was not treatment for dental ailment and only a cyst was removed from his mandible by way of surgery  during the period as inpatient  and even  the exclusion clauses 4.3 (xxii) & 4.7  in no way prohibits the Opposite Parties to deny the claim made by the Complainant and hence the claim repudiated by the 2^nd Opposite Party is not sustainable and therefore the claim made by the Complainant in this Complaint has to be allowed.

          8. The Opposite Party would reply that the 3^rd party administrator had rightly repudiated the claim as per terms and condition of the policy and therefore no interference can be made by this Forum and requests to reject this Complaint.

          9. Ex.A6 is the discharge summary issued to the Complainant and he had undergone surgery at Mehta Hospital on 18.12.2014 for the disease   Odontogenic Keratocyst and he was diagnosed to have mandiable cyst and that cyst was removed in the surgery done to him. It is necessary to extract the Ex.A3 terms and policy conditions in respect of clauses 4.3 (xxii) & 4.7.

4.3 During the period of insurance cover, the expenses on treatment of following ailment/ diseases/ surgeries for specified period are not payable if contracted and/or manifested during the currency of the policy.

              (xxii)  Congenital internal diseases.                2 years

4.7 Any dental treatment or surgery which is corrective, cosmetic or of aesthetic procedure, filing of cavity, root canal including wear and tear etc unless arising from disease or injury and which requires hospitalization for treatment.

The 2^nd Opposite Party repudiated the claim on the ground that the Complainant was treated  for genetic disorder and congenital disease. Nowhere in Ex.A4 discharge summary it was stated that the Complainant was treated for genetic disorder and congenital disease. On the other hand it was stated that he was treated for mandible cyst as inpatient.

10. The Opposite Parties have not filed any proof that the treatment given for mandible cyst or Odontogenic Keratocyst either it is a Genetic disorder or congenital disease. Even as per the exclusion clause 4.3 (xxii) within two years of policy period, the claim made for congenital internal disease are not payable by the insurance. However in the case in hand, this Complainant was continuously having insurance cover from 16.09.2003 onwards till the period of claim and hence the above said exclusion clause no way prohibits the Complainant to claim the expenses incurred by him. Likewise as per exclusion clause 4.7 any dental treatment or surgery which is corrective and the same treated by way of hospitalization this exclusion clause no way prohibits the claim. In the case in hand also the Complainant was treated as inpatient for four days. Therefore, the claim was repudiated by the Opposite Parties quoting the exclusion clauses 4.3 (xxii) & 4.7 is not sustainable and consequently we hold that the Opposite Parties have committed deficiency in service in rejecting the claim made by the Complainant.  

 

11. POINT NO:2

          The Complainant filed Ex.A5 final bill for the period 18.12.2014 to 22.12.2014 a sum of Rs.1,35,424/-. As the Opposite Parties repudiated the claim, the Complainant is entitled for the said sum of Rs.1,35,424/- from the Opposite Parties towards incurring expenditure at Mehta Hospital. Due to repudiation of pre-authorization and also claim made by the Complainant, he had suffered with mental agony is accepted and for the same it would be appropriate to direct the Opposite Parties to pay a sum of Rs.50,000/- towards compensation for mental agony, besides a sum of Rs.5,000/- towards litigation expenses.

          In the result the Complaint is partly allowed. The Opposite Parties 1 & 2 jointly or severally are   ordered to pay a sum of Rs.1,35,424/- (Rupees one lakh thirty five thousand four hundred and twenty four only)  to the Complainant towards the medical expenses incurred  by him and also to pay  a sum of Rs. 50,000/- (Rupees fifty  thousand only) towards compensation for 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 30^th day of June 2017.

 

MEMBER – II                                                               PRESIDENT

 

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 01.08.2014                   Policy Schedule

Ex.A2 dated 18.12.2014                   Bill

Ex.A3 dated 18.12.2014                   Advance Receipt

Ex.A4 dated 22.12.2014                   Discharge Summary issued by Metha Hospitals                                                   

                                                    Pvt. Ltd.

 

Ex.A5 dated 22.12.2014                   Final Bill

Ex.A6 dated 22.12.2014                   Receipt

Ex.A7 dated NIL                     Receipt for Pre-Authorization

Ex.A8 dated 13.01.2015                   Second Opposite Party’s letter of repudiation

Ex.A9 dated 24.03.2015                   Repudiation Statement

Ex.A10 dated 25.03.2015       Complainant’s letter to Opposite Party &

                                                    Acknowledgement cards

 

Ex.A11 dated 30.03.2015                 Second Opposite Party’s email to Complainant

Ex.A12 dated 01.04.2015                 Complainant’s letter to 1^st Opposite Party &

                                                    Ack.card

 

Ex.A13 dated NIL                             Certificate issued by Dr.Varun Acharya

Ex.A14 dated 08.07.2015                 Complainant’s counsel’s notice to Insurance

                                                      Company & Ack. Cards   

                  

Ex.A15 dated NIL                             Medi claim policy

Ex.A16 dated 16.09.2003                 Policy Schedule

Ex.A17 dated 30.08.2004                 Policy Schedule

Ex.A18 dated 09.09.2005                 Policy Schedule

Ex.A19 dated 15.09.2006                 Policy Schedule

Ex.A20 dated 10.09.2007                 Policy Schedule

Ex.A21 dated 11.09.2008                 Policy Schedule

Ex.A22 dated 07.09.2009                 Policy Schedule

Ex.A23 dated 14.09.2010                 Policy Schedule

Ex.A24 dated 03.10.2011                 Policy Schedule

Ex.A25 dated 14.09.2012                 Policy Schedule

Ex.A26 dated 12.09.2013                 Policy Schedule

LIST OF DOCUMENTS FILED BY THE OPPOSITE PARTY :

 

Ex.B1 dated NIL                     Note from 2^nd Opposite Party (TPA) for

                                                   repudiating the claim

 

Ex.B2 dated NIL                     Medical Literatures relating to Keratocystic

                                                   Odontogenie Tumour

 

 

 

MEMBER – II                                                               PRESIDENT