Tamil Nadu

South Chennai

CC/363/2018

R Viswanath - Complainant(s)

Versus

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

M/s M Bhuvaneswari

19 Sep 2022

ORDER

Date of Complaint Filed : 09.03.2018

Date of Reservation      : 01.09.2022

Date of Order               : 19.09.2022

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

CHENNAI (SOUTH), CHENNAI-3.

 

PRESENT:    TMT. B. JIJAA, M.L.,                                            : PRESIDENT

                        THIRU. T.R. SIVAKUMHAR, B.A., B.L.,           :  MEMBER  I 

                        THIRU. S. NANDAGOPALAN., B.Sc., MBA.,   : MEMBER II

 

CONSUMER COMPLAINT No.363/2018

MONDAY, THE 19^th DAY OF SEPTEMBER 2022

   
R. Vishwanath,

S/o. Ramasamy,

Room no.3, SRS Hall, 11/23,

Jubilee Road,

West Mambalam,

Chennai - 600 033.                                                        ... Complainant            

 

..Vs..

1.United India Insurance Company Ltd,

   No.24, Whites Road,

   Royapettah,

   Chennai - 600 014.

 

2.Medi Assist TPA Pvt Ltd,

   RWD Atlantis, 2^nd Floor,

   Nelson Manickam Road,

   Railway Colony,

   Aminjikarai,

   Chennai - 600 029.

 

3.Medi Assist TPA Pvt Ltd,

   Tower D, 4^th Floor,

   IBC Knowledge park,

   4/1, Bannerghatta Main Road,

   Bangalore 560029.                                                   ...  Opposite Parties

******

Counsel for the Complainant            : M/s. M. Bhuvaneswari

Counsel for the 1^st Opposite Party     : M/s. Nageswaran & Narichania

Counsel for 2^nd & 3^rd Opposite Party  : Exparte

 

On perusal of records and after having heard the oral arguments of the Counsel for the Complainant and Counsel for the 1^st Opposite Party, we delivered the following:

ORDER

Pronounced by the President Tmt. B. Jijaa, M.L.,

1.      The Complainant has filed this complaint as against the Opposite Parties under section 12 of the Consumer Protection Act, 1986 and prays to compensate the bill amount covered under Policy No.070300/48/14/41/00001557 of Rs.3,08,000/- settled to the Hospital together with 12% p.a from October 2015 till the date of order and 6% future interest from the date of order till the date of realization and to pay notional damages of a sum of Rs.1,00,000/- for the mental agony suffered by the Complainant along with cost.

2.     The averments of Complaint in brief are as follows:-

The Complainant was working in Hindustan Aeronautics Limited (HAL) from the year 1966 and relieved from service on 30.04.1994. HAL introduced Medical Insurance for retired employees. He took medical Insurance from the Opposite Party vide Policy No.070300/48/14/41/00001557. The Complainant had a Heart Attack during January 2015 for which he undergone treatment at Vijaya Heart Foundation. He was admitted in the Hospital on 24.06.2015 and underwent surgery and implantation stents and there after discharged on 26.06.2015. The Complainant incurred expenses for a sum of Rs.3,04,000/- for the said surgery. He claimed for reimbursement from the 3^rd Opposite Party. He received many communications from the Opposite Parties seeking documents and he had sent all the documents which they sought for. His claim was closed and further on his representation it was reopened. On 04.09.2017 the Complainant received a communication from the 1^st Opposite Party stating that 3^rd Opposite Party had repudiated his claim on the ground that there was inordinate delay in submission of documents.  While so, on 30.01.2018 the Complainant caused a legal notice to the Opposite Party which was duly served on the Opposite Parties. But the Opposite Parties did not choose to reply to the legal notice sent by the Complainant. The act of the Opposite Parties had caused hardship and mental agony to the Complainant, which amounts to deficiency in service. Hence the complaint.

3. Written Version filed by the 1^st Opposite Party in brief is as follows:-

        The 1^st Opposite Party states that a Tailor made Group Health Insurance Policy bearing No.07030048144100001557 for a period from 01.02.2015 to 31.01.2016 was  issued by Division Office 3, Classic Building No.24, Rich Mond Road, Bangalore-560025. The Policy was issued to cover the insured, Mrs. Hindustan Aeronautics Ltd., Employees and their families. This Forum does not have territorial jurisdiction to try the complaint as the policy of insurance was issued by the Divisional Office III Bangalore. The Complainant lodged a claim with the 3^rd Opposite Party for reimbursement of the expenses incurred and the claim was processed by the 3^rd Opposite Party. The claim of the Complainant was for medical management of Coronary artery disease, angina pain, Type-2 Diabetes Mellitus and hypertension. The 3^rd Opposite Party had requested the Complainant to furnish various documents including breakup details for consolidated inpatient bill stent sticker invoice, investigation reports and various documents related to the insured regarding the Identity proof and various receipts. The Complainant did not furnish documents as sought by the 3^rd Opposite Party. Therefore the 3rd Opposite Party by its letter dated 17.10.2015 had closed the claim of the Complainant. The Complainant once again requested the Opposite Party to consider the claim which was reopened and once again assessed. Finally by letter dated 15.12.2017 the claim of the Complaint was declined due to the delay on the complainant to furnish the documents for processing the claim. The claim of the Complainant was declined as per Commission No.5.5 of the Policy condition. The act of the 1^st Opposite Party in dealing with the claim of the Complainant cannot be turned as deficiency in service on the part of this Opposite Party. Hence the complaint is to be dismissed.

4.   The Complainant submitted his Proof Affidavit and Written Arguments. On the side of the Complainant, documents Ex.A-1 to Ex.A-9  were marked. The 1^st  Opposite Party submitted its Written Version and Proof Affidavit and on the side of the 1^st Opposite Party no document was marked.

5.     The 2^nd and 3^rd Opposite Parties did not appear before this commission even after sufficient notice on them and remained absent and hence set exparte.

Points for Consideration

1. Whether this Commission has got territorial Jurisdiction to entertain this complaint?

2. Whether there is deficiency in service on the part of the Opposite Parties?

3. Whether the Complainant is entitled for reliefs claimed?

4. To what other reliefs the Complainant is entitled to?

Point No.1:-

        The 1^st Opposite Party had raised the issue of territorial jurisdiction  as the Policy was issued by the Divisional Office III from the Opposite Party at Bangalore and that there is no cause of action which has arisen at Chennai. Hence the Commission has no jurisdiction to decide the complaint.

        Reliance was placed by the 1^st Opposite Party on the order passed by Hon’ble Supreme Court in (2010) 1 SCC 135, wherein it was held that “branch office would mean branch office where cause of action has arisen but not each and every branch office of the Opposite Party where it is situated”. In the present case, the 1^st Opposite Party is the Head office. Moreover in the repudiation letter dated 15.12.2017 the United Insurance Co. Ltd., had stated that if the Complainant was not satisfied with their denial reason, the Complainant would contact their Regional Office or head office for redressal. The 1^st Opposite Party being the Head Office of the United India Insurance, is proper party, whose office falls within the jurisdiction of this Commission. Hence this Commission has territorial Jurisdiction to entertain the complaint. The 1^st Opposite Party relied upon the Judgement reported in IV (2010) (PJ 3 (SC) Suraj Mal Ram Niwas Oil Mills (P) Ltd., Vs. United India Insurance Company and another, wherein it was observed that the terms of contract of insurance have to be strictly conserved to determine the entrant of liability of the insurer. In the present case, claim the Complainant is not beyond the terms of the contrast of insurer.

Point No.2:

The admitted facts are that the Complainant took medical Insurance from the Opposite Parties vide Policy No.No.07030048144100001557 for a period from 01.02.2015 to 31.01.2016. The Complainant was admitted in the hospital on 24.06.2015 and after undergoing various tests he underwent surgery and implantation of stents and thereafter discharged on 26.06.2015. The contention of the Complainant was that he had incurred medical expenses for a sum of Rs.3,08,000/- for the said surgery.  After recovering from illness he made a claim for reimbursement of medical expenses with necessary documents to the 3^rd Opposite Party. The 3^rd Opposite Party on 17.10.2015 had closed the claim of the Complainant as “No Claim”.  Further on representation the claim was reopened, after furnishing all the documents the Complaint received a communication on 04.09.2017 from the 1^st Opposite Party stating that the 3^rd Opposite Party had repudiated the claim on the ground that there was inordinate delay in submission of mandatory documents and that the 1^st Opposite Party concur with the decision of the 3^rd Opposite Party.

        Further contended that the Complainant is bound by the terms and conditions of the policy and as per condition No.5.5 of the Policy the Complainant failed to furnish the necessary documents to the 3^rd Opposite Party even after various letters written by the 3^rd Opposite Party to furnish the documents regarding the claim, which is clear breach of policy condition No.5.5.

        On careful perusal of complaint, written version, Proof affidavit, Exhibits on both the sides and upon hearing the oral arguments of the Complainant and the Opposite Party, the claim of the Complainant was repudiated by the 1^st Opposite Party for breach of condition No.5.5 of the Policy Document. Clause 5.5 of the Policy Document is extracted hereunder “(5.5) All supporting documents relating to the claim must be filed with TPA within 15 days from the date of discharge from the hospital. Incase of post-hospitalisation, treatment (limited to 60 days), all claim documents should be submitted within 7 days after completion of such treatment.

Note: waiver of this Condition may be considered in extreme cases of hardship where it is proved to the satisfaction of the company that under the circumstances in which the insured was placed it was not possible for him or any other person to give such notice or file claim within the prescribed time-limit”.

As Complainant had not made arrangements to pursue the claim and  submit the documents to the 3^rd Opposite Party, the claim was rejected by the 3^rd Opposite Party on 17.10.2015 fow want of documents.

        The Complainant has undergone surgery and it would not be possible for him to collect the documents and produce to the Opposite Party within the time limit as prescribed in clause 5.5 of the Policy document. It is pertinent to note that as per clause 5.5 in certain circumstances the time period could be waived if it was not possible for the insured to file the claim in time. Even after receipt of the documents furnished by the Complainant the 1^st Opposite Party after reopening the case of the Complainant had repudiated the claim of the Complainant on the ground of delay in furnishing the documents as found in Ex.A-8. It is not the case of the Opposite Parties that the documents have not been furnished by the Complainant but there was delay on the part of the Complainant in producing the documents. The Supreme Court recently in C.A.No.4071 of 2022, Gurmel Singh Vs Branch Manager, National Insurance Company Ltd, reported in 2022 SCC OnLine SC 666 has held that there should not be denial of claim by the Insurance companies on technical grounds and directed the insurance company to settle the claim of the insured.

The 1^st Opposite Party relied upon the Judgement reported in IV (2010) (PJ 3 (SC) Suraj Mal Ram Niwas Oil Mills (P) Ltd., Vs. United India Insurance Company and another, wherein it was observed that the terms of contract of insurance have to be strictly conserved to determine the entrant of liability of the insurer. In the present case, claim the Complainant is not beyond the terms of the contrast of insurer.

In view of the foregoing discussion this Commission is of the considered view that the act of the Opposite Parties in repudiating the claim of the Complainant on technical ground that there was delay in furnishing the documents by the Complainant amounts to deficiency in service. Accordingly, Point No.1 is answered.

Point Nos.3 and 4:

As discussed and decided  that the Opposite Parties had committed deficiency of service in repudiating the claim of the Complainant the Opposite Parties 1 to 3 are liable to pay a sum of Rs 308000/- towards the bill amount settled to the Hospital (RM.Cordiac Centre) and to pay a sum of Rs 20 000 for the deficiency in service and mental agony caused along with cost of Rs.3000/- towards litigation. Accordingly, Point Nos.2 and 3 are answered.

In the result the Complaint is allowed in part. The Opposite Parties 1 to 3 are directed to pay a sum of Rs.3,08,000/-(Rupees Three Lakh and Eight Thousand Only) towards the bill amount settled to the Hospital (R.M Cardiac Center) and to pay a sum of Rs.20,000/- (Rupees Twenty Thousand Only) towards deficiency in service and mental agony  along with cost of Rs.3000/- (Rupees Three Thousand Only) to the Complainant, within 8 weeks from the date of receipt of this order, failing which the above amounts shall carry interest at the rate of 9% p.a from the date of receipt of this order till the date of payment.

In the result the Complaint is allowed.

Dictated to Steno-Typist, transcribed and typed by her, corrected and pronounced by us in the Open Commission, on 19^th of September 2022..

 

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                    B.JIJAA   

         MEMBER II                       MEMBER I                        PRESIDENT

 

List of documents filed on the side of the Complainant:-

Ex.A1	22.06.2015 28.06.2015	Medical Records of the Complainant
Ex.A2	24.06.2015 26.06.2015	Inpatient Bill issued by R.M Cardiac Centre
Ex.A3	24.06.2015	Invoice issued by R.M Cardiac Centre
Ex.A4	26.06.2015	Receipt issued by R.M Cardiac Centre
Ex.A5	28.06.2015	Medical test report of the Complainant
Ex.A6	17.10.2015	Letter issued by the 3rd Opposite Party
Ex.A7	04.09.2017	Repudiation letter by the 1st Opposite Party
Ex.A8	15.12.2017	Repudiation letter by the 1st Opposite Party through E-mail
Ex.A9	30.01.2018	Legal notice sent by the Complainant to all the Opposite Parties along with acknowledgement

 

List of documents filed on the side of the Opposite Parties:-

NIL

 

 

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                    B.JIJAA

         MEMBER II                       MEMBER I                         PRESIDENT