Complaint presented on : 03.11.2012
Order pronounced on : 03.03.2016
DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (NORTH)
2nd 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
THURSDAY THE 3rd DAY OF MARCH 2016
C.C.NO.142/2013
Mrs.Uma Prakash,
Flat No.3A, Ramaniyam Towers,
12,Greenways Road,
R.A.Puram, Chennai – 600 028.
..... Complainant
..Vs..
| 1.United India Insurance Co. Ltd., Rep. by its Sr. Divisional Manager, Divisional Office :010700, 1st Floor, Silingi Building, 134, Greams Road, Chennai – 600 006. 2.United India Insurance Co. Ltd., Rep. by its Deputy General Manager, Head Officer, 3rd Floor, Hamid Building, 190 Anna Salai, Chennai – 600 006. 3.Family Health Plan (TPA) Ltd., Rep. by its Manager, No.2, Arugraha Building, 2nd Floor, Nungambakkam High Road, Chennai – 600 034. 4. Heritage Health TPA Pvt. Ltd., Represented by its Manager, GC Towers, Flat No.5, New No.31, Old No.17, Duraisamy Road, T.Nagar, Chennai – 600 017. | |
| ...Opposite Parties | |
Date of complaint : 26.07.2013
Counsel for Complainant :M/S R.Chandrasudan
Counsel for 1st & 2nd Opposite party :M.B.Gopalan
Counsel for 3rd Opposite Party : Ex parte on 17.03.2014
Counsel for 4th Opposite Party : Dismissed on 17.06.2014
O R D E R
BY PRESIDENT THIRU. K.JAYABALAN B.SC., B.L.,
This complaint is filed by the complainant u/s 12 of the Consumer Protection Act.1986.
1.THE COMPLAINT IN BRIEF:
The Complainant took family Mediclaim/Health Plan Policy for herself and her husband from the 1st & 2nd Opposite Party in the month of March 2003. The policy issued for the period 05.03.2003 to 04.03.2004. Following the year the Complainant and her husband suddenly took a decision to go to USA and hence they handed over a cheque to her agent Mr.Thiyagarajan to pay the premium and renew the policy for the next period2004 – 2005. On return they came to know that the agent had not handed over the cheque to the 1st & 2nd Opposite Party and thereby caused a break in their policy. The Complainant again paid premium for individual Health Insurance Policy on 22.05.2006 and their mediclaim policy was issued to her for the period 22.05.2006 to 21.05.2007. The Complainant was having pain in joints and to take Ayervedic treatment, she consulted Kottakal Arya Vaidya Sala at Chennai on 06.06.2006 & 14.06.2006 and they prescribed certain medicine. After monitoring her status the doctor advised her to visit their main branch at Kerala. Then she visited Kottakal Arya Vaidya Sala, at Kerala on 24.06.2006 and took treatment as an outpatient. Her problem was diagnosed has Rheumatoid Arthritis and she was admitted at Kottakal Hospital between 05.10.2006 and 19.10.2006. The discharge summary was issued for the period 05.10.2006 to 19.10.2006. The Complainant made a first claim along with necessary documents for the amount spent during that period. Again she was admitted in that Hospital at Kottakal on 28.08.2007 and was discharged on 26.09.2007 by incurring an expenditure of Rs.43,947/- and to claim the said amount she submitted the 2nd claim to the insurance company on 04th October 2007. For the relevant period the 1st & 2nd Opposite Party issued policy for the period 22.05.2007 to 21.05.2008. An another policy issued to the Complainant for the period 22.05.2008 to 21.05.2009. The Complainant took treatment between the period 15.09.2008 to 13.10.2008 incurring an expenditure of Rs.52,100/- and to claim the said amount the Complainant submitted 3rd claim to the Insurance Company. The Complainant again made her 4th claim for the renewed policy for the period 22.05.2010 to 21.05.2011. The Complainant also submitted a 5th claim. The 3rd & 4th Opposite Parties are third party administrators (TPA) and reminded the Complainant to file certain documents in respect of claims. The Complainant also further filed certain documents to the Opposite Parties. Inspite of furnishing documents, the Opposite Party 1 & 2 repudiated the Complainant’s claim. However the 4th claim was paid. Further the 2nd, 3rd & 4th claims status are not known to this Complainant. Hence the Complainant filed this Complaint to order the 1st, 2nd, 3rd and 5th claims and also to pay compensation with costs of this Complaint.
2.WRITTERN VERSION OF THE 1st & 2nd OPPOSITE PARTIES IN BRIEF:
The Complainant has not chosen to file even a single policy despite the fact that the Complaint is made seeking relief in respect of several claims. The Complainant availed a fresh Individual Mediclaim/ Health Insurance policy for the period 22.05.2006 to 21.05.2007 by payment of necessary premium through cheque dated 22.05.2006. The policy was issued and accepted subject to terms and conditions stipulated therein. The Complainant was under treatment for knee pain in India at least since March 2006. The insurance thus availed in May 2006 was a fresh policy subject to terms stipulated therein especially the exclusion of pre-existing diseases. The Complainant made a claim for treatment at Kottakkal Arya Vaidyasala in October 2006. The ailment was clearly pre-existing as was revealed by prescriptions and medical records subsequently received. The Discharge Summary clearly mentions that the ailment was of “gradual onset” and not suddenly in June 2006. This was also substantiated by medical records of treatment in March 2006 namely prescription dated 20.03.2006 and 24.03.2006 which the Complainant had furnished to the Opposite Party, but has conveniently failed to state in the Complaint. This Opposite Party submits that the pre-existing disease exclusion contemplates a waiting period of four years after commencement of the policy, if no treatment is undergone during the said period. Though the Complainant had been taking continuous treatment even during this period, giving her the benefits of the four year period, the claim made for treatment in 2010 was paid. The claims for the earlier period are not payable for the reason stated above as the treatment is for pre-existing ailment. Therefore the Opposite Parties 1 & 2 prays to dismiss the Complaint with costs.
3.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?
4.POINT:1
The admitted facts are that the Complainant initially took policy for the year 2003 & 2004 and later there is a break in not paying the premium for the period 2005 to 2006 and after that the Complainant took Mediclaim/ Family Health Plan Policy for the period 22.05.2006 to 21.05.2007 from the 1st & 2nd Opposite Party and thereafter the Complainant regularly paid the premium and renewed the policy every year and the Complainant took treatment at Kottakal Arya Vaidyasala, Kottakal at Kerala and towards treatment for the amount incurred by the Complainant , the Complainant made totally 5 claims year by year and out of 5 claims the 1st claims was repudiated by the 1st & 2nd Opposite Party and the 4th claim only paid and in respect of the other claims the Complainant went to the insurance ombudsman and he also rejected the claim by his order dated 13.09.2011 which is marked as Ex.A26 & Ex. B6 and against the said rejection order the Complainant filed this Complaint against the insurance company.
5. The Complainant filed this Complaint seeking relief to pass award in respect of the 1st , 2nd, 3rd,and 5th claims and also compensation contending that the Opposite Parties committed Deficiency in Service by not honouring the above claims.
6. The Complainant claimed a sum of Rs.22,037/- in the 1st claim, Rs.43,947/- in the 2nd claim, Rs.52,100/- in the 3rd claim and Rs.30,957/- in the 5th claim with interest in all the claims apart from compensation with litigation expenses. The Complainant took treatment at Kottakal Arya Vaidyasala for Rheumatoid Arthritis. The 1st & 2nd Opposite Party would contend that even prior to the inception of the 1st policy i.e. Ex.A2 and B1, the Complainant took treatment for jaw joint at Kottakal as per Ex.B5 and therefore the Complainant is having pre-existing disease and therefore she is not entitled for the claim. The Complainant replied that the treatment for jaw joint is not a disease of Rheumatoid Arthritis and therefore the same cannot be treated as pre-existing disease.
07. Terms and condition of the policy is available in Ex.B3. It is relevant to extract clause 5.13 as follows:
Pre-existing diseases/illnesses exclusion shall get deleted once the insured person completes three year claim free policy periods i.e. From 4th year onwards, the pre-existing diseases exclusion condition shall not apply provided no claims were made/reported during the earlier three continuous policy periods with us.
As per the above condition the first 3 years the Complainant is not entitled for any claim and from the 4th year onwards she is entitled to medical claim. The 1st policy period is 22.05.2006 to 21.05.2007. For the first 3 years the Complainant is not entitled for claim till 21.05.2009. After 21.05.2009 the Complainant is entitled for mediclaim as per the above clause 5.13. The Complainant made 3rd claim for the treatment period 15.09.2008 to 13.10.2008 and 1st & 2nd claims are the prior period to the 3rd claim. All the 3 claims falls in the first 3 years period of the policy. Since the claims 1 to 3 falls within the period of claim free policy periods and therefore the rejection of the first claim and not honouring the 2nd and 3rd claim is in order as per the above clause and not awarding these claims the Opposite Parties have not committed any Deficiency in Service.
08. The Complainant pleaded in her Complaint that she made 5th claim for the period 2011-2012 and the same not cleared by the Opposite Parties that treatment at private hospital that does not come under the purview of the insurance claims. The fact of 5th claim was not denied by the insurance company in his written version. Since the Insurance Company has not denied the 5th claim, the fact remains that the statement of the Complainant that she made 5th claim is accepted. The Complainant also claimed an amount of Rs.30,957/- towards her medical expenses for the period 2011-2012. This period also falls after the 4th claim and therefore clause 5.13 of the policy is no hurdle for claiming this amount by the Complainant. Though the 5th claim was not cleared as the Complainant taken treatment in a private hospital. The Complainant taken treatment in the same hospital for the period of 4th & 5th claims. When the 4th claim is honoured the Complainant is naturally entitled for the 5th claim also. The said amount claimed by the Complainant reflected in Ex.A25 issued by the Kottakal Arya Vaidyasala. Absolutely there is no explanation on the part of the Opposite Party for the 5th claim made by the Complainant. Therefore failure to honor the 5th claim by the insurance company is a defect on his part and therefore the Opposite Parties 1 & 2 committed Deficiency in Service and accordingly this point is answered. However the Opposite Parties 3 & 4 are only 3rd party agents (TPA) and they have nothing to do with the passing award in respect of the insurance claim and therefore, it is held that the 3rd & 4th Opposite Parties have not committed any Deficiency in Service.
09.POINT:2
Since the Opposite Parties committed Deficiency in Service, the Complainant suffered with mental agony is acceptable. The Complainant claimed 18% interest from the date of the claim. However the date of 5th claim is not mentioned in the Complaint and the copy of the claim form also not filed and therefore the awarding of interest is not considered. However the Complainant is entitled for a sum of Rs.30,957/- towards the 5th claim and also a compensation of Rs.15,000/- besides a sum of Rs.5,000/- towards litigation expenses.
In the result the Complaint is partly allowed. The 1st & 2nd Opposite Parties are ordered to pay a sum of Rs.30,957/- (Rupees thirty thousand nine hundred and fifty seven only) towards medical expenses to the Complainant and also to pay a sum of Rs.15,000/- (Rupees fifteen 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. The Complaint in respect of the 3rd & 4th Opposite Parties are dismissed.
Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 03rd of March 2016.
MEMBER – II PRESIDENT
LIST OF DOCUMENTS FILED BY THE COMPLAINANT:
Ex.A1 dated 05.03.03 Family health issued by the 1st & 2nd Opposite Party
To 0.03.04 for policy No.011900/48/02/00972
Ex.A2 dated 22.05.06 Receipt issued by the 1st & 2nd Opposite Party for
Policy No.01190/48/06/20/000227
Ex.A3 dated 06.06.06 The prescription issued by Kottakal Arya Vaidya
Sala
Ex.A4 dated 24.06.06 The prescription issued by Kottakal Arya Vaidya
Sala
Ex.A5 dated 05.10.06 The Discharge Summary issued by Kottakkal Arya
To 19.10.06 Vaidya Sala
Ex.A6 dated 10.02.07 Letter from the 3rd Opposite Party to I requesting for
additional reports
Ex.A7 dated 03.10.07 Reply from 1 to the 3rd Opposite Party
Ex.A8 dated 21.05.07 The policy schedule issued by the 1st & 2nd Opposite
Party for policy No.011900/48/07/20/00000241
Ex.A9 dated 26.09.07 The discharges Summary issued by Kottakkal Arya
Vaidya Sala
Ex.A10 dated 04.10.07 The 2nd claim form submitted to the 1st & 2nd
Opposite Party
Ex.A11 dated 07.11.07 The letter issued by the 4th Opposite Party to 1
Ex.A12 dated 18.02.08 The letter issued by the 4th Opposite Party to 1st &
2nd Opposite Party in regard to 2nd claim
Ex.A13 dated 29.02.08 The letter issued by the 4th Opposite Party to I in
regard to 2nd claim
Ex.A14 dated 20.05.08 The receipt issued by the 1st & 2nd Opposite Party
for the period 22.05.08 to 21.05.09 & policy No.
011900/48/08/97/00000232
Ex.A15 dated 15.09.08 The hospitalization bill issued by Kottakal Arya
To 13.10.08 Vaidya Sala dated 12.10.08
Ex.A16 dated 23.12.08 The 3rd claim form submitted to the 1st & 2nd
Opposite Party
Ex.A17 dated 16.01.09 The letter received from the 4th Opposite Party
Ex.A18 dated 21.02.09 The letter from 1’s husband to the 1st Opposite
Party to look in to the 3 pending claims
Ex.A19 dated NIL The letter from the complainant’s husband to the
1st Opposite Party
Ex.A20 dated NIL Letter from the M.D of the 3rd Opposite Party at
Hyderabad that the 1st claim has been repudiated
with reasons
Ex.A21 dated 03.12.09 The Sr.Divisional Manager of the 1st Opposite
Party that her claim is repudiated
Ex.A22 dated 08.09.10 Letter from the 1st Opposite Party to the
complainant that his grievance is under process
Ex.A23 dated 12.11.10 Letter from the DGM of the 2nd Opposite Party
explaining the reasons for the reppuidiation of the
1st claim
Ex.A24 dated 26.11.10 The letter from 4th Opposite Party to the
complainant that her 4th claim has been approve
and cheque is enclosed
Ex.A25 dated 04.07.11 The hospitalization bill issued by Kottakal Arya
Vaidy Sala
Ex.A26 dated 13.09.11 The award passed by the Insurance Ombudsman
Ex.A27 dated NIL The article aboiut a study specific to rhematiod
arthritis made by various universities in the U.S.
LIST OF DOCUMENTS FILED BY THE OPPOSITE PARTIES:
Ex.B1 dated NIL Insurance Policy for the period 22.05.2006 to
21.05.2007
Ex.B2 dated NIL Insurance Policy for the period 22.05.2007 to
21.05.2008
Ex.B3 dated NIL Insurance Policy for the period 22.05.2008 to
21.05.2009
Ex.B4 dated 20.03.2006 & Medical Prescription isued by Kottakkal Arya
24.03.2006 Vaidya Sala
Ex.B5 dated 19.10.2006,
26.09.2007 & Discharge Summary of Complainant
13.10.2008
Ex.B6 dated 13.09.2011 Insurance Ombudsman Award
MEMBER – II PRESIDENT