Tamil Nadu

South Chennai

CC/308/2013

V.Srinivasan - Complainant(s)

Versus

TTK Health Care Services (P) Ltd - Opp.Party(s)

M/s.Sathish Rajan

18 Apr 2018

ORDER

 

                                                                        Date of Filing  : 24.09.2013

                                                                          Date of Order : 11.05.2018

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (SOUTH)

@ 2^ND Floor, Frazer Bridge Road, V.O.C. Nagar, Park Town, Chennai – 3.

 

PRESENT: THIRU. M. MONY, B.Sc., L.L.B, M.L.                    : PRESIDENT

                 TMT. K. AMALA, M.A., L.L.B.                                : MEMBER-I

 

C.C. No.308 /2013

DATED THIS FRIDAY THE 11^TH DAY OF MAY 2018

                                 

Mr. V. Srinivasan,

S/o. G. Venkatesa Naidu,

B-2, II Floor, 3^rd Block,

Shivani Apartments,

East Coast Road,

Thiruvanmiyur,

Chennai – 600 041.                                               .. Complainant.                                                         ..Versus..

1. The Manager,

M/s. TTK Health Care Services (P) Ltd.,

Anmol Palani,

L2, No.88, G.N. Chetty Road,

T. Nagar,

Chennai – 600 017.

 

2.  The Manager,

M/s. United India Insurance Co. Ltd.,

Branch Office  (010603),

“Gee Gee” Complex, III Floor,

No.42, Anna Salai,

Chennai – 600 002.                                             ..  Opposite parties.

          

Counsel for complainant         :  M/s. S. Sathish Rajan & others

Counsel for opposite parties  :  M/s. Nageswaran & Narichania

 

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite parties under section 12 of the Consumer Protection Act, 1986 seeking to reimburse the sum of Rs.63,941/- incurred towards medical expenses with interest at the rate of 12% p.a. to the complainant, to pay a sum of Rs.2,00,000/- towards compensation for mental agony and to pay the cost of the complaint.

1.    The averments of the complaint in brief are as follows:

The complainant is the holder of Mediclaim Insurance policy with the 2^nd opposite party under the Group Mediclaim Insurance  scheme of State Bank of India Pensioner Association, Chennai for the year 2012-2013 vide Policy No.010603/48/11/05/00001211.   The claim if any arise, it should be settled through 1^st opposite party TTK ID No.CHE-UI-SI289-001-00000171-A.  Further the complainant submits that he was developed pain and swelling on his left chest.    As per the advice of the Doctor, the complainant was admitted in Fortis Malar Hospital, Adyar on 23.08.2012.  After various tests, the Doctor diagnosed that the complainant had the disease as “LEFT GYNAECOMASTIA-PAGET’S DISEASE”. The complainant had undergone surgery and Excision biopsy test for suspected malignancy and fortunately the result proved negative. The complainant was treated as inpatient for 3 days from 23.08.2012 and discharged on 25.08.2012.  Further the complainant submits that immediately after his admission in the hospital for surgery, the hospital informed both the opposite parties and sought for cashless treatment.  But the opposite parties advised the complainant to pay the entire medical expenses and submit the claim thereafter.   Accordingly, the complainant after discharged from the hospital on 04.09.2012 submitted the claim form with all particulars and medical bill.   On 16.10.2012, the opposite parties repudiated the complainant’s claim stating that the surgery was a cosmetic surgery, as per the policy terms and conditions in clause 4.6 the claim cannot be entertained.     Hence the complaint is filed.

2.     The brief averments in the written version filed by the opposite parties is as follows:

The opposite parties specifically deny each and every allegations made in the complaint and puts the complainant to strict proof of the same.  The opposite parties state that the complainant is a Mediclaim policy holder and the policy is subsisting, the claim if any is subject to the terms and conditions of the policy and its maintainability is to be settled through the 1^st opposite party.   The complainant is a holder of cashless ID card also.  The 3^rd party administrator M/s. TTK Health Care Service (P) Ltd. requested additional information from M/s. Fortis Malar Hospital wherein the complainant underwent surgery.  After due discussion, the opposite parties came to the conclusion that the surgery conducted  was cosmetics.   M/s Fortis Malar Hospital in its clinical findings dated: 25.08.2012 stated that Plague like Lesion with Gynaecosmastia with Mammary Tissue (Gynaecosmastia) no evidence of malignancy in section studied shows the treatment / surgery falls under cosmetic surgery.   But the medical literature is very clear that Gynaecosmastia is not a precancerous condition but rather that the hormonal changes (relative increase in extogents lower levels of androgens) that produce Gynaecosmastia in adult men also increase the risk of developing breast cancer.   Further the opposite parties state that the cosmetic surgery was excluded vide policy condition 4.6.   Hence the opposite parties repudiated the claim.   Hence there is no deficiency on the part of the opposite parties and the complaint is liable to be dismissed.

3.   In order to prove the averments in the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A18 are marked.  Proof affidavit of the opposite parties filed and documents Ex.B1 to Ex.B7 are filed and marked on the side of the opposite parties.

4.     The points for consideration is:-

1. Whether the complainant is entitled to a sum of Rs.63,941/- with interest at the rate of 12% p.a. as prayed for?
2. Whether the complainant is entitled for a sum of Rs.2,00,000/- towards compensation for mental agony with cost as prayed for?

5.    On point                   

Both parties filed their respective written arguments.  Heard the opposite parties’ Counsel also.  Perused the records namely the  complaint, written version, proof affidavits, documents etc.   Admittedly, the complainant is the holder of Mediclaim Insurance policy with the 2^nd opposite party under the Group Mediclaim Insurance scheme of State Bank of India Pensioner Association, Chennai and renewed for the year 2012-2013 vide Policy No.010603/48/11/05/00001211.   The claim if any arise, it should be settled through 1^st opposite party TTK ID No.CHE-UI-SI289-001-00000171-A.  Ex.A1 is the copy of policy.  Further the complainant contended that he was developed pain and swelling on his left chest.    As per the advice of the Doctor, the complainant was admitted in Fortis Malar Hospital, Adyar on 23.08.2012.  After various tests, the Doctor diagnosed that the complainant had the disease as “LEFT GYNAECOMASTIA-PAGET’S DISEASE”. The complainant had undergone surgery and Excision biopsy test for suspected malignancy and fortunately the result proved negative. The complainant was treated as impatient for 3 days from 23.08.2012 and discharged on 25.08.2012 as per Ex.A10.  The various tests and expenditure will be seen from Ex.A2 to Ex.A9 and Ex.A11.   

6.     Further the complainant contended that immediately after his admission in the hospital for surgery, the hospital informed both the opposite parties and sought for cashless treatment.  But the opposite parties advised the complainant to pay the entire medical expenses and submit the claim thereafter.   Accordingly, the complainant after discharged from the hospital on 04.09.2012 submitted the claim form with all particulars and medical bill as per Ex.A13.   On 16.10.2012, the opposite parties repudiated the claim as per Ex.A14 stating that the surgery was a cosmetic surgery as per the policy terms and conditions in clause 4.6 the claim cannot be entertained.    But it is apparently clear from the pleadings and records, that the complainant was aged 59 years at the time of surgery and had developed pain and swelling on his left chest, was compelled to undergo surgery for therapeutic surgery for removal.  As per Ex.A17 & Ex.A18, the certificates issued by the Doctor, who conducted surgery and also the endorsement as per Ex.B3, it is very clear that “The surgery done was not cosmetic surgery" proves the surgery was extremely necessitated in order to avoid further complications.   

7.     Further the complainant contended that in Robbins and Cotran - Pathologic Basis of Disease “it is believed that Gynecomastia itself is not a precancerous condition, but rather that the hormonal changes (relative increase in estrogens, lower level of androgens) that produce Gynecomastia in adult men also increase their risk of developing breast cancer” proves that  the therapeutic surgery to the complainant  is a necessary one proves the deficiency in service on the part of the opposite parties.  The complainant is claiming a sum of Rs.63,941/- towards medical expenses and Rs.2,00,000/- towards compensation for mental agony.

8.     The learned Counsel for the opposite parties contended that  admittedly, the complainant is a Mediclaim policy holder and the policy is subsisting.    The claim if any is subject to the terms and conditions of the policy and its maintainability is to be settled through the 1^st opposite party.   The complainant is a holder of cashless ID card also.  The 3^rd party administrator M/s. TTK Health Care Service (P) Ltd. requested additional information from M/s. Fortis Malar Hospital wherein the complainant underwent surgery.     After due discussion, the opposite parties came to the conclusion that the surgery conducted  was cosmetic.   M/s Fortis Malar Hospital in its clinical findings dated: 25.08.2012 stated that Plague like Lesion with Gynaecosmastia with Mammary Tissue (Gynaecosmastia) no evidence of malignancy in section studied shows the treatment / surgery falls under cosmetic surgery.   But the medical literature is very clear that Gynaecosmastia is not a precancerous condition but rather that the hormonal changes (relative increase in extogents lower levels of androgens) that produce Gynaecosmastia in adult men also increase the risk of developing breast cancer.   Further the contention of the opposite parties is that the cosmetic surgery was excluded vide policy condition 4.6.   Hence the opposite parties repudiated the claim.   But the Doctor who conducted surgery also issued Ex.A17 and Ex.A18 certificates and made an endorsement in Ex.B3 stating that the surgery is not for cosmetics and it reveals that it is therapeutic.   On a careful perusal of Ex.A17, Ex.A18 and Ex.B3, it is very clear that the surgery done was not a cosmetic surgery.   The opposite parties have not raised any substantial contention regarding the claim towards medical treatment and compensation.  Considering the facts and circumstances of the case, this Forum is of the considered view that the opposite parties shall pay a sum of Rs.63,941/- with interest at the rate of 9% p.a. with compensation Rs.30,000/- and  cost of Rs.5,000/- to the complainant.

  In the result, this complaint is allowed in part.  The  opposite parties 1 & 2 are jointly and severally liable to     pay a sum of Rs.63,941/- (Rupees sixty three thousand nine hundred and forty one only) with interest at the rate of 9% p.a. from the date of filing of this complaint i.e. 24.09.2013 to till the date of this order and to pay a sum of Rs.30,000/- (Rupees thirty thousand only) towards compensation for mental agony with cost of Rs.5,000/- (Rupees Five thousand only) to the complainant.

The aboveamounts shall be payablewithin six weeks from the date of receipt of the copy of this order, failing which, the said amounts shall carry interest at the rate of 9% p.a. to till the date of payment.

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 Forum on this the 11^th day of May 2018. 

 

MEMBER –I                                                                      PRESIDENT

COMPLAINANT SIDE DOCUMENTS:

		Copy of policy renewal with policy conditions
		Copy of cash bill
		Copy of bill by Department of Radiology
		Copy of cash bill
		Copy of cash bill
		Copy of cash bill
		Copy of deposit receipt
		Copy of payment receipt
		Copy of inpatient bill (Detail)
		Copy of Discharge Summary
		Copy of cash bill
		Copy of Certificate issued by the Surgeon
		Copy of the claim form submitted by the complainant
		Copy of the letter sent by the 1st opposite party rejecting the claim
		Copy of e-mail sent by the complainant to reopen the claim
		Copy of e-mail by the 1st opposite party rejecting the claim
		Copy of the certificate issued by the Surgion who conducted the Surgery
		Copy of the certificate issued by the Surgion who conducted the Surgery

 

OPPOSITE  PARTIES SIDE DOCUMENTS:  

Ex.B1	20.08.2012	Copy of C.T. Chest scan Report
Ex.B2	21.08.2012	Copy of diagnostic Report
Ex.B3	23.08.2012	Copy of additional information request
Ex.B4	23.08.2012	Copy of additional information request
Ex.B5	23.08.2012	Copy of diagnostic Report
Ex.B6	24.08.2012	Copy of additional information request
Ex.B7	25.08.2012	Copy of Dental Cashless Access

 

 

MEMBER –I                                                                      PRESIDENT