Tamil Nadu

North Chennai

CC/32/2015

S.Kanhayalal Jain, - Complainant(s)

Versus

UIIC Ltd., by its Manager, - Opp.Party(s)

Sunil & S.Natarajan

24 May 2018

ORDER

 

                                                            Complaint presented on:  03.02.2015

                                                                Order pronounced on:  24.05.2018

 

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

              THIRU. M.UYIRROLI KANNAN B.B.A., B.L.,      MEMBER - I

 

THURSDAY  THE 24^th  DAY OF MAY 2018

 

C.C.NO.32/2015

 

S.Kanhayalal Jain,

“Mishri Krupa”,

#:39, Kalathi Pillai Street,

Sowcarpet Chennai – 79.

 

                                                                                    ….. Complainant

 

..Vs..

United India Insurance Co Ltd.,

Rep. by its Manager,

#:52 General Muthia Street,

Sowcarpet Chennai – 79.

.....Opposite Party

Date of complaint                                 : 18.02.2015

Counsel for Complainant                      : Mr.Yurendrakumar

Counsel for Opposite Party                      : M.B.Gopalan, N.Vijayaraghavan,

                                                                    M.B.Raghavan

 

 

 

 

 

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 a sum of Rs.48,509/- towards medical expenses met by him in the hospital with interest from 27.12.2013 and also to pay compensation for deficiency in service and mental agony with cost of the complaint u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IN BRIEF:

          The complainant wife underwent Eye-test on 27.12.2013 at Amrit Hospital, Chennai – 79 and she was diagnosed Cataract on her right eye. She underwent Cataract surgery for photo C Multifocal on 28.12.2013 and she was discharged on 11.01.2014. The complainant made mediclaim of Rs.48,509/- towards medical expenses met by him. However, her claim was restricted to Rs.20,450/- on 29.01.2014 quoting exclusion clause.

          2. The denial of entire claim made by the complainant is deficiency on the part of the opposite party. The policy nowhere provides for any such exclusion to restrict the claim made by her. The claim made by the complainant is genuine; the resultant mental agony caused by the opposite party has to be compensated. Hence the complainant filed this complaint to direct the opposite party to pay a sum of Rs.48,509/- towards medical expenses met by him in the hospital with interest from 27.12.2013 and also to pay compensation for deficiency in service and mental agony with cost of the complaint.

 

3. WRITTEN VERSION OF THE  OPPOSITE PARTY IN BRIEF:

          The opposite party admits that the complainant wife underwent cataract surgery at Amrit Hospital and claimed Rs.48,509/- submitting various bills for doctors fees, medical test, lens implant etc., The complainant had individual health policy of the opposite party for the period 19.07.2013 to 18.07.2014 covering himself and his wife. The coverage under the policy is only for reasonable expenses and any excess or unnecessary expenses cannot be claimed as a matter of course.  

          4. The complainant claim was processed by the TPA (3^rd party administrator) and it was found that bills during hospitalization and doctors fee was allowed as claimed and the cost of lens was found to be in excess of the normal costs and the complainant had chosen multifocal lens instead of normal lens and TPA allowed Rs.8,000/- as against Rs.34,000/-. Accordingly TPA allowed Rs.20,450/- towards reasonable and necessary charges for the treatment. Hence there is no deficiency committed to the opposite party 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 party?

          2. Whether the complainant is entitled to any relief? If so to what extent?

6. POINT NO :1 

          The facts are not dispute between the parties are that the complainant availed  health policy for the period 19.07.2013 to 18.07.2014 for himself and his wife and the opposite party issued Ex.A1 policy with terms and conditions  to him  and the  complainant  wife underwent Eye-test on 27.12.2013 at Amrit Hospital, Chennai – 79 and she was diagnosed Cataract on her right eye and she underwent Cataract surgery  for photo C Multifocal on 28.12.2013  and she was discharged on the same day   under Ex.A2 discharge summary  and  the complainant made mediclaim of Rs.48,509/- towards expenses met by him and  however, the opposite party allowed only a sum of Rs.20,450/-  and rejected the rest of the claim.  

          7. The complainant made a claim of Rs.48,509/- and in the said amount only a sum  of Rs.20,450/- was allowed and the same was not accepted by the complainant as he wanted full claim. The opposite party taken a stand in written version that the TPA only processed the claim and he allowed hospitalization and professional charges and however, he found that lens cost was  found to be more than the normal lens and in that respect he had allowed only  Rs.8,000/-.

8. The 3^rd party administrator (TPA) has not issued the policy to the Consumer/complainant. Hence there is no privity of contract between the complainant and the TPA in respect of Ex.A1 policy issued by the opposite party and therefore, the TPA has no right to decide the claim based on the policy issued to the complainant. If at all the TPA can only collect claim papers from the consumers and place before the opposite party for the decision and he cannot take any decision. Hence the opposite party also based on the conclusion of the TPA has partly allowed the claim of the complainant is not justifiable.

9. The TPA decided and allowed only Rs.8,000/- for  normal lens cost as against Rs.34,000/- Multifocal lens. No terms and conditions quoted by the opposite party in the written version that the patient should chose only normal lens and not multifocal lens. Normally the patients will chose the lens for their convenience with consultation of the doctor. One cannot restrict the patient to chose only this lens and not the other and therefore in this respect by allowing Rs.8,000/- the opposite party has committed deficiency.  The opposite party has not applied its mind in considering the claim made by the complainant. Merely accepting conclusion of the TPA and allowing the TPA to decide the claim and the opposite party has not decided the claim independently applying his mind and allowing the claim partly, proves that the opposite party has committed deficiency in service in deciding the claim of the complainant.

10. POINT NO:2

The complainant made a claim of Rs.48,509/- along with inpatient bills, professional charges bill and medical test bills etc., So, the complainant submitted all the bills with claim for the amount claimed by him. We decided above that partly allowing the claim is deficiency on the part of the opposite party.  The complainant also not received the part claim amount allowed by the opposite party. Therefore, the opposite party can be directed to pay the claim amount of Rs.48,509/- to the complainant. By denial of the claim the complainant suffered with mental agony is accepted and for the same, it would be appropriate to direct the opposite party to pay a sum of Rs.25,000/- towards compensation for the same, besides a sum of Rs.5,000/- towards litigation expenses.

          In the result the Complaint is partly allowed. The Opposite Party is ordered to pay a sum of Rs.48,509/- (Rupees forty eight thousand five hundred and nine  only) towards the claim amount to the Complainant and also to pay  a sum of Rs. 25,000/- (Rupees twenty five  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 claim and compensation 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 24^th day of May 2018.

 

MEMBER – I                                                                PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 19.07.2013                   Mediclaim policy with annexure

Ex.A2 dated NIL                     Discharge summary

Ex.A3 dated NIL                     Claim Details

Ex.A4 dated 29.01.2014                   opposite party’s letter

LIST OF DOCUMENTS FILED BY THE OPPOSITE PARTY :

 

Ex.B1 dated 27.02.2015                   Invoice bill of Rs.8,000/- for normal lens

 

 

 

 

MEMBER – I                                                               PRESIDENT