Tamil Nadu

North Chennai

CC/93/2015

M/s.Dhanalakshmi Vijayakumar - Complainant(s)

Versus

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

S.Vijayakumar

10 Aug 2016

ORDER

 

 

 

                                                            Complaint presented on:  11.05.2015

                                                                Order pronounced on:  29.08.2016

 

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

                    TMT.T.KALAIYARASI, B.A.B.L.,           MEMBER II

 

MONDAY THE 29^th  DAY OF AUGUST 2016

 

C.C.NO.93/2015

 

 

Mrs.Dhanalakshmi Vijayakumar,

W/o S.Vijayakumar,

AP 1048 17^th Street,

G Block, Belly Area,

Anna Nagar, Chennai - 40.

                                                                                               ..... Complainant

 

..Vs..

	1.United India Insurance Company Ltd.,   Divisional Office, Catholic Centre, First Floor, 64 Armenian Street, Chennai – 1. Represented by its Branch Manager.   2.M/s. Vipul Medcorp TPA Private Limited, New No.517, Old No.338,   (Opp to G.R.Complex) Chennai – 35. Represented by its Manager Mr.Rajasekaran
	.....Opposite Parties

Date of complaint                                  15.06.2015

Counsel for Complainant                      : M/s.S.Vijayakumar

Counsel for opposite parties                    : Ex - parte (on 16.07.2015)

 

 

O R D E R

 

BY MEMBER  TMT.T.KALAIYARASI,  B.A.B.L.,       

          This complaint is filed by the complainant u/s 12 of the Consumer Protection Act.1986.

1.THE COMPLAINT IS IN BRIEF:

          The Complainant is holding a Mediclaim Policy vide policy No.01310048139700000921 File No.15RBO7UID 3712 Card No.0320010009468203 with the 1^st Opposite Party since in the year 2004. The policy is renewed from time to time every year in the month of March and the premium was paid well in advance on 27.02.2015. Accordingly the last renewal was done on 04.03.2015.The Complainant got injured in her left shoulder on 24.12.2014 while lifting of a bucket with water. She consulted orthopedic surgeon and he advised to undergo a surgery.  Accordingly she was admitted in Laskhmi Sundaravadana Hospital on 02.03.2015 and surgery was conducted on 04.03.2015 and she was discharged on 05.03.2015. The Complainant was having Mediclaim with the 1^st Opposite Party and the Complainant informed the same to the 2^nd Opposite Party before surgery and thereafter only she was admitted in the hospital. The Complainant submitted mediclaim with the 2^nd Opposite Party on 09.03.2015 for reimbursement of the bill raised by the hospital for the sum of Rs.1,70,355/- with requested documents. The 2^nd Opposite Party issued a notice to the Complainant on 18.03.2015 informing her to submit a self declaration letter. The Complainant also submitted the self declaration letter through mail on 27.03.2015. Even after that the Opposite Parties have not processed and paid the claim amount to the Complainant inspite of that she was having a valid mediclaim policy establishes that the Opposite Parties have committed Deficiency in Service. Hence the Complainant filed this Complaint for claiming  reimbursement of mediclaim amount with compensation for mental agony and cost of the Complaint.

2. Though the Opposite Parties 1 & 2 received notice, they did not appear on 16.07.2015 and hence the Opposite Parties were called absent and set ex-parte.

          3. The Complainant had filed her proof affidavit. Ex.A1 to Ex.A10 was marked on the side of the Complainant.

          4. The Complainant had also filed written argument and oral argument of the Complainant was heard.

5. 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 relief?

6. POINT NO :1

          The case of the Complainant is that  she is holding a mediclaim policy of the 1^st Opposite Party from the year 2004 onwards and she renewed the same periodically and lastly she renewed Ex.A2 policy for the period 04.03.2015 to 03.03.2016 and during that period she sustained injury on her left shoulder and hence treatment for the said injury she was admitted in the Lakshmi Sundaravadana Hospital  on 02.03.2015 and surgery was conducted and discharged on 05.03.2015 under Ex.A3 discharge summary and  the said hospital  raised Ex.A4 bill for an amount of Rs.1,68,695/- and based on that claim the Complainant made mediclaim with the 2^nd Opposite Party who is the Third Party Agent(TPA) of the 1^st Opposite Party/ insurer  and however the Opposite Parties have not passed any order even after receipt of Ex.A8 self declaration by the 2^nd Opposite Party at his request and therefore the Opposite Parties failed to pass or pay the claim proves that they have committed Deficiency in Service.

          7. Ex.A5 dated 09.03.2015 is the check list of the documents submitted along with the claim to the 2^nd Opposite Party. The 2^nd Opposite Party requested the Complainant under Ex.A7 letter dated 18.03.2015 to submit self declaration letter and the Complainant submitted the same on 23.03.2015 as Ex.A8 self declaration to the 2^nd Opposite Party. The Complainant’s husband also sent Ex.A9 legal notice dated 06.04.2014 and even after receipt of the said notice, the Opposite Parties have not passed any orders on the claim of the Complainant. There is no contra evidence on behalf of the Opposite Parties to reject the evidence of the Complainant. The Complainant is having valid Ex.A2 medicalim policy and during the period only she had undergone treatment, bills were raised and claim also have been paid till the date of filing of this Complaint and failure to honour the claim of the Complainant is a clear case of deficiency and therefore we hold that the Opposite Parties 1 & 2 have committed Deficiency in Service.

 8. POINT NO: 2

          The claim made by the Complainant is for an amount of Rs.1,70,355/- The Complainant herself admitted in her proof affidavit and written arguments that the 2^nd Opposite Party credited a sum of Rs.1,53,275/- on 15.05.2015 towards her settlement of claim. The Complainant further stated in her proof affidavit that she received such payment without prejudice to the remedies available in the pending disposal of this Complaint in this Forum. However, the Complainant had not stated anything in her proof affidavit or written arguments that the amount paid to her on 15.05.2015 towards her claim is incorrect.  Though the Complainant claimed a sum of Rs.1,70,355/- in the Complaint, Ex.A4 Hospital Bill  is available only for an amount of Rs.1,68,695/-. Therefore the Complainant is entitled only for the amount of Rs.1,68,695/-  as claim from the Opposite Parties. Since the Complainant herself admitted that a sum of Rs.1,53,275/- was settled to her on 15.05.2015, the Complainant is entitled for only a difference amount Rs.15,420/- from the Opposite Parties towards her claim. Therefore, it would be appropriate to order a sum of Rs.15,420/- towards the claim of the Complainant is justifiable.  Even before the 1^st hearing the Opposite Parties paid a part claim amount to the Complainant and therefore for mental agony a sum of Rs.2,000/- can be ordered, besides a sum of Rs.5,000/- towards litigation expenses and accordingly it can be ordered.

          In the result the Complaint is partly allowed. The Opposite Parties 1 & 2 jointly or severally are ordered to pay a sum of Rs.15,420 /- (Rupees fifteen thousand four hundred and twenty only) towards the claim amount to the Complainant and also to pay  a sum of Rs.2,000/- (Rupees  two 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 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 29^th  day of August 2016.

 

MEMBER – II                                                               PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated  25.02.2015              Consultant  Orthopedic Surgeon’s Prescription                                                       to the Complainant Ex.A2 dated  27.02.2015              Mediclaim policy issued by the 1st Opposite                                                       Party to the Complainant Ex.A3 dated 05.03.2015               Discharge summary issued by the Laskmi                                                       Sundaravadanan Hospital to the Complainant Ex.A4 dated 05.03.2015               Bill submitted by Lakshmi Sundaravadanan                                                       Hospital to the Complainant Ex.A5 dated 09.03.2015               Checklist for claim submission form from the                                                       2nd Opposite Party to the Complainant Ex.A6 dated 10.03.2015               Letter from the Complainant’s husband to the                                                       2nd Opposite Party Ex.A7 dated 18.03.2015               Letter from the 2nd Opposite Party to the                                                       Complainant’s husband Ex.A8 dated 23.03.2015               Self Declaration Letter submitted by the                                                       Complainant Ex.A9 dated 06.04.2015               Letter from the Complainant’s husband to the                                                       2nd Opposite Party, along with the                                                       acknowledgement card Ex.A10 dated 04.03.2014             Individual Health Insurance Policy

 

MEMBER – II                                                               PRESIDENT