Tamil Nadu

North Chennai

CC/72/2021

Sandeep S Shah - Complainant(s)

Versus

The United India Insurance Company Limited Rep by its Branch Manager - Opp.Party(s)

Party in Person

30 Jan 2024

ORDER

Complaint presented on  :29.09.2020       Date of disposal            :30.01.2024

                                                                                  

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

CHENNAI (NORTH)

@ 2^ND 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

                                         THIRU V. RAMAMURTHY, B.A., B.L., PGDLA : MEMBER-II

 

C.C. No.72/2021

 

DATED THIS TUESDAY THE 30th DAY OF JANUARY 2024

 

Sandeep S Shah,

No.213 & 214 Rajendra Apartments,

No.158/29&30 Barakka Road,

Secretariat Colony,

Kelly’s Chennai-600 010                                                     .. Complainant.                                                                         ..Vs..

 

1.The United India Insurance Company Ltd,

Rep by its Branch Manager,

No.52, General Muthaiah Mudali Street,

Sowcarpet,

Chennai-600 079.

 

2.Heritage Health Insurance

Rep by its Director

TPA Private Ltd,

Prince Center, 2^nd Floor,

S-206, No.709-710,

Mount Road, Thousand Lights,

Chennai-600 006

          ...  Opposite parties.

 

Counsel for the Complainant                   : M/s.Samir & Shah

Counsel for the 1^st Opposite party           : M/s.C.Paranthaman

Counsel for the 2^nd Opposite party          : Exparte

ORDER

THIRU. G. VINOBHA, M.A., B.L., PRESIDENT

          This complaint has been filed by the complainant against the opposite parties under section 35 of the Consumer Protection Act, prays to directing the Opposite parties jointly and severally to pay Rs.54837/- with interest @ 12%p.a on Rs.18,000/- from the date of complaint till the actual payment or realization and cost of the complaint.

 

1.THE COMPLAINT IN BRIEF:

          The complainant states that the unforeseen health condition subscribed the health insurance policy with the 1^st opposite party way back in the year 1990 and ever since then the health insurance policy is being regularly renewed without any intervention. Lastly policy was renewed in the month of August 2017 covering period from 21.08.2017 to 20.08.2018 and the policy No. assigned was 0108022817P106608601 and further according to the complainant the sum assured is Rs.5lakhs and as per clause 1.2.1 of the policy. Expenses in respect of the following specified illnesses will be restricted as detailed as Hospitalisation Benefit is Cataract, Haranya, Hystertomy and the limits per surgery restricted to actual expenses incurred or 25% of the sum insured. Thus as per terms and policy the opposite party is bound to reimburse the claim up to 25% of the sum assured i.e.1,25,000/- (25% of 5 lakhs) or actual expenses whichever is less. The complainant underwent a cataract operation in respect of his right eye on 10.05.2018 at Dr.Ravishankar Eye Clinic and Nursing Home, Chennai-600 112 for which hospital charged Rs.48,000/- which was paid by the complainant by means of bankers cheque drawn on Union Bank of India, Purasawalkam, Chennai. The complainant further states that after completion of the cataract operation, Dr.Ravishankar Eye clinic and Nursing Home raised bill for Rs.48,544/- and based on that complainant made claim for the same with the 1^st opposite party. However after considerable delay of more than 4 months without any intimation/confirmation to the complainant M/s.Heritage Health Services pvt ltd on 08.10.2018 processed the claim for a sum of Rs.30,544/- by way of NEFT as against the claim made for Rs.48,544/- Even if simple arithmetic logic is applied even in that case from and out of Rs.48,544/- if Rs.5000/- is disallowed by the opposite party, even then the opposite party is bound to process the claim to the tune of Rs.43,544/- as against that they paid only a sum of Rs.30544/- without any logic, basis or reason. At the time of renewal of the policy opposite party failed to grant no claim discount and at the same time increase the renewal premium which is totally against the Rules and Regulations of IRDA as well as against the ethic and principle of natural justice. The complainant further states that after receipt of the letter of the 1^st opposite party complaint issued a legal notice dated 30.19.2019. Further that the manner in which the 1^st opposite has rejected the part of the claim to the tune of Rs.18,000/ is totally against the terms and policy. The complainant prayed to pay Rs.54837/- with interest @ 12%p.a on Rs.18,000/- from the date of complaint till the actual payment or realization and cost of the complaint. Hence this complaint.

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

          The 1^st opposite party submits that it is true that the complainant took individual health policy-Gold vide policy No.0108022817P106608601 period from 21.08.2017 to midnight on 20.08.2018. The policy was issued along with terms and conditions to the complainant. The complainant after taking treatment at Dr.Ravishankar Eye Clinic and Nursing Home, Chennai he submitted claim form. The 1^st opposite party submits that on 08.10.2018 the 2^nd opposite party sent a letter as per terms of the policy the sum of Rs.30,544/- is entitled. The 1^st opposite party submits that the complainant not accepted the claim and returned the cheque on 10.01.2019. The complainant submits though he submitted the bills for Rs.48,544/- as per the condition of the policy Rs.30,544/- the cheque was issued. The 1^st opposite party submits that there is no any deficiency service as alleged by the complainant and there is no merits in the complaint.

3. POINTS FOR CONSIDERATION:

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

2. Whether the complainant is entitled to the reliefs prayed in the complaint. If, so to what extent?

The complainant had filed proof affidavit, written arguments and documents Ex.A1 to Ex.A9 were marked on his side.The 1^st opposite party had filed written version, proof affidavit, written arguments and no documents were marked. The 2^nd opposite party remained exparte.

4. Point No.1:-

          It is an admitted fact that the complainant has taken a health insurance policy with the 1^st opposite party which was renewed year after year and lastly the policy was renewed 21.08.2017 to 20.08.2018 and further it is an admitted fact that the sum assured under the policy is Rs.5lakhs further the opposite party admitted that the complainant has underwent right eye cataract surgery on 10.05.2018 at Dr.Ravishankar eye clinic Chennai for which the complainant has submitted claim of Rs.48,000/- to the 1^st opposite party through the 2^nd opposite party who is acting as TPA for the 1^st opposite party. But according to the complainant after a considerable delay of more than 4 months on 08.10.2018 the claim was processed and a sum of Rs.30544/- alone was sent to the complainant instead of Rs.48544/- and hence the complainant contended that the rejection of claim to the tune of Rs.18000/- which was disallowed by the opposite parties is against the IRDA Rules and against the policy conditions therefore the complainant alleged the same as deficiency in service and claimed the rejected amount of Rs.18000/- along with interest.

          But on the other hand the 1^st opposite party contended that the policy was issued along with terms and conditions to the complainant. The complainant after taking treatment at Dr.Ravishankar Eye Clinic and Nursing Home, Chennai he submitted claim form. The 1^st opposite party submits that on 08.10.2018 the 2^nd opposite party sent a letter as per terms of the policy the sum of Rs.30,544/- is entitled. The 1^st opposite party submits that the complainant not accepted the claim and returned the cheque on 10.01.2019. The complainant submits though he submitted the bills for Rs.48,544/- as per the condition of the policy Rs.30,544/- the cheque was issued and denied deficiency in service. The 2^nd opposite party remained exparte.

          EX.A1 is the health policy issued to the complainant and as per clause 1.2.1 the policy covered for cataract, haranya and other surgeries the actual expenses incurred or 25% of the sum insured whichever is less, Ex.A2 is Discharge summary from which it is found that the complainant underwent a right eye cataract surgery on 10.05.2018 at Dr.Ravishankar eye hospital, Ex.A3 on 06.06.2018 the 2^nd opposite party requested certain additional documents and information for processing the claim and Ex.A4 is reply by the complainant, Ex.A5 are reports and bills which were given by the hospital and it is found that the complainant was charged Rs.48,000/- by the hospital on 11.05.2018 which was paid by the complainant for which he has raised a claim with the 1^st opposite party which was partly sanctioned and it is found from Ex.A6 that though the complainant has submitted bills for Rs.48544/- the 1^st opposite party has deducted Rs.18,000/- as not payable towards implants, assistant charges and operation theatre charges, Ex.A7 is letter from the complainant by returning the cheque for Rs.30544/- to the 1^st opposite party and claiming the entire amount and it is found from Ex.A8 the returned cheque was again sent to the complainant and Ex.A9 is legal notice issued by the complainant.

          On perusal of documents and averments of both the parties it is found that of the clause 1.2.1 of the policy the complainant is entitled for actual expenses incurred or 25% of the sum insured whichever is less for cataract surgery admittedly the sum insured is Rs.5lakhs, hence the opposite parties 1 and 2 are liable to pay the actual expenses incurred by the complainant for Rs.48544/- The opposite party has not given any valid explanation for deducting Rs.18,000/- as not payable towards implants, assistant charges and operation theatre charges. Such deduction of Rs.18000/- by the opposite parties is unjustified and against the rules and regulations of IRDA further it is found from Ex.A6 and A8 that even the partial claim was sanctioned by the opposite parties only on 08.10.2008 belatedly after 4 months from the date of surgery which also amounted to deficiency in service on the part of opposite parties 1 and 2. It is found from Ex.A8 that the complainant as received the cheque amount of Rs.30544 which was again sent by the 1^st opposite party. Hence it is found that the rejection of part of the claim by the opposite parties as well as the delayed processing of claim amounted to deficiency in service on the part of opposite parties. Point No.1 is answered accordingly

Point No.2:

           Based on the findings given to the PointNo.1, since there is deficiency in service is observed on the part of opposite parties 1 and 2, the complainant is entitled  for a sum of Rs.18,000/- with interest at 9%p.a from 11.06.2018 till date of payment and also Rs.5000/- towards cost of the complaint.  Point No.2 is answered accordingly.

          In the result the complaint is partly allowed.  The opposite parties 1 and 2 are jointly and severally directed to pay a sum of Rs.18,000/- with interest at 9%p.a from 11.06.2018 till date of payments and also Rs.5000/- towards cost of the complaint.  The above amount shall be paid to the Complainants 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 order to till the date of payment.

 

          Dictated by 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 30^th January 2024.

 

MEMBER I                                  MEMBER – II                           PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1	08.08.2017	Individual Health Policy
Ex.A2	10.05.2018	Discharge Summary
Ex.A3	06.06.2018	Query Letter 2nd respondent to complainant
Ex.A4	11.06.2018	Reply to the query letter
Ex.A5	Various Dates	Bunch of Reports and Misc.Papers
Ex.A6	08.10.2018	Claim Settlement Advice
Ex.A7	21.12.2018	Letter from complainant
Ex.A8	10.01.2019	Letter from 1st respondent to the complainant
Ex.A9	30.01.2019	Advocate notice with A.D.Card

 

 

LIST OF DOCUMENTS FILED BY THE   OPPOSITE PARTIES:

 

                             No Documents

 

MEMBER – I                         MEMBER – II                       PRESIDENT