Tamil Nadu

StateCommission

A/147/2018

K. Ramesh, Coimbatore - Complainant(s)

Versus

The United India Insurance, Coimbatore - Opp.Party(s)

K. Sudha

12 Apr 2023

ORDER

IN THE TAMILNADU STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI.

 

Present: Hon’ble THIRU  JUSTICE R. SUBBIAH  :     PRESIDENT

                 THIRU R   VENKATESAPERUMAL         :      MEMBER

 

F.A. No. 147 of 2018

(Against the order passed in C.C. No.42 of 2014 dated 30.04.2018 on the file of the D.C.D.R.F., Coimbatore.

 

Wednesday, 12^th day of April 2023

K. Ramesh

S/o.Krishna Iyer

10/35, Elaimpirai 2nd Street

Sivakami Nagar, Vadavalli

Coimbatore.                                               .. Appellant/Complainant

 

- Vs –

 

1.  The United India Insurance Co. Ltd.,

     III, E.P.Building

     24, Mill Road, Coimbatore  - 641 004.                                            

 

2.  M/s.MD India Healthcare

      Services (TPA) Pvt. Ltd.,

     89, Grey Town

     Near Nehru Stadium

     Coimbatore - 641 018.

 

3.  M/s.MD India Healthcare

      Services (TPA) Pvt. Ltd.,

    S.No.46/1E Space, A-2 Building

    3rd Floor, Pune Nagar Road

      Vadgaonsheri,  Pune-411 014.                      ..  Respondents/

                                                                             Opposite Parties

 

 Counsel for the Appellant /Complainant      : M/s. K. Sudha

 

 Counsel for the 1st Respondent/1st OP       :  M/s. T. Ravikumar

 

 For Respondents 2 & 3/2^nd & 3^rd Complainant      : Party-in-person

 

                                               

        This appeal came before us for final hearing on 05.01.2023, and on hearing the arguments of the counsel for the Appellant and on perusing the material records, this Commission made the following :-

O R D E R

R.SUBBIAH J., PRESIDENT

                Not being satisfied with the order passed by the District Consumer Disputes Redressal Forum, Coimbatore, in C.C. No.42 of 2014, dated 30.04.2018, the present appeal has been filed by the complainant under Section 15 of the Consumer Protection Act, 1986.

 

 

        2.     The factual background culminating in this appeal is as follows:   The case of the complainant before the District Forum is that he had taken a health insurance policy from the 1st opposite party.  Since 1997, he was continuously having the said policy with the 1st opposite party, without any break.  While so, in the year 2010, he underwent Angiogram Test, for which he had spent a sum of Rs.19,000/-.  However, he has not claimed the amount under the said policy.  Later, on 22.11.2013, he developed chest pain and immediately he was admitted in Kalpana Medical Centre (P) Ltd., Coimbatore, in Intensive Care Unit and later he was shifted to a Ward.  On 25.11.2013 he got discharged from the hospital.  He had spent Rs.28,690/- towards medical expenses.  He paid the entire amount to the hospital and later preferred a claim for the same with the 2nd opposite party, vide Claim No.1747683 on 07.12.2013.  But the 2nd opposite party had raised several queries on the claim made by the complainant.  Infact, the complainant had submitted the claim form along with all the required documents, which are self explanatory.  Though the complainant was in immediate post hospitalisation situation, he gave all the clarifications as required by the 2nd and 3rd opposite parties.   However, the opposite parties did not come forward to settle the claim.  Hence, he issued a legal notice on 10.01.2014 to all the opposite parties.  Though the notice was received by the opposite parties, none of them had neither sent a reply nor settled the claim amount. Hence, he filed a complaint before the District Forum seeking the following directions to the opposite parties, jointly and severally, to pay the complainant,

1. the claim amount of Rs.28,690/- along with interest @ 18% pa from 07.12.2013 till the date of payment;
2. a sum of Rs.3,00,000/- towards compensation for financial loss, mental agony, strain, pain and sufferings; and
3. a sum of Rs.7500/- towards legal expenses.

 

 

        3.   Opposing the allegations made by the complainant, the 1st opposite party had filed a written version.  It is admitted that the complainant had taken a Mediclaim policy right from the year 2006, as individual Mediclaim Policy.  The terms and conditions mentioned in the said policy would bind the complainant.  The opposite party could settle the claim only as per the terms and conditions of the policy.  In this case, the claim made by the complainant on the previous occasion was settled.  The 2nd and 3rd opposite parties are the authorities for settling the claim of the 1st opposite party.  The complainant had not submitted records to show the date of admission in ICU as requested by the 2nd opposite party.  The expenses incurred by the complainant could be scrutinised only after receiving the medical report from the Hospital.  Due to non-production of certain documents on the side of the complainant, the opposite parties could not settle the claim.  Thus, there is no deficiency of service on the part of the opposite parties and hence sought for dismissal of the complaint.

 

 

        4.  In order to prove the case, on the side of the complainant, along with proof affidavit and additional proof affidavit, 17 documents were filed and the same were marked as Ex.A1 to A17.  The opposite parties have filed their proof affidavit but have not filed any documents. 

 

 

        5.  The District Forum, on analyzing the entire evidence and records, had come to the conclusion that Exhibits A4 to A10 produced on the side of the complainant would show that the complainant had been holding Medi claim policy with the 1st opposite party continuously from 14.11.2006 to 29.11.2013.  From Exhibits A1 to A3, it could be seen that the complainant had paid Rs.1,50,000/- for cardiac treatment.   The said payment has been settled by the opposite parties on 25.08.2000.  Thereafter, the complainant is having a continuous coverage of more than 48 months and therefore he is eligible to claim for hospitalization from 22.11.2013 to 25.11.2013 as per the conditions of the policy.  As per Ex.A17, the Accounts Statement issued by the HDFC Bank, it is seen that the complainant had already been paid a sum of Rs.26,895/- as claimed by him and only the difference amount of Rs.1795/- is yet to be paid to the complainant.  Hence, directed the opposite parties, jointly and severally, to pay the difference amount of Rs.1795/- with interest at the rate of 9% pa, along with Rs.2000/- towards compensation for mental agony with interest at the rate of 9% pa and Rs.2000/- towards cost of the proceedings. 

 

 

        6.  It is the grievance of the complainant that though his claim was for Rs.28,690/- towards medical expenses, the District Forum had chosen to award only Rs.1795/- which is on the lower side.  The District Forum had wrongly assumed that the amount of Rs.26,895/- settled on 13.06.2014 in his daughter's account, is for the present claim No.1747683 dated 07.12.2013.  But, the said amount was settled, with regard to a later claim post complaint, since the complainant had to undergo another hospitalization, subsequent to the filing of this complaint.  The District Forum had failed to take note of the additional proof affidavit filed by the complainant, wherein he has clearly mentioned about the subsequent claim and the settlement.  Thus, he prays for enhancement of the award amount towards medical expenses.

        7.   There is no representation for the opposite parties. Keeping in mind the submission made by the Counsel for the Appellant, we have carefully gone through the entire material available on record. 

 

 

        8.  We find that, as per Ex.A17, the opposite parties/ Insurance company had already deposited a sum of Rs.26,895/- to the credit of the Claimant's daughter in her HDFC Account.  Hence, the question of granting enhancement of the amount does not arise.  Further, the complainant has not made out any case by producing tangible evidence to prove his case that the sum of Rs.26,895/- was settled only in respect of subsequent treatment i.e., for the treatment taken after filing complaint but the subject claim, namely, claim No.1747683 dated 07.12.2013 was not settled.  In fact, the grounds raised in the appeal are not supported by any documentary evidence and such an appeal has to be dismissed.  Therefore, we are of the opinion that the complainant has not made out a case, for enhancement of compensation.  Hence, the appeal is liable to be dismissed.

 

 

       

       

        9.  Therefore, we find no merit in this appeal and the appeal is dismissed.  No order as to costs.

 

 

R   VENKATESAPERUMAL                                                                                             R.SUBBIAH

         MEMBER                                                                                                                      PRESIDENT

 

 

Index :  Yes/ No

 

AVR/SCDRC/Chennai/Orders/April/2023