Complaint presented on  :  03.11.2012

                                                                Order pronounced on  :  03.03.2016

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

THURSDAY  THE  3^rd   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..

Date of complaint                                  : 26.07.2013

Counsel for Complainant                      :M/S R.Chandrasudan

Counsel for  1^st & 2^nd  Opposite party     :M.B.Gopalan

Counsel for 3^rd Opposite Party                       : Ex parte on 17.03.2014

Counsel for 4^th 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 1^st & 2^nd 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 1^st & 2^nd 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 2^nd claim to the insurance company on 04^th October 2007.  For the relevant period the 1^st & 2^nd 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 3^rd claim to the Insurance Company. The Complainant again made her 4^th claim for the renewed policy for the period 22.05.2010 to 21.05.2011. The Complainant also submitted a 5^th claim. The 3^rd & 4^th 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 4^th claim was paid. Further the 2^nd, 3^rd & 4^th claims status are not known to this Complainant. Hence the Complainant filed this Complaint to order the 1^st, 2^nd, 3^rd and 5^th claims and also to pay compensation with costs of this Complaint.

2.WRITTERN VERSION OF THE 1st & 2^nd  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 1^st & 2^nd  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 1^st claims was repudiated by the 1^st & 2^nd Opposite Party and  the 4^th 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 1^st , 2^nd, 3^rd,and 5^th 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 1^st claim, Rs.43,947/- in the 2^nd claim, Rs.52,100/- in the 3^rd claim and Rs.30,957/- in the 5^th  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 1^st & 2^nd Opposite Party would contend that   even prior to the inception of the 1^st 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 4^th 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 4^th year onwards she is entitled to medical claim. The 1^st 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 3^rd claim for the treatment period 15.09.2008 to 13.10.2008 and 1^st & 2^nd claims are the prior period to the 3^rd 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 2^nd and 3^rd 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 5^th 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 5^th claim was not denied by the insurance company in his written version. Since the Insurance Company has not denied the 5^th claim, the fact remains that the statement of the Complainant that she made 5^th 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 4^th claim and therefore clause 5.13 of the policy is no hurdle for claiming this amount by the Complainant. Though the 5^th 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 4^th & 5^th claims. When the 4^th claim is honoured the Complainant is naturally entitled for the 5^th 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 5^th claim made by the Complainant. Therefore failure to honor the 5^th 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 3^rd 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 3^rd & 4^th 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 5^th 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 5^th 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 1^st & 2^nd  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 3^rd & 4^th  Opposite Parties are dismissed.     

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 03^rd  of March  2016.

MEMBER – II                                                               PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 05.03.03           Family health issued by the 1^st & 2^nd Opposite Party

                 To 0.03.04           for policy No.011900/48/02/00972

Ex.A2 dated 22.05.06           Receipt issued by the 1^st & 2^nd 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 3^rd Opposite Party to I requesting for

                                                additional reports                             

Ex.A7 dated 03.10.07           Reply  from 1 to the 3^rd Opposite Party       

Ex.A8 dated 21.05.07            The policy schedule issued by the 1^st & 2^nd 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 2^nd claim form submitted to the 1^st & 2^nd

                                                  Opposite Party

Ex.A11 dated 07.11.07           The letter issued by the 4^th Opposite Party to 1

Ex.A12 dated 18.02.08           The letter issued by the 4^th Opposite Party to 1^st &         

                                                  2^nd Opposite Party in regard to 2^nd claim

Ex.A13 dated 29.02.08           The letter issued by the 4^th Opposite Party to I in

                                                   regard to 2^nd claim     

Ex.A14 dated 20.05.08           The receipt issued by the 1^st & 2^nd 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 3^rd claim form submitted to the 1^st & 2^nd

                                                    Opposite Party

Ex.A17 dated 16.01.09           The letter received from the 4^th Opposite Party

Ex.A18 dated 21.02.09           The letter from 1’s    husband to  the 1^st Opposite

                                                     Party to look in to the 3 pending claims

Ex.A19 dated  NIL                            The letter from the complainant’s husband to the

                                                 1^st Opposite Party

Ex.A20 dated NIL                             Letter from the M.D of the 3^rd Opposite Party at

                                                     Hyderabad that the 1^st claim has been repudiated

                                                     with reasons

Ex.A21 dated 03.12.09            The Sr.Divisional Manager of the 1^st Opposite

                                                     Party that her claim is repudiated

Ex.A22 dated 08.09.10            Letter from the 1^st Opposite Party to the

                                                     complainant that his grievance is under process

Ex.A23 dated 12.11.10            Letter from the DGM of the 2^nd Opposite Party

                                                     explaining the reasons for the reppuidiation of the

                                                     1^st claim

Ex.A24 dated 26.11.10            The letter from 4^th Opposite Party to the

                                                     complainant that her 4^th 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