Date of Filing : 29.04.2013
Date of Order : 02.03.2015.
DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, CHENNAI(SOUTH)
2nd Floor, Frazer Bridge Road, V.O.C.Nagar, Park Town, Chennai-3
PRESENT: THIRU. B. RAMALINGAM M.A.M.L., : PRESIDENT
TMT. K.AMALA, M.A.L.L.B, : MEMBER II
C.C.NO.148/2013
MONDAY THIS 2nd DAY OF MARCH 2015
Mr. S. P. Meenakshi Sundaram,
S/o. S. Pannerkai Perumal,
Plot No.402, TNHB, Perumal Pattu,
Veppampattu,
Tiruvallur District.
Tamil Nadu 602 024. ..Complainant
..Vs..
1. The Chairman,
United India Insurance Co. Ltd.,
Head Office,
Whites Road, Royapettah,
Chennai 600 014.
2. The Manager,
United India Insurance Co. Ltd.,
7th Floor,
Tarapore Towers,
826 Anna salai,
Chennai 600 002. .. Opposite parties.
For the Complainant : M/s. S.Mohanasundarajan & other
For the Opposite parties : M/s. M.B. Gopalan & other
This complaint is being filed by the complainant u/s 12 of the C.P. Act 1986 to refund a sum of Rs.35,317 with interest and to pay Rs.5,00,000/- as compensation with cost of this proceedings to the complainant.
ORDER
THIRU. B. RAMALINGAM PRESIDENT
1.The case of the complainant is briefly as follows:-
The complainant has taken a family Medical Health Insurance Policy of United India Insurance Company Limited and the limit of the said policy is upto Rs.1,00,000/- with effect from 27.1.2012 to 26.1.2013. The complainant has also paid the premium for the said policy. After a period of three months from the date of policy, the complainant was unwell with acute low back ache. Therefore the complainant has approached the Ayuvedic Medical College Hospital, Poonamallee, Chennai. The doctor of the said hospital had advised to undergo treatment of oil massage so as to enable the complainant to recover from the said ailment. As per the advice of the doctor, the complainant got admitted to the said medical hospital for undergoing the treatment from 29.4.2012 to 12.5.2012. The complainant has also paid necessary medical expenses for taking the said treatment. On 21.5.2012 the complainant made representation along with the medical bills, relevant documents to the opposite party requesting to disburse the medical claim. After receipt of the said representation from the complainant the opposite party rejected the medical claim made by the complainant through letters of the opposite party dated 24.7.12 and 30.11.2012 with untenable reason. Therefore the opposite party submitted that as per clause-2 contained in the Insurance policy that the treatment can be taken either in Government Hospital or medical college hospital and also the complainant has not complied with the norms prescribed under Clause.2 of the said policy. As such the act of the opposite parties is amounts to deficiency of service and which caused mental agony and hardship to the complainant. As such the complainant has sought for refund amount of Rs.35,317/- with interest and Rs.5,00,000/- as compensation with cost of this proceedings to the complainant. Hence the complaint.
2. Written version of opposite parties is as follows:-
The complaint as against the 1st opposite party is wholly unnecessary and untenable. The 1st opposite party as chairman of the company has no direct dealing in respect of the issuance of policy and handling of claims. The 2nd opposite party and various such offices with responsible officials are designated to handle the operational aspects. For any grievance over decision on a claim the 1st opposite party cannot be unreasonably sued in his capacity as the head of the opposite party company, especially when the office which had issued the policy is being independently sued. The compliant as against the 1st opposite party is liable to be dismissed in limine. The complainant availed Health Insurance Policy afresh for the period from 27.1.2012 to 26.1.2013. The policy was a fresh insurance subject to various terms and conditions stipulated therein. The complainant made a claim for treatment of low back pain from 29.4.12 to 12.5.2012 at Sri Jayendra Sarawathi Ayurveda College and Hospital. On examination of the medical records submitted by the complainant it was revealed that as per exclusion 4.1. of the policy, pre-existing condition is not covered. As per clause 2.1 Ayurvedic treatment is covered only if taken at the Government institution whereas the treatment was taken at a private institution. There is no negligence and deficiency of service on the part of the opposite parties and prays to dismiss the complaint.
4. Complainant has filed his Proof affidavit and Ex.A1 to Ex.A8 were marked on the side of the complainant. Opposite parties have filed their proof affidavit and no document was marked on the side of the opposite parties.
5. The points that arise for consideration are as follows:-
- Whether there is any deficiency in service on the part of the opposite parties ?
- To what relief the complainant is entitled to?
6. Point Nos.1 & 2:
Perused the complaint, complainant’s proof affidavit, documents Ex.A1 to Ex.A8, written version filed by the opposite parties, and proof affidavit of the opposite parties. On considering the both sides case it is not disputed that the complainant has taken Family Medical Health Insurance Policy of the United India Insurance Company Limited and the limit of the said policy is upto Rs.1,00,000/- with effect from 27.1.2012 to 26.1.2013, Ex.A1 also proves the same. It is also not disputed by the opposite parties that the complainant has admitted in Ayurvedic Medical College Hospital, Poonamallee, Chennai for his low back ache illness and taken treatment from 29.4.2012 to 12.5.2012 as inpatient. The medical certificate with discharge summary in Ex.A2 also proves the same. Further as per the insurance policy the complainant has submitted mediclaim form to the opposite party claiming the medical expenses incurred by him for the said treatment a sum of Rs.35317/-. However the same was rejected by the opposite party letterEx.A4 stating that the illness for which the complainant has taken treatment is of the pre-existing illness at the time of taking the policy, the nature of illness is to be treated as OPD and not required for any hospitalization and the treatment taken by the complainant is Ayurvedic treatment taken in a private hospital other than Government Hospital as per the terms and conditions of the insurance policy clause 4.1. and clause 1.1. and hospital definition Note (2).
7. Further the learned counsel appearing for the complainant has submitted that the said above objections and the reasons stated by the insurance company / opposite party repudiating the claim are not sustainable. Because as per the medical certificate given by the hospital in which the complainant has taken treatment it is clearly stated that at the time of admitting in the hospital for treatment he was suffering from Low back ache from the period of two months and the illness is not chronic but acute and the insurance was taken on 27.1.2012. As such the said illness suffered by the complainant not considered to be a pre-existing illness at the time of taking policy is acceptable. Therefore the repudiation of the claim of the complainant on the said ground by the opposite party is not sustainable.
8. Further the nature of ground on which the claim of the complainant is repudiated that the nature of the illness which the complainant is taken treatment is not required for hospitalization but can be treated only as OPD is not acceptable. As submitted by the learned counsel for the complainant that the nature of illness and suitable treatment to be given for the said illness is depend on the decision of the doctor who is giving treatment to the patient. As such this complainant went to the Ayurvedic hospital for treatment of Low back ache the doctors who have treated the complainant has decided that the said illness is to be treated by admitting the complainant in the hospital. Accordingly the complainant was admitted in the hospital from 29.4.2012 to 12.5.2012 as inpatient he was treated as mentioned in the discharge summary Ex.A2, where the nature of treatment given to the complainant reveals as Ayurvedic Panchararma Treatment. Therefore as submitted by the learned counsel for the complainant the treatment was given to the complainant after admitting him as inpatient in the hospital considering the nature of the illness and requirement of the treatment on the decision of the concerned doctors. Contrary to this, the repudiation of the opposite party stating that the illness not required inpatient treatment is not sustainable.
9. Further the opposite party has repudiated the claim by saying that the treatment taken by the complainant is in a private hospital and not in a Government hospital as such under the terms and conditions of the policy mentioned in caluse.2 the claimant cannot be complied with. However in respect of this contention the learned counsel appearing for the complainant has submitted that the hospital in which the complainant has taken treatment is of Government recognized Ayurvedic hospital which is also recognized by Central Council for Indian Medicine. Therefore the rejection of the claim of the complainant on the above said reason is also not sustainable. Further on going through the certificate Ex.A6 given by the hospital in which the complainant has taken treatment will reveal the facts that the illness suffered and taken treatment by the complainant is low back ache which is acute nature and which require, in patient treatment of the complainant. Accordingly he was given treatment on the basis of prerogative of the physician after observing the patient at that particular consulting movement. Further it is also to be noted as mentioned in the discharge summary given by the hospital the complainant was with satisfaction of the treatment given by the hospital he was cured of his pain which is not disputed by the opposite parties.
10. Therefore as discussed above the complainant having taken the insurance policy in the opposite parties insurance company during that period, the complainant has suffered illness and taken treatment in the Government recognized Ayurvedic hospital as inpatient and incurred a sum of Rs.35,317/- as per the Insurance policy the claimant has submitted the claim before the opposite parties. The opposite parties would have complied the claim by way of reimburse the said amount to the complainant instead of that repudiated the said claim on unsustainable grounds with reference to non-applicable to the terms and conditions of the insurance policy is amount to deficiency of service. Therefore the opposite parties instead of sanctioning the reimbursement of the mediclaim submitted by the complainant repudiating the same on invalid, unsustainable grounds, the opposite parties’ insurance company have committed deficiency of service which caused mental agony and hardship to the complainant are all acceptable.
11. Therefore we are of the opinion that the opposite parties are liable to pay the mediclaim of the complainant for a sum of Rs.35,317/- with interest at the rate of 9% p.a. from the date of claim i.e. 21.5.2012 to till the date of payment and also to pay a sum of Rs.10,000/- as just compensation for mental agony and hardship and also to pay a sum of Rs.5,000/- as cost of this proceedings to the complainant and the Points 1 & 2 are answered in favour of the complainant.
In the result, the complaint is partly allowed. The opposite parties are jointly and severally directed to pay the mediclaim of the complainant for a sum of Rs.35,317/- (Rupees Thirty five thousand three hundred and seventeen only) with interest at the rate of 9% p.a. from the date of claim i.e. 21.5.2012 to till the date of payment and also to pay a sum of Rs.10,000/- (Rupees Ten thousand only) as compensation for mental agony and hardship and also to pay a sum of Rs.5,000/- (Rupees five thousand only) as cost of this proceedings to the complainant.
The above said compensation and cost amount shall be payable within six weeks from the date of receipt of copy of this order, failing which the amount shall carry interest at the rate of 9% per annum from the date of order passed till the date of realization.
Dictated to the steno-typist transcribed and typed by her corrected and pronounced by us on this the 2nd day of March 2015.
MEMBER-II PRESIDENT.
Complainant’s Side documents :
Ex.A1 – 27.1.2012 - Copy of Insurance Company.
Ex.A2 – 20.5.2012 - Copy of Medical Certificate with Discharge Summary.
Ex.A3- 21.5.2012 - Copy of Claim filed by the complainant.
Ex.A4- 24.7.2012 - Copy of letter of the opposite party.
Ex.A5- 30.11.2012 - Copy of letter of the opposite party.
Ex.A6- 16.8.2012 - Copy of Certificate of the hospital.
Ex.A7- 22.12.2012 - Copy of legal notice.
Ex.A8- 22.8.2013 - Copy of claim settlement Memo.
Opposite parties’ side documents: - .. Nil ..
MEMBER-II PRESIDENT.
