Tamil Nadu

North Chennai

CC/02/2015

B.Manikandan,S/o.Bharathi dasan, - Complainant(s)

Versus

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

C.Kandaswamy

09 Apr 2018

ORDER

 

                                                            Complaint presented on:  23.12.2014

                                                                Order pronounced on:  09.04.2018

 

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

 

MONDAY  THE 09^th   DAY OF APRIL 2018]=

 

C.C.NO.02 /2015

 

B.Manikandan ,

Son of Mr.Bharathidasan,

No.13 and 14 Karthik Flat,

F2 Athipet, Main Road,

Kuppam, Ambattur, Chennai – 600 058.

                                                                                            ….. Complainant

 

..Vs..

1.United India Insurance Company Ltd.,

Corporate  Cell,

Church Gate, Mumbai, PIN – 400 020.

 

2.Insurance Ombudsman,

RBI Buildings,

Rajaji Salai, Chennai – 600 001.

.....Opposite Parties

Date of complaint                                 : 02.01.2015

Counsel for Complainant                       : M/s. C.Kandaswamy, S.P.Satishkumar

Counsel for 1^st Opposite Party                  : M.B.Gopalan Associates,

                                                                    N.Vijayaraghavan, M.B.Raghavan

 

Counsel for 2^nd opposite party                 : Ex-parte (on 09.03.2015)

 

O R D E R

 

BY PRESIDENT THIRU. K.JAYABALAN B.Sc., B.L.,

          This complaint is filed by the complainant to direct the 1^st opposite party to pay a sum of Rs.2,14,764/- 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 availed a group Mediclaim Policy through his employer M/s. Sodexo Facilities M G T Services India Private Limited covering his family members. The complainant wife gave birth a male child at Subam Nursing Home, Madurai. After 20 days of his birth, he noticed swelling in the back side of the child. After taking scan and on the advice of the doctor, the child was admitted at Apollo hospital, Chennai on 06.05.2013. On 07.05.2013 a surgery was conducted and thereafter the child was recovered.

          2. The complainant made a claim for the sum of Rs.2,44,764/- towards medical expenses for the treatment of his son. The 1^st opposite party rejected the Mediclaim that the complainant son suffering from congenital external disease and the same was not covered under the policy terms and conditions of clause 4.9. The Apollo Hospital never said that the child was suffering from congenital disease. After rejection of the claim, the complainant also approached the second opposite party and he had also not accepted the claim of the complainant. Hence the complainant filed this complaint to direct the 1^st opposite party to pay a sum of Rs.2,14,764/- and also to pay compensation for deficiency in service and mental agony with cost of the complaint.

3. WRITTEN VERSION OF THE   1^st OPPOSITE PARTY IN BRIEF

          The first opposite party admits that the complainant taken family group Mediclaim Policy through his employer for the period 01.04.2013 to 31.03.2014. The policy was extended to cover the complainant/ employee, his wife and his child. The policy was issued subject to the specific exclusion clause 4.9 that the congenital external/ internal diseases or defects not covered.

          4. The complainant made a claim for treatment of his son for S1 level terminal Lipoma with tethered cord urinary retention, anemia. On examination of the medical records, it was clearly revealed that the treated condition caused by Tethered cord, which is a congenital birth defect caused by the base of the spinal cord being attached instead of being free. Hence the claim was rejected under the exclusion clause 4.9 of the policy. The other averments made in the claim are not sustainable this opposite party is not committed any deficiency in service and prays to dismiss the complaint with costs.

          5. The 2^nd opposite party called absent and he was set ex-parte.

6. POINTS FOR CONSIDERATION:

          1. Whether there is deficiency in service on the part of the opposite parties?

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

7. POINT NO :1 

           The admitted facts are that the complainant availed Ex.A1 Group Mediclaim Policy through his employer M/s. Sodexo Facilities M G T Services India Private Limited covering his family members and the complainant wife gave birth a male child at Subam Nursing Home, Madurai and after 20 days of his birth, he noticed swelling in the back side of the child and on the advice of the doctor Ultrasonography was taken and Ex.A4 report was obtained and the said report suggested possibility of Spina Bifida Occulta at S1 level with Lipomeningocele / Lipoma and Tethered Cord and on 13.02.2013 Ex.A5 MRI Scan was taken and based on those scan reports, the child was admitted at Apollo Hospital, Chennai on 06.05.2013 and a surgery was conducted for LIPOMA EXCISION AND UNTETHERING OF THE CORD on 07.05.2013 and the child was discharged on 13.05.2013 and  thereafter the child was recovered and the discharge summary issued by the Apollo Hospital is marked as Ex.A8 and thereafter the complainant made claim to the 1^st opposite party for a sum of Rs.2,14,764/- towards medical expenses and however the 1^st opposite party rejected the claim through Ex.A2 letter that as per the medical opinion, the hospitalization is for the management of the child disease S1 level terminal lipoma with tethered cord is related to an external congenital disease under clause 4.9 of the terms and conditions of the policy and the complainant also approached the Insurance Ombudsman, Chennai and he had confirmed the rejection made by the 1^st opposite party under Ex.A10 award and hence the complainant approached the forum for Redressal.  

8. It is not in dispute that on the date of treatment the policy issued by the 1^st opposite party is in force and the complainant can make medi-claim during that period. The 1^st opposite party rejected the claim on the basis of the child was suffering congenital external disease, relying on clause 4.9 of terms and conditions of the policy. The 1^st opposite party filed Ex.B1 policy with terms and conditions. The complainant would contend that the terms and conditions were not issued to him along with Ex.A1 policy. The 1^st opposite party has not filed any proof to show that the terms and conditions issued to the complainant along with the policy and hence we hold that the same was not furnished to the complainant with policy.

9. The terms and conditions of the policy clause 4.9 deals with congenital external/ congenital internal disease with sum other diseases. However in the said clause, nowhere stated what are the congenital external and internal diseases. In Ex.A2 rejection letter, the claim was rejected as the child was suffering external congenital disease. The procedure was done at the Apollo Hospital for the disease LIPOMA EXCISION AND UNTETHERING OF THE CORD. Absolutely no evidence produced by the first opposite party that the treated disease to the child was congenital external disease. The 1^st opposite party has filed Ex.B2 Medical opinion to establish that the child was suffering with congenital condition. The said opinion did not say that as per Ex.A2 rejection letter that the child was suffering with congenital external disease. Further the Ex.B2 opinion was issued by the Dr. Karthikeyan, of Metha Hospitals Pvt. Ltd. The said doctor gave opinion perusing case records of the child. However he had not stated in his report what were the documents perused by him to issue the said opinion. Normally, any evidence of the expert without being examining them no credence could be given to the report. The doctor who issued Ex.B2 opinion has not filed proof affidavit to prove his opinion. Hence, we reject Ex.B2 opinion as the same was not proved in the manner known to law. When Ex.B2 goes, there is no other evidence is available to establish that the child was suffering from congenital disease. Therefore we hold that the child was not suffering with any congenital disease for the treatment given to the child and hence it is further held that the 1^st opposite party committed deficiency in service in rejecting the claim of the complainant on the ground of congenital disease.

 

10. POINT NO:2

          Though the complainant made a claim of Rs.2,44,764/- from the 1^st  opposite party, the complainant sought relief of  Rs.2,14,764/- towards the medical expenses in the complaint. He also filed Ex.A9 inpatient bill for the treatment given by the Apollo hospital. Since we held above that the 1^st opposite party committed deficiency in service, he is liable to pay the claim amount of Rs.2,14,764/- to the complainant. Due to rejection of the claim, the complainant suffered with mental agony is accepted and for the same the 1^st opposite party can be directed to pay a sum of Rs.50,000/- towards compensation for deficiency in service and mental agony, besides a sum of Rs.5,000/- towards litigation expenses. No relief sought against the second opposite party in the complaint.

          In the result the Complaint is partly allowed. The 1^st Opposite Party is ordered to pay a sum of Rs.2,14,764/- (Rupees two lakhs fourteen thousand seven hundred  and  sixty four  only) towards the medical expenses to the Complainant and also to pay  a sum of Rs. 50,000/- (Rupees fifty  thousand only) towards compensation for deficiency in service and mental agony, besides a sum of Rs. 5,000/- (Rupees five thousand only)  towards litigation expenses. No relief sought against the 2^nd  opposite party in the complaint.

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 medical expenses 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 09^th day of April 2018.

MEMBER – I                                                                PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated NIL                     Insurance Policy

Ex.A2 dated 12.08.2013                   Copy of order of 1^st opposite party representation

Ex.A3 dated NIL                     Health Record Xerox

Ex.A4 dated 13.02.2013                   Xerox scan report

Ex.A5 dated 18.02.2013                   Advanced Scan Report Xerox

Ex.A6 dated 18.06.2013                   Xerox copy of certificate

Ex.A7 dated 14.03.2013                   Medical Certificate

Ex,A8 dated 13.05.2013                   Xerox copy discharge summary

Ex.A9 dated 13.05.2013                   Inpatient Bill

Ex.A10 dated 26.03.2014                 Copy of order with letter

LIST OF DOCUMENTS FILED BY  THE 1st OPPOSITE PARTY:   Ex.B1 dated NIL                      Insurance Policy   Ex.B2 dated 02.08.2013            Medical Opinion
MEMBER – I                                                               PRESIDENT