Tamil Nadu

South Chennai

126/2011

G.Allan Rayen - Complainant(s)

Versus

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

P.Vasuddsevan

11 Dec 2015

ORDER

                                                                          Date of Complaint  : 29.04.2011

                                                                Date of Order        : 11.12.2015

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, CHENNAI (SOUTH)

2^nd 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 – I

                     DR.T.PAUL RAJASEKARAN, M.A D.Min HRDI, AIII,BCS : MEMBER - II

                                                     

C.C.No. 126 / 2011

THIS  FRIDAY  11^TH  DAY OF  DECEMBER 2015

 

G. Allan Rayen,

Stanfab Apparels,

14, Industrial Estate,

East Mogapair,

Chennai 600 037.                                               .. Complainant.

                                                         - Vs-

1. The Branch Manager, United India Insurance Co. Ltd., Lakshmi Bhavan, III Floor, 609, Anna Salai, Chennai 600 006.   2. The Branch Manager, Medsave Healthcare (TPA) Ltd., IC Shakthi Tower, I Floor, 766, Anna Salai, Chennai 600 002.                                                   .. Opposite parties.    For the complainant                     :  M/s.Dr.P.Vasudevan & another		.. Opposite party.
For the opposite party-1                   :  M/s. S.K.Krishnamurthy For the opposite party-2                   :   Exparte.

         Complaint under section 12  of the Consumer Protection Act, 1986 for a direction to the opposite parties   to pay a sum of Rs.38,186/- towards the claim amount and also to pay a sum of Rs.1,00,000/- as mental agony and also to pay a sum of Rs.50,000/- as damages with cost of the complaint to the complainant.    

ORDER

THIRU.   T.PAUL RAJASEKARAN ::    MEMBER-II

1.The case of the complainant is briefly as follows:-

The complainant states that he had taken an individual medical insurance with the opposite parties from 24.11.2008 to 23.11.2009.    The complainant’s son was hospitalized at Kumaran Hospitals Pvt. Ltd., Chennai from 1.5.2009 to 4.5.2009 for the treatment for PHIMOSTS BOO PUR and the complainant incurred an expenditure of Rs.38,186/-.   Subsequently the complainant made a claim for Rs.38,186/- through his claim dated 11.5.2009 to the opposite parties.  But there was no response from the opposite parties which resulted in the complainant suffering from great physical stress and mental agony.  

2.     The complainant further stated that the reasons given by the 2^nd opposite party is not tenable under law since Clause 4.1 of the Terms and conditions of the policy.   The complainant has issued legal notice through his counsel to the opposite parties  which was received by them but they did not even bother to reply to the same.  As such the act of the opposite parties are amounts to deficiency of service and which caused mental agony and hardship to the complainant.   Hence the complaint.

 

Written version of  1st opposite party is as  follows:-

3.     It denies all the averments and allegation contained in the complaint except those that are specifically admitted herein.   It is pertinent to mention that admittedly Mr.Jaswanth Rayen was treated for “Congenial Disease” it can evidently inferred on perusal of the medical certificate issued by the treated doctor.  In terms of the Discharge Summary “the patient admitted with history of Febrile fitz at the age of one, pain for post two years and urine in continuous on and off”.  This forum is well aware that the Legal aspects of settlement of claims involves examination of the claim in relation to the Coverage under policy and compliance with policy conditions, Warranties and exclusions.    The claim was rejected under 4.1. clause of the platinum policy.   Hence there is no deficiency of service on the part of the opposite parties and  the compliant is liable to be dismissed.

4.     Even after receipt of the notice, the 2^nd opposite party was called absent and did not file written version.  Hence, the 2^nd opposite party was set exparte on 14.7.2011.     

5.   Complainant has filed his Proof affidavit and  Ex.A1 to Ex.A9 were marked on the side of the complainant.   1^st Opposite party have filed his proof affidavit and Ex.B1  marked on the side of the 1^st opposite party. 

6.      The points that arise for consideration are as follows:-

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

 

2. To what relief the complainant is entitled to?  

7.   POINTS 1 & 2 :

   Perused the complaint  filed by the complainant, written version filed by the  opposite parties, proof affidavit filed by the complainant and the  opposite parties and  Ex.A1 to Ex.A9  filed on the side of the complainant and considered both side arguments.

8.     The complainant had taken an individual medical insurance with the opposite parties from 23.11.2004 to 23.11.2008 without any break (Ex.A1) in page No.7 of Ex.A1 the opposite party issued an individual medi claim policy stating that  the insured person was covered under “platinum policy”, no warranty was imposed and the insured and his spouse were covered in the same policy under “gold policy” and warranty was imposed ‘pre existing disease are not covered as per condition laid down in the policy, in the same policy insured’s parents were covered under “senior citizen policy” by imposing warranty as ‘preexisting diseases are excluded’.    The complainant’s son aged 6 years was admitted in Kumaran Hospital Private Limited, Chennai on 1.5.2009 and surgery was conducted and the same day and he was discharged on 4.5.2009 by diagnosing (PHIMOSIS) and the procedure followed (PUV FULGURATION BALANOPLASTY).  The case history shown in the discharge summary reveals that the patient had difficulty in micturation, history of Urine in continues on and off with pain for past two years, history of fever on and off and history of Febrile Fits at the age of one. Under investigation the patient was found to have PHIMOSIS.   Based on the claim form and medical certificate submitted by the complainant (Ex.A5) the opposite party had repudiated the claim considering the nature of disease as Congenital (Ex.A6).    Actually the complainant’s son had the “Febrile Fits” which is also known as “fever fits” or “Febrile Convulsion” which commonly occur between the age of six months to five years in infants due to intracranial infection or metabolic problems, the long term out come risk of Neurological problem.

9.     The diagnosis referred by the Doctor who had operated the patient ”PHIMOSIS” also means “Clitoral Phimosis”,  this means the fore skin is fused to the glands and is not retractable.   Phimosis is deemed pathological, when it causes problems such as difficulty in Urinating.    Infant appears to be in pain with Urination or has oblivion ballooning of the fore skin with Urination or apparent discomfort.  In this type of diagnosis doctors go to surgery either by circumcision, or dorsal slit (Super incision) or ventral slit (Subter incision).   The surgeon made Fulguration and Boo correction. 

10.    On going through Proof affidavit, written version and documents/typeset filed by both the parties, we find the “Febrile fits” occurred to the infant at the age of one, does not have any bearing on PHIMOSIS and the opposite party has not submitted any expert opinion substantiating the PHIMOSIS is the outcome of the Febrile fits which occurred to the patient at the age of one.    The opposite party had repudiated the claim on the basis of condition No.4.1 of the policy is not justifiable.    Hence we are of the considered view that the repudiation made by the opposite party is not fair enough in denying the cashless facility (Ex.A3) and also repudiation under Ex.A6.  Where the TPA vide their letter 4.11.2010 (Ex.A9) informing the complainant, the claim form was sent to the insurer for rejection.  But till this date the insurer  has not responded to the complainant, about the rejection, which proves the deficiency of service and also creating pain and agony to the insured person whereby the utmost good faith the insured is having on the insurer  has become stake/questionable. 

11.    Hence, we are of the considered view that the benefit of doubt has to be given to the complainant and the reimbursement of the medical expenses claimed by the complainant Rs.38,186/- has to be settled to the complainant with interest at the rate of 9% p.a. from 11.5.2009 (date of submission of claim form with documents to the TPA ) to till the date of payment  and also to pay a sum of Rs.10,000/- as just and reasonable compensation and also to pay a sum of Rs.5,000/- as litigation charges to the complainant.  As such, 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 a sum of  Rs.38,186/- (Rupees Thirty eight thousand one hundred and eighty six only) towards reimbursement of medical expenses with interest at the rate of 9% p.a. from 11.5.2009 to till the date of payment and also to pay a sum of Rs.10,000/- (Rupees ten thousand only) as compensation  and also to pay a sum of Rs.5,000/- (Rupees five thousand only)  as litigation expenses to the complainant within six weeks from the date of this order failing which the compensation amount (Rs.10,000/-)  shall carry  interest at the rate of 9% p.a. from the date of this order to till the date of payment.

        Dictated directly by the Member-II to the Assistant, transcribed and computerized by her, corrected by the Member-II and pronounced by us in the open Forum on this the  11th    day of  December   2015.

 

MEMBER-I                        MEMBER-II                             PRESIDENT.

Complainant’s side documents :

Ex.A1-                - Copy of Individual Medi claim policy.

Ex.A2- 29.4.2009  - Copy of request letter from Kumaran Hospitals.

Ex.A3- 30.4.2009  - Copy of letter from 2^nd opposite party to the Hospital.

Ex.A4- 4.5.2009    - Copy of Discharge summary.

Ex.A5- 9.5.2009    - Copy of mediclaim form submitted to the opposite parties.

Ex.A6- 5.6.2009    - Copy of letter from 2^nd opposite party to 1^st opposite party.

Ex.A7- 26.10.2010         - Copy of legal notice.

Ex.A8- 28.10.2010         - Copy of Ack card.

Ex.A9- 4.11.2010  - Copy of reply notice.

Opposite parties’ documents :  

 

Ex.B1-                - Copy of Exclusions Clause 4.1.

 

 

 

MEMBER-I                        MEMBER-II                             PRESIDENT.