Tamil Nadu
North Chennai
CC/398/2018
Pannalal Jain Tatia - Complainant(s)
Versus
The Oriental Insurance Company Ltd., - Opp.Party(s)
K.Moorthy
16 Nov 2023
ORDER
Complaint presented on : 27.08.2012
Date of disposal : 16.11.2023
DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,
CHENNAI (NORTH)
@ 2ND Floor, T.N.P.S.C. Road, V.O.C. Nagar, Park Town, Chennai – 600 003.
PRESENT: THIRU. G. VINOBHA, M.A., B.L. : PRESIDENT
TMT. KAVITHA KANNAN, M.E., : MEMBER-I
C.C. No.398/2018
DATED THIS THURSDAY THE 16TH DAY OF NOVEMBER 2023
Mr.Pannalal Jain Tatia
No.9, “Jai Villa” still water
Sun Rise Avenue,
Kapaleshwar Nagar,
Neelangarai,
Chennai-600 041.
…..Complainant
..Vs..
The Oriental Insurance Company Limited
Rep by its Senior Branch Manager,
City Branch Office No.7
“Kamala Arcade” II Floor,
306/669,Anna Salai,
Chennai-600 006.....Opposite Party
Counsel for Complainant : M/s.K.Moorthy and 3 others
Counsel for opposite party : Mr.S.K.Krishnamurthy
ORDER
THIRU. G. VINOBHA, M.A., B.L., PRESIDENT
This complaint has been filed by the complainant against the opposite party under section 12 of the Consumer Protection Act, 1986 prays to pay a sum of Rs.1,47,227/- for claim 1 and Rs.1,00,000 towards claim 2 and 3 difference amount as paid by the complainant to the hospital together with interest at the rate of 18%p.a from 20.07.2011 till the payment in full and to pay Rs.5,00,000/- towards mental agony and cost of the complaint.
This complaint filed before DCDRC Chennai South and numbered of CC 197/2012 was transferred to this commission as per the proceedings of the Registrar SCDRC in RC.NoA1/2282/2018 dated 11.09.2018 and renumbered as CC 398/2018.
1.THE COMPLAINT IN BRIEF:
The Complainant was hale and healthy when the policy was taken and no misrepresentation on any account was made by the complainant. The complainant state that the Medi-claim policy was availed with the Oriental Insurance Company Ltd during 2023for himself and his wife and were duly covered till date and is been renewed every year without fail. The complaint arises from the fact that the claims were settled partially and the amount incurred towards hospitalization was not paid in full. The shelter taken by insurance company in admitting the claim 1 sought for is that the surgeon fees and other deductions has not been paid second party. The actual expenses incurred in Claim 1 is Rs.2,44,327 and in Claim 2 and 3 are Rs.2,50,656.36/- and Rs.9,18,322/- but the claim amount approved was only Rs.97,100/- in claim 1 and Rs.4,00,000/- in claim 2 and 3 together. The complainant submits that the sum insured available was Rs.5,00,000/- but the second party has paid only Rs.97,100/- without giving any reasonable reasons for deduction of the claim amount at any point of time. The Second party did not care to consider the sequence of surgeries and the lawful resultant claim made by the complainant. Claim No.1 is the total amount claimed amount including pre hospitalization, post hospitalization charges Rs.2,44,327/- Amount Settled is Rs.97,100, Balance amount to be paid by the 2nd party is Rs.1,47,227/- and the Claim No.2 is pre hospitalization charges is Rs.32,304/- hospitalization is Rs.1,94,841/-, post hospitalization charges is Rs.23,510 and the total amount claimed is Rs.2,50,656/- Claim No.3 is Total amount claimed Rs.9,18,322 amount settled together in both claim 2 & 3 together Rs.4,00,000 and the balance amount to be paid by the opposite party Rs.1,00,000/- The complainant state that repudiation of balance amount of claim by this opposite parties on this frivolous ground is malafide, arbitrary and not in accordance with the policy and regulations of Insurance Regulatory and Development Authority. The complainants state that the balance amount of claim is payable in terms of the policy of insurance issued by the opposite parties and the opposite parties are prohibited from taking shelter under an erroneous interpretation of a policy clause denying a genuine claim payable in full without any deductions under the policy and hence claimed the balance amount under the two policies and also claimed compensation.
2.WRITTEN VERSION FILED BY THE OPPOSITE PARTY IN BRIEF:
The Opposite party deny the allegations set out in the complaint. The complaint is liable to be dismissed for Non-joinder of necessary party, M/s.Vipul Medcorp TPA Private Ltd a company licensed by IRDA to practice as a 3rd party administrator, which is in processing the claim of the complaint and disbursed the claim amount as per the policy terms and conditions. There were several communication were made between the complainant and M/s.Vipul Medcorp TPA Private Ltd as per policy terms and conditions. Further in terms of the complaint the entire allegation has been raised against the 2nd opposite party but except this opposite party none has been showed as party which warrants dismissal of the complaint. This opposite party is nationalized company under the control of the ministry of finance, Government of India was made to incur the cost in contesting this vexatious petition. In terms of the policy any one illness will be deemed to mean continuous period of illness and it includes relapse within 105 days from the date of discharge from the Hospital nursing home from where the treatment was taken. Occurrence of the same illness after a lapse of 105 days as stated above will be considered as fresh illness for the purpose of this policy. As such the sum insured exhausted as max liability paid in the previous claim and enhanced sum insured is not payable as per the insurance contract. But without any legality the present complaint is filed, which warrants dismissal with cost. The complaint is devoid of merits and liable to be dismissed.
3. POINTS FOR CONSIDERATION:
1. Whether there is Unfair Trade Practice and Deficiency of service on the opposite party?
2. Whether the complainant is entitled for the reliefs claimed in the complaint and if so, to what extent?
3. To what relief?
Proof Affidavit of Complainant and Ex.A1 to Ex.A96 marked on the complainant side. The Opposite party has filed written version but not filed proof affidavit, written arguments and documents.
Point No: 1
The fact that the complainant has availed two Medical Insurance policies from the opposite party 1.Policy.No411901/48/2010/1768 for the period from 16.02.2010 to 15.02.2011 for a sum of Rs.5,00,000/- and another policy with policy no.411901/48/2011/2860 from 16.02.2011 to 15.02.2012 for a sum of Rs.5,00,000/- and further fact that the complainant has been paying the premium amount without any default and such mediclaim policy was availed for himself and his wife from the year 2003 onwards is not disputed by the opposite party similarly there is no dispute with regard to the fact that in respect o f claim no.1 the complainant was admitted for hernia surgery from 04.02.2011 to 10.02.2011 and subsequently readmitted on 12.02.2011 to 14.02.2011. In Laser and Laproscobic hospital and further in respect of claim no.2 he was admitted on 09.04.2011 to 15.04.2011 for the illness
Osteitis Pubis and in respect of claim no.3 he was admitted on 26.04.2011 and discharged on 12.05.2011 in respect of Post Laproscobic Bilateral Inguinal Hernioplasty ,Osteomyelitis of Pubis Bone illness for which he has taken treatment in the concerned hospitals is not disputed by the opposite party. But according to the complainant in respect of 1st claim though the sum assured was Rs.5 lakhs the opposite party instead of sanctioning the actual expenses of Rs.244327 has only partially sanctioned Rs.97100 which is arbitrary and without any reasoning and therefore claim the balance amount which was disallowed by the opposite party and similarly according to the complainant in respect of 2 and 3 though he as incurred Rs.250656.36/- and Rs.918322/- but the opposite party totally approved and sanctioned only Rs.4,00,000/- though the complainant has insured for the sum of Rs.5lakhs and therefore the complainant alleged unfair trade practice and deficiency in service and claimed balance of the disallowed amount in respect of claim.no.2 and 3.
But the opposite party mainly contended that the complainant has failed to implead M/s.Vipul Medcrop TPA who is 3rd party administrator appointed by the company to process the claim and therefore contended that the complaint is bad for non-joinder of necessary party and further contended that the claim of the complainant was considered as per the terms and conditions of the policy and exclusions and denied unfairness and deficiency in service.
Ex.A1 to A3 were in respect of Mediclaim policy availed by the complainant in the year 2008 and 2009 and it does not relate to the dispute in the present complaint Ex.A4 is mediclaim policy of the complainant from 16.02.2010 to15.02.2011 with policy number ending with 1768 and the sum assured with Rs.5lakhs for complainant and his wife each it is found in Ex.A4 the name of Vipul Medcrop TPA which also found similarly in Ex.A24 which is another mediclaim policy ending with number 2860 which is for the period from 16.02.2011 to 15.02.2012 for a sum of Rs.5lakhs in respect of complainant and his wife each and in Ex.A24 also the name of 3rd party administrator is found. Though the opposite party contended that Vipul Medcrop TPA who is processing the claim and hence contended that it is a necessary party but on perusal of the mediclaim policy and its terms and conditions which were marked as Ex.A96 it is found that the mediclaim insurance contract is entered only between the complainant and opposite party and there is no privity of contract between the complainant and Vipul medcrop TPA which was appointed by the opposite party and therefore there is no force in the contention of the opposite party that the complaint is bad for non-joinder of necessary party.
The complainant has filed Ex.A4 to Ex.A29 which were pharmacy bill, surgery bill, medical instrument invoice and discharge summary in respect of claim no.1 It is found from Ex.A35 that bills were submitted to the opposite party claiming Rs.244327/- which includes hospitalization in respect of 1st claim twice and pre hospitalization and post hospitalization expenses and it is further found that the complainant was availing the policy from the year 2002 without any break it is found from Ex.A43 which is claim form submitted to the opposite party the hospital charges including the expenses for surgery and doctors fees is shown as Rs.184400/- and it is further found from Ex.A55 that the complainant has claimed Rs.1,20,000 as doctor fees alone out of the total bill amount of Rs.244327/- and according to the opposite party as PPN Tariff they used to pay only Rs.1,50,000/- in respect of the similar illness and therefore the opposite party has sanctioned only Rs.97100/- and repudiated the balance claim. The complainant by relying upon clause 1.2c of the terms and conditions contended that the surgeon, medical practioner, specialist fees are fully reimbursable and therefore contended that he is entitled for entire expenses but it is found in the said clause that only reasonable and customary expenses or reimbursable and hence the doctors fee of Rs.1,20,000/- for the alleged illness seems to be higher in value and hence the opposite party was justified in allowing only a partial amount in respect of the doctors fees. As per clause 1.2 reimbursement is allowed only for hospitalization expenses for the illness or injury and further as per clause 4.10 the expenses incurred in respect o f evaluation/diagnostic purposes which is not followed by active treatment where excluded and as per clause 4.17 all non medical expenses including personal comfort and convenience and diet charges cosmetics and napkins etc where excluded under the policy similarly there is restrictions of the room rent payable in respect of each policy and on perusal of the claim form submitted by the complainant in respect of claim no.1 that the bills included certain non medical items, Expenses for food and other convenience and similarly the room rent as well as the doctors fees were claimed by the complainant excessively but at the same time considering the documents filed by the complainant in respect of claim no.1 and hospitalization period for twice and further considering the fact that the complainant has availed the policy from the year 2002 without any break and who is not a defaulter in payment of premium since the complainant is eligible for the insured amount of Rs.5 lakhs the sanction of Rs.97100 alone by the opposite party out of the claim of Rs.244327/- is found to be unfair and deficiency in service on the part of opposite party in respect of claim no.1 further there is no valid explanation from the opposite party as to how Rs.97100/- alone was eligible amount and considering the nature of illness and the treatment underwent by the complainant this commission is of the considered opinion that the complainant is entitled for Rs.1,97,100/- in respect of claim no.,1 and after deduction the already approved amount of Rs.97100/- the opposite party is liable to pay a further sum of Rs.1lakh to the complainant with interest 6% p.a from 20.07.2011 till date of payment in respect of claim no.1.
In respect of claim no.2 and 3 it is alleged by the complainant that though claim was submitted for Rs.250656/- and Rs.918322/- the opposite party sanctioned only Rs.4 lakhs which is unfair and against the terms of the insurance and claim Rs.1 lakh from the opposite party since the complainant is eligible for assured sum of Rs.5 lakhs but the opposite party contended that Rs.4 lakhs was arrived as per the terms and conditions of the policy and exclusions and denied deficiency in service. As per the terms and conditions of the policy the complainant is entitled only for a prescribed amount towards room rent depending upon the nature of the policy on perusal of Ex.A59 it is found that a sum of Rs.429400 + Rs.28300 was claimed towards room rent alone by the complainant from 30.04.2011 to 12.05.2011 and it is further found that the complainant has occupied a suite in the Apollo which is a luxury suite which is not an essential requirement for the illness and treatment undergone by the complainant therefore the room rent claimed by the complainant is found to be excessive and not reasonable as per the terms and conditions of the policies and hence it was rightly negatived by the opposite party and further it is found from bills in EX.A59 that the complainant has claimed certain non medical items which include several food items and beverages which were excluded under the policy it is found from Ex.A56 that the complainant was in patient in Apollo specialty hospital from 09.04.2011 to 15.04.2011 in respect of Oseteits Pubis but there was no surgery during this period and it is further found that the complainant was again readmitted on 26.04.2011 to 12.05.2011 in Apollo hospital for undergoing pubic bone curettage and removal of mesh surgery and in respect of the 2nd claim he has claim Rs.2,50,656 and in respect of 3rd claim a sum of Rs.918292 was claimed which includes hospitalization, pre and post hospitalization treatment but since the 2nd and 3rd illness admissions occurred within 105 days by relying upon clause 3.17 of the terms and conditions the opposite party has not considered it as fresh illness for the purpose of the policy and such decision arrived by the opposite party is found to be lawful as per the terms of the policy which cannot be contended as unfair and it will not amount to deficiency in service further by fixing a ceiling in respect of room rent and by excluding non medical items and also by fixing reasonable restrictions as per terms of the policy in respect of surgeon and doctor’s fees the opposite party has rightly approved and sanctioned Rs.4 lakhs in respect of claim no.2 and 3 which will no amount to arbitrary, unreasonable, unfair and deficiency in service on the part of opposite party. Hence based on the averments and points discussed earlier it is found that there is unfairness and deficiency in service on the part of opposite party in partially approving Rs.97100 alone in respect of claim.no.1 and in respect of claim no.2 and 3 there is no deficiency in service on the part of opposite party. Point no.1 answered accordingly.
Point No. 2 and 3
Based on findings given to point.no.1 since there is deficiency in service on the part of opposite party in respect of claim no.1 hence the opposite party liable to pay further Rs.1 lakh to the complainant with interest 6% p.a from 20.07.2011 till date of payment and also liable to pay Rs.25000/- towards compensation for mental agony suffered by complainant due to deficiency in service of the opposite party and further liable to pay Rs.5000/- towards cost of the complaint. The complainant is not entitled for Rs.1 lakh in respect of claim no.2 and 3. Point no.2 and 3 is answered accordingly.
In the result the complaint is partly allowed, The opposite party is directed to pay further sum of Rs.1 lakh to the complainant with interest 6% p.a from 20.07.2011 till date of payment in respect of claim no.1 and also directed to pay Rs.25000/- towards compensation for mental agony suffered by complainant due to deficiency in service of the opposite party and directed to pay Rs.5000/- towards cost of the complaint. The above amount shall be paid to the complainant within two months from the date of receipt of the copy of this order failing which the above said amount shall carry 9% interest from the date of this order to till the date of payment. The relief prayed in respect of claim no.2 and 3 is dismissed.
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 Commission on this the 16th day of November 2023
MEMBER – I PRESIDENT
LIST OF DOCUMENTS FILED BY THE COMPLAINANT:
Ex.A1 | 12.02.08 | Mediclaim Policy No.411900/48/2008/2409 |
Ex.A2 | 12.02.09 | Mediclaim Policy No.411900/48/2009/1276 |
Ex.A3 | 05.02.10 | List of Medical items supplied for operation |
Ex.A4 | 15.02.10 | Mediclaim Policy No.411900/48/2010/1276 |
Ex.A5 | 16.02.10 | Identity card issued by the opposite party |
Ex.A6 | 07.08.10 | Scan charges paid receipt |
Ex.A7 | 16.08.10 | Pharmacy Bill |
Ex.A8 | 05.09.10 | Scan charges paid receipt |
Ex.A9 | 29.01.11 | Investigation Report |
Ex.A10 Ex.A11 | 31.01.11
31.01.11 | Scan charges paid receipt
Scan report |
Ex.A12 | 31.01.11 | Echo Cardiography Report |
Ex.A13 | 31.01.11 | Scan report |
Ex.A14 | 05.02.11 | Pharmacy Bill |
Ex.A15 | 04.02.11 | Email Communication |
Ex.A16 | 04.02.11 | Discharge Summary |
Ex.A17 | 05.02.11 | Pharmacy Bill |
Ex.A18 | 05.02.11 | Doctor prescription |
Ex.A19 | 07.02.11 | Pharmacy Bill |
Ex.A20 | 07.02.11 | Surgery Bill |
Ex.A21 | 07.02.11 | Medical Invoice |
Ex.A22 | 08.02.11 | Pharmacy Bill |
Ex.A23 | 08.02.11 | Prescription |
Ex.A24 | 09.02.11 | Mediclaim Policy No.411900/48/2011/2860 |
Ex.A25 | 09.02.11 | Medical Instrument invoice |
Ex.A26 | 10.02.11 | Pharmacy Bill |
Ex.A27 | 10.02.11 | Prescription with pharmacy bill |
Ex.A28 | 10.02.11 | Surgery bill |
Ex.A29 | 10.02.11 | Surgery bill paid receipt |
Ex.A30 | 12.02.11 | Discharge Summary |
Ex.A31 | 12.02.11 | Prescription |
Ex.A32 | 14.02.11 | Surgery charges paid receipt |
Ex.A33 | 14.02.11 | Pharmacy Bill |
Ex.A34 | 14.02.11 | Medical treatment bill |
Ex.A35 | 07.03.11 | Letter from Alert to Vipul Medcorp |
Ex.A36 | 10.03.11 | Pharmacy Bill |
Ex.A37 | 17.03.11 | Scan charges paid receipt |
Ex.A38 | 17.03.11 | Medical biochemistry report |
Ex.A39 | 22.03.11 | Bill cum receipt for blood test |
Ex.A40 | 22.03.11 | Test report |
Ex.A41 | 23.03.11 | Pharmacy Bill |
Ex.A42 | 03.04.11 | Pharmacy Bill |
Ex.A43 | 04.04.11 | Claim Form |
Ex.A44 | 05.04.11 | Hospital bill |
Ex.A45 | 05.04.11 | Lab report |
Ex.A46 | 06.04.11 | Out patient bill/receipt |
Ex.A47 | 06.04.11 | Scan report |
Ex.A48 | 07.04.11 | Request for investigation |
Ex.A49 | 06.04.11 | Lab report |
Ex.A50 | 08.04.11 | Medical bills and reports |
Ex.A51 | 09.04.11 | Medical bills and reports |
Ex.A52 | 14.04.11 | Lab test report |
Ex.A53 | 15.04.11 | Pharmacy Bill |
Ex.A54 | 15.04.11 | Letter to opposite party |
Ex.A55 | 15.04.11 | Letter to opposite party |
Ex.A56 | 15.04.11 | Discharge summary |
Ex.A57 | 22.04.11 | Pharmacy Bill and reports |
Ex.A58 | 25.04.11 | Out patient bill |
Ex.A59 | 26.04.11 | In patient bill |
Ex.A60 | 26.04.11 | ECG reports |
Ex.A61 | 26.04.11 | Hospital bill for food |
Ex.A62 | 27.04.11 | Email communication |
Ex.A63 | 27.04.11 | Medical Reports |
Ex.A64 | 28.04.11 | Medical Reports |
Ex.A65 | 29.04.11 | Medical Reports |
Ex.A66 | 30.04.11 | Medical Reports |
Ex.A67 | 01.05.11 | Medical Reports |
Ex.A68 | 02.05.11 | Medical Reports |
Ex.A69 | 03.05.11 | Claim Form |
Ex.A70 | 03.05.11 | Medical Reports |
Ex.A71 | 04.05.11 | Medical Reports |
Ex.A72 | 05.05.11 | Medical Reports |
Ex.A73 | 05.05.11 | Claim form |
Ex.A74 | 06.05.11 | Letter to Vipul Medcorp |
Ex.A75 | 07.05.11 | Checklist for claim submission |
Ex.A76 | 07.05.11 | Medical Reports |
Ex.A77 | 08.05.11 | Medical Reports |
Ex.A78 | 09.05.11 | Medical Reports |
Ex.A79 | 10.05.11 | Apollo Hospital Deposit receipt |
Ex.A80 | 10.05.11 | Medical Reports |
Ex.A81 | 11.05.11 | Medical Reports |
Ex.A82 | 12.05.11 | Medical Bills |
Ex.A83 | 12.05.11 | Pharmacy Bill |
Ex.A84 | 12.05.11 | Discharge summary |
Ex.A85 | 09.06.11 | Email communication |
Ex.A86 | 02.07.11 | Letter to Vipul Medcorp |
Ex.A87 | 18.07.11 | Letter from Complainant to Opposite party |
Ex.A88 | 18.07.11 | Letter from Complainant to Arbitrator |
Ex.A89 | 20.07.11 | Letter from Vipul Medicorp to complainant |
Ex.A90 | 25.07.11 | Copy of Cheque |
Ex.A91 | 27.07.11 | Letter from Vipul Medicorp to complainant |
Ex.A92 | 04.08.11 | Letter from Vipul Medicorp to complainant |
Ex.A93 | 09.01.12 | Letter from complainant to opposite party |
Ex.A94 | 12.01.12 | Letter from Arbitrator to opposite party |
Ex.A95 | 27.01.12 | Letter from opposite party to complainant |
Ex.A96 |
| Terms and conditions |
MEMBER – I PRESIDENT
CC.NO.398/2018, Dated:16.11.2023
Order Pronounced, In the result the complaint is partly allowed, The opposite party is directed to pay a sum of Rs.1 lakh to the complainant with interest 6% p.a from 20.07.2011 till date of payment in respect of claim no.1 and directed to pay Rs.25000/- towards compensation for mental agony suffered by complainant due to deficiency in service of the opposite party and directed to pay Rs.5000/- towards cost of the complaint. The above amount shall be paid to the complainant within two months from the date of receipt of the copy of this order failing which the above said amount shall carry 9% interest from the date of this order to till the date of payment. The relief prayed in respect of claim no.2 and 3 is dismissed.
Member-I President |
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