Tamil Nadu

South Chennai

CC/77/2015

A.Chelladurai, S/o.K.Arthaneriswaran - Complainant(s)

Versus

United India Insurance Co Ltd - Opp.Party(s)

P.S.Vasanth Kumar

18 Sep 2019

ORDER

                                                                  Complaint presented on : 06.02.2015

                                                                    Date of Disposal            : 18.09.2019

                                                                                  

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (SOUTH)

@ 2^ND Floor, T.N.P.S.C. Road, V.O.C. Nagar, Park Town, Chennai – 3.

 

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

TR. R. BASKARKUMARAVEL, B.Sc., L.L.M., BPT., PGDCLP.  : MEMBER

 

C.C. No.77/2015

DATED THIS WEDNESDAY THE 18^TH DAY OF SEPTEMBER 2019

                                 

A. Chelladurai,

S/o. Late K. Arthaneriswaran,

No.18/4, Mettu Street,

Nerinjipettai Post,

Erode – 638 311,

Tamil Nadu.                                                                 .. Complainant.

                                                                                           ..Versus..

 

1. United India Insurance Co. Ltd.,

Regional Office, Chennai,

Represented by its Regional Manager,

LCB, Auras Corporate Center,

No.98/A, Dr. Radhakrishnan Road,

Chennai – 600 004. 

 

2. M/s. Raksha (TPA) Pvt. Ltd.,   

Head Office,

Represented by its General Manager,

No.15/5, Mathura Road,

Faridabad – 121 003.

 

3. M/s. Raksha TPA Pvt. Ltd.,   

Regional Office,

Represented by its Regional Manager,

No.18/4, PLN Complex,

Conran Smith Road,

Gopalapuram,

Chennai – 600 086.                                                 ..  Opposite parties.

 

Counsel for the complainant           : M/s. P.S. Vasanthkumar &

                                                           another

Counsel for the 1^st opposite party  : M/s. M.B. Gopalan & others

For the opposite parties 2 & 3        : Authorized representative,

                                                           Mr. Srihari Kumaran

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite parties 1 to 3 under section 12 of the Consumer Protection Act, 1986 prays to reimburse the amount of Rs.1,31,893/- paid by the complainant to G. Kuppusamy Naidu Memorial Hospital at Coimbatore after the treatment which is covered by the policy No.500200/48/13/41/00000263 issued by the 1^st opposite party and pay interest to the said amount at 12% per annum 25.04.2014 till the date of actual payment to the complainant and to pay a sum of Rs.1,00,000/- towards compensation for mental agony, pain, deficiency and negligence in service with cost of Rs.25,000/- to the complainant.

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

The complainant submits that he employed in M/s. IFMR Rural Channels and Services Private Ltd., Taramani, Chennai.  The complainant company had taken medi-claim insurance policy for the benefits of his employees and their family members including the complainant’s father, K. Arthanarieshwaran vide medi claim policy No.500200/48/13/41/00000263 for the period from 01.08.2013 to 31.07.2014.  The assured sum for the complainant and his family is of Rs.5,00,000/-.  The 2^nd opposite party is the Third Party Administrator (TPA) of the 1^st opposite party and the 3^rd opposite party is the Third Party Administrator of the complainant situated at Chennai.  The complainant’s father K. Arthanarieshwaran took treatment in G. Kuppusamy Naidu Memorial Hospital, Coimbatore for Cancer in oropharynx and Oesophagus. The complainant’s father K. Arthanarieshwaran took treatment on various days on 28.11.2013 to 30.11.2013, 19.12.2013 to 22.12.2013, 14.03.2014 to 17.03.2014,  04.04.2014 to 07.04.2014 & 25.04.2013 to 28.04.2014 and the complainant had filed the discharge summary for the treatment.  The complainant’s father also taken chemotherapy treatment in G. Kuppusamy Naidu Memorial Hospital, Coimbatore on the above mentioned days.  G. Kuppusamy Naidu Memorial Hospital, Coimbatore hospital issued a bill for the treatment taken by the complainant’s father for a sum of Rs.1,31,893/-.  While taking treatment, the complainant requested the opposite parties for cashless treatment for his father.  Since the 4^th opposite party had not tied up for cashless medical claim with the opposite party, the complainant was asked to pay the medical bill amount.  But the complainant’s father K. Arthanarieshwaran died on 14.05.2014.  The complainant processed the medical claim for Rs.1,31,893/- which was repudiated by the opposite parties on 13.11.2014 stated that using of intoxicating (Tobacco) is not covered under the policy as per clause 4.9 of the G.M.C. Policy condition of the 1^st opposite party.   On 27.03.2014, the grievance officer sent a reply confirming the repudiation of the claim is correct and directed the complainant to approach the Insurance Ombudsman.  On 27.03.2014, the complainant addressed a complaint to the Insurance Ombudsman, Chennai.   The insurance OMBUDSMAN accepted the stand of the opposite party and not awarded the claim of the complainant dated:27.05.2014.   The complainant sent earlier medi-claim settlement for the year 2010-2011 for his father from I.C.I.C.I. Lombard dated:08.10.2010 to the opposite parties.   Eventhough the policy is for medi-claim and treatment is one and the same for cancer in the same hospital.   The opposite parties repudiated the claim against the policy condition and acted with malafide intention of unfair trade practice which amount to deficiency in service.   Hence, the complaint is filed.

3.      The brief averments in the written version filed by 1^st opposite party is as follows:

The 1^st opposite party specifically denies each and every allegation made in the complaint and put the complainant to strict proof of the same.   The 1^st opposite party states that the complainant availed Group Mediclaim Policy covering the family members which was subsisting.  The employees’ policy is also subsisting.  As per the Exclusion 4.9 of the Policy treatment arising out of use of intoxiacating substances is not covered. The complainant made a claim for the treatment of his father K. Arthanarieshwaran at G. Kuppusamy Naidu Memorial Hospital, Coimbatore for oral cancer.  The medical records and the history of the patient reveals smoking Beedi 10/ day for 10 years which falls within the exclusion of ‘intoxicating’ substance under 4.9 of the Policy. Hence, the 2^nd opposite party, the Third Party Administrator repudiated the claim.   Therefore, there is no deficiency in service on the part of the 2^nd opposite party and hence, the complaint as against the 2^nd opposite party is liable to be dismissed.

4.      The brief averments in the written version filed by opposite parties 2 & 3 is as follows:

The opposite parties 2 & 3 specifically deny each and every allegation made in the complaint and put the complainant to strict proof of the same.   The opposite parties 2 & 3 registered under the Companies Act, 1956 is licensed under IRDA Act, 2001 to act as a facilitator for the processing of the claim.   The insurance contract is between the insured and the insurer i.e. The United India Insurance Co. Ltd.   As per the privity of the contract, the insurance company by itself or its TPA is obliged to process the claim as per the terms and conditions of the policy.   By the virtue of the Memorandum of the Understanding, signed with the United India Insurance Company Ltd. the opposite parties 2 & 3 are nominated as the Third Party Administrator for arranging to process the claims as per the terms and conditions laid by the Insurance Company.  The opposite parties 2 & 3 state that the complainant was covered under group mediclaim policy No.500200/48/13/41/00000263 issued by the United India Insurance Co. Ltd., Chennai and the claims in respect of K. Arthanareeswaran were recommended for repudiation as per the policy terms and conditions laid down by the 1^st opposite party and the files were forwarded to the 1^st opposite party for their perusal and further action.  The opposite parties 2 & 3 state that the opposite party has recommended the claim for repudiation in accordance with the terms and conditions of the medi-claim policy entered between the complainant and the 1^st opposite party which was agreed by the complainant.   It is further submitted that the opposite parties 2 & 3 is just a third party administrator who act as a facilitator for the processing of the claims as per the policy terms and conditions laid down by the 1^st opposite party.  It is therefore submitted that the name of the opposite parties 2 & 3 are liable to be deleted as they are not a necessary parties to the present complaint.

6.     To prove the averments in the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A14 are marked.  Proof affidavit of the 1^st opposite party is filed and no document is marked on the side of the 1^st opposite party.   Inspite of sufficient time is given the opposite parties 2 & 3 has not come forward to file proof affidavit to prove the contentions raised in the written version and hence proof affidavit of the opposite parties 2 & 3 were ‘closed’.

7.      The points for consideration is:-

1. Whether the complainant is entitled to get refund of a sum of Rs.1,31,893/- with interest at the rate of 12% p.a. as prayed for?

 

2. Whether the complainant is entitled to a sum of Rs.1,00,000/- towards compensation for mental agony, pain, deficiency in service, negligence with cost of Rs.25,000/- as prayed for?

8.     On point:-                                       

The opposite parties 2 & 3 has not come forward to file proof affidavit to prove the contentions raised in the written version.  Both complainant and 1^st opposite party filed their respective written arguments.  Heard their Counsels also.  The complainant pleaded and contended that he employed in M/s. IFMR Rural Channels and Services Private Ltd., Taramani, Chennai.  The complainant company had taken medi claim insurance policy for the benefits of his employees and their family members including the complainant’s father, K. Arthanarieshwaran vide medi claim policy No.500200/48/13/41/00000263 for the period from 01.08.2013 to 31.07.2014 as per Ex.A1.  Ex.A2 is the copy of the Member ID card issued by the opposite party.  The sum assured for the complainant and his family is of Rs.5,00,000/-.  The 2^nd opposite party is the Third Party Administrator (TPA) of the 1^st opposite party and the 3^rd opposite party is the Third Party Administrator of the complainant situated at Chennai.  The 4^th opposite party is the Hospital situated at Coimbatore wherein, the complainant’s father K. Arthanarieshwaran took treatment for Cancer in oropharynx and Oesophagus. The complainant’s father K. Arthanarieshwaran took treatment on various days on 28.11.2013 to 30.11.2013, 19.12.2013 to 22.12.2013, 14.03.2014 to 17.03.2014, 04.04.2014 to 07.04.2014 and 25.04.2013 to 28.04.2014 as per Ex.A3 to Ex.A7, copy of Discharge Summaries.  The complainant’s father also taken chemotherapy treatment in 4^th opposite party hospital on the above mentioned days.  The 4^th opposite party hospital issued a bill for the treatment taken by the complainant’s father for a sum of Rs.1,31,893 /- as per Ex.A8.  While taking treatment, the complainant requested the opposite parties for cashless treatment and his father. But the complainant’s father K. Arthanarieshwaran died on 14.05.2014 and Ex.A9 is the copy of Death Certificate.  The complainant processed the medical claim for Rs.1,31,893/- which was repudiated by the opposite parties on 13.11.2014 as per Ex.A11 stating that using of intoxicating (Tobacco) is not covered under the policy as per clause 4.9 of the G.M.C. Policy condition of the 1^st opposite party.  Ex.A12 is the copy of Health Insurance Policy terms and conditions of the 1^st opposite party.  But on a careful perusal of Ex.A12, the Health Insurance Policy - Group, it is very clear in clause 4.9 which reads as follows:

4.9 “Convalescence, general debility; run-down condition or rest cure, Obesity treatment and its complications including morbid obesity, Congenital external disease /defects or anomalies, treatment relating to all psychiatric and psychosomatic disorders, infertility, Sterility, venereal disease, intentional self injury and use of intoxication drugs / alcohol”.

proves that there is no iota of any evidence to show the use of tobacco.  On 27.03.2014, the complainant addressed a complaint to the Insurance Ombudsman, Chennai as per Ex.A13.  Thereafter, the complainant filed this complaint claiming reimbursement of medical expenses for a sum of Rs.1,31,893/- with compensation and cost for the deficiency in service and unfair trade practice.

9.     The learned Counsel for the 1^st opposite party would contend that admittedly, the complainant availed Group Mediclaim Policy covering the family members which was subsisting.  The employees’ policy is also subsisting.  As per the Exclusion 4.9 of the Policy treatment arising out of use of intoxiacating substances is not covered.  The complainant made a claim for the treatment of his father K. Arthanarieshwaran at G. Kuppusamy Naidu Memorial Hospital, Coimbatore for oral cancer.  The medical records and the history of the patient reveals smoking Beedi 10/ day for 10 years which falls within the exclusion of ‘intoxicating’ substance under 4.9 of the Policy. Hence, the 2^nd opposite party; the Third Party Administrator repudiated the claim.  But on a careful perusal of the Exclusion clause 4.9, there is nothing about the tobacco included as an ‘intoxicating’ substances proves the deficiency in service and unfair trade practice.  Considering the facts and circumstances of the case, this Forum is of the considered view that the opposite parties 1 to 3 are jointly and severally shall refund a sum of Rs.1,31,893/- with a compensation of Rs.25,000/- and cost Rs.10,000/- to the complainant.

In the result, this complaint is allowed in part.   The opposite parties 1 to 3 are jointly and severally liable to refund a sum of Rs.1,31,893/- (Rupees One lakh thirty one thousand eight hundred and ninety three only) and to pay a sum of Rs.25,000/- (Rupees Twenty five thousand only) towards compensation for mental agony with cost of Rs.10,000/- (Rupees Ten thousand only) to the complainant.  

The above  amounts shall be payable  within 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 18^th day of September2019. 

 

MEMBER                                                                                PRESIDENT

 

COMPLAINANT SIDE DOCUMENTS:-

Ex.A1		Copy of policy documents of the complainant issued by the 1st opposite party for 01.08.2013 to 31.07.2014
Ex.A2		Copy of Member ID card issued by the opposite parties
Ex.A3		Copy of Discharge Summary for 28.11.2013 to 30.11.2013 issued by G. Kuppusamy Naidu Memorial Hospital, Coimbatore
Ex.A4		Copy of Discharge summary for 19.12.2013 to 22.12.2013 issued by G. Kuppusamy Naidu Memorial Hospital, Coimbatore
Ex.A5		Copy of Discharge summary for 14.03.2014 to 17.03.2014 issued by G. Kuppusamy Naidu Memorial Hospital, Coimbatore
Ex.A6		Copy of Discharge summary for 04.04.2014 to 17.04.2014 issued by G. Kuppusamy Naidu Memorial Hospital, Coimbatore
Ex.A7		Copy of Discharge summary for 25.04.2014 to 28.04.2014 issued by G. Kuppusamy Naidu Memorial Hospital, Coimbatore
Ex.A8		Copy of payment of medical bills
Ex.A9	14.05.2014	Copy of Death Certificate of the complainant’s father
Ex.A10	30.06.2014	Copy of claim forms
Ex.A11	30.11.2014	Copy of the repudiation letter issued by the 3rd opposite party to complainant
Ex.A12		Copy of the terms and conditions of the Health Insurance Policy of the 1st opposite party
Ex.A13	27.03.2014	Copy of the complaint filed by the complainant before the insurance OMBUDSMAN, Chennai
Ex.A14	08.12.2010	Copy of the mediclaim settlement details (2010-11) by ICICI Lombard

 

1^ST OPPOSITE PARTY SIDE DOCUMENTS:-  NIL

OPPOSITE PARTIES 2 & 3 SIDE DOCUMENTS:-  ‘Closed as no Proof Affidavit’

                              

 

MEMBER                                                                                                                                                                              PRESIDENT