Tamil Nadu

South Chennai

288/2010

A.madhu - Complainant(s)

Versus

Branch Manager, National Insurance Company Ltd., - Opp.Party(s)

Sampath Kumar Associates

08 Dec 2021

ORDER

                                                                                                                                                                 Date of Complaint Filed: 30.04.2010

                                                                                                                                                                 Date of Reservation: 17.11.2021

                                                                                                                                                                 Date of Order: 08.12.2021

                                                                                                       

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

CHENNAI (SOUTH)

 

Present:

 

                  Thiru. R.V.R. Deenadayalan, B.A., B.L.                                  : President

                 Thiru. T. Vinodh Kumar, B.A., B.L.                                           : Member

 

CONSUMER COMPLAINT No.288/2010

 

WEDNESDAY, THE 08^TH DAY OF DECEMBER 2021

                                

 A.Madhu,  New No.578, II Floor,

Swarnambagai Street, Opp.South Sivan Koil,

Kodambakkam, Chennai – 600 024 .                                                       .. Complainant.                   

                                                                //Verses//

1.The Branch Manager,

    National Insurance Company Limited,

   37, Pantheon Road,

   Chennai – 600 008.                                                                         ..  Opposite party.

******

Counsel for the complainant                        : M/s.Sampath Kumar&Associates,

Counsel for the opposite party                     : M/s. Sankara Narayanan, Adv.,

 

            On perusal of both side records and after having heard the argument of the complainant we delivered the following:

ORDER

Pronounced by the President Thiru. R.V.R. Deenadayalan, B.A., B.L.

 

            The complainant has filed this complaint under section 12 of the Consumer Protection Act, 1986 for seeking direction to pay medical expenses of Rs.22,810/- along with interest and litigation expenses.

2. In order to prove the case, on the side of the complainant proof affidavit submitted as his evidence and documents Ex.A1 to Ex.A16 were marked and filed written argument also adduced oral argument on his side.  While so, on the side of the opposite party proof affidavit submitted as his evidence but no documents and written argument was filed and not adduced oral argument on his side hence written argument treated as oral argument on the opposite party side.

            3. The averments of the complaint in brief are as follows:-

            The complainant’s mother Mrs.Leealavathi was admitted in the Apollo Hospitals, Chennai on 30.06.2004 and she was discharged on 03.07.2014.  The complainant is a policy holder under the group Mediclaim insurance Policy of Apollo Hospital enterprises limited.  As per policy the complainant is entitled to reimburse of medical expenses for the treatment taken to his mother.   The opposite party is the insurance company and therefore the complainant made a claim through Apollo Hospitals but the same was repudiated by the insurance company on the ground complainant’s mother was not admitted for treatment and she was admitted only for evaluation purposes in Apollo Hospitals. Hence the complainant filed this complaint to pay medical expenses of Rs.22,810/- along with interest and litigation expenses.

            4.Written version of opposite party in brief:-

            This complaint is filed without impleading M/s. Apollo Hospitals Enterprise limited who is the insured person under the Group Mediclaim Policy and who is very much a necessary party.  The opposite party has already communicated their considered decision, after due application of mind, vide their letter dated 28.09.2005 addressed to M/s Apollo Hospitals Limited, Chennai, Stating that the claim made by the complainant for Rs.22,008.60/- by way of reimbursement of medical expenses towards hospitalization of his mother Mrs.Leealavathi, aged 72 years in the Apollo Hospitals, Chennai between 30.06.2004 and 03.07.2004 cannot be admitted as the admission of his mother for evaluations purposes for which outpatient management would have been sufficient. The claim made is clearly barred by time and the same cannot be sought to be revived under the guise of proceedings.

            5. As per the terms and conditions of Mediclaim Insurance Policy, the opposite party has powers and authority to refer the claim to any Medical Practitioner authorized by the opposite party in case of any alleged injury or disease requiring hospitalization when and so often as may be reasonably required by the opposite party.  As per condition No.4.10 of the policy excludes charges incurred at hospital or nursing home primarily for diagnostic and evaluation proposes in the absence of positive presence of any aliment, sickness or injury for which confinement is required at a hospital. The medical records and bills produced along with the claim form were referred to a competent registered medical practitioner Dr.K.Sriram of M/s Unique Home health Care Limited in the independent opinion expressed by him upon scrutiny of entire papers, Dr.K.Sriram was of clear and categorical opinion that Mrs.A.Leelavathi, a 72 year old woman was admitted for evaluation of headache and giddiness, as categorically reflected in the discharge summary of Apollo Hospitals and such evaluation could have been done as an outpatient as there is no acute problem requiring admission.  The complainant’s mother underwent any surgical treatment during the period of hospitalization. The complainant, who is himself an employee in Apollo Pharmacy, was able to get his mother admitted without there being any compelling reason necessitating the same. Hence it is requested to dismiss this complaint.

            6.The points for consideration are:-

1) Whether there is any deficiency in service on the part of the opposite party?

2) Whether the complainant is entitled to get reliefs as claimed in the complaint?

3) To what relief, the complainant is entitled?

7. Point No.1:-

 

            It is an admitted the fact that the complainant’s mother was admitted on 30.06.2004 and she was discharged on 03.07.2004 in the Apollo Hospitals, Chennai.  It is also admitted the fact that on 28.09.2005 the claim was made to the opposite party through M/s Apollo Hospital and the claim was repudiated, as that she was admitted only for evaluation purposes and also outpatient management would have been sufficient.  The repudiation letter was made on 28.09.2005, but this complaint was filed before this commission on 30.04.2010.

            8. As per Section 24 of Consumer Protection Act 1986 the complaint shall be filed within two years from the date of cause of action arise.  In this case the cause of action arises on 28.09.2005 itself and therefore limitation period is 27.09.2007 but this complaint was filed on 30.04.2010.  The complainant has not filed a petition Under Section 24(1)(2) of Consumer Protection Act 1986 to condone the delay to file this complaint. Therefore this complaint is filed after the limitation period.

            9. Further Ex.A16 is the Discharge Summary of Apollo Hospital.  In Discharge summary it is clearly mentioned as “72 years old lady was admitted for evaluation of her complaints.  CECT scan brain revealed no abnormality.  Routine blood investigations including CBC/RPII and fasting lipid profile were within normal limits.  She was referred to a Gastroenteroligist for her complaints of dyspepsia.  OGD scopy was s/o cobblestone mucosal appearance of the stomach.  USG abdomen revealed diffuse fatty changes of liver.  She was referred to an ENT surgeon whose advice was followed.  Neuropsychological assessment revealed mind impairment of memory function, high anxiety and hysteroid personality trait.  Dr.Sorojini, Gastroenterologist was consulted and her advice was followed. Therefore the complainant’s mother was not given treatment and the complainant’s mother was admitted only for evaluation purposes as stated by the opposite party. 

            10. The complainant is the employee of the opposite party and hence he was easily admitted his mother in the Apollo Hospitals and in the hospital no treatment was given to the complainant’s mother. As stated by the opposite party in its written version in condition clause 4.10 the policy excludes charges incurred at hospital or nursing home primarily for diagnostic and evaluation proposes in the absence of positive presence of any aliment, sickness or injury for which confinement is required and therefore the repudiation made by the opposite party is acceptable one. Considering the above fact we found that the opposite party has not committed any deficiency in service on it part.  Accordingly point No.1 is answered.

 

            11. Point Nos.2 & 3:-

            We have discussed and decided that there is no limitation to file this complaint and there is no deficiency in service on the part of the opposite party and hence the complainant is not entitled to get any reliefs as claimed in this complaint. Accordingly point Nos. 2&3 are answered.

            In the result, this complaint is dismissed. No costs.

            Dictated to steno-typist, transcribed and typed by him, corrected and pronounced by us in the open commission, on this the 08^th day of December 2021.

 

VINODH KUMAR                                                                                                           R.V.R.DEENADAYALAN

         MEMBER                                                                                                                           PRESIDENT

 

 

 

            List of documents filed by the complainant:-

 

Ex.A1	09.08.2009	Letter of Tambaram consumer protection society.	Xerox
Ex.A2	08.03.2009	Letter of tambaram consumer protection society.	Xerox
Ex.A3	08.12.2008	Letter of tamil nadu Medical Council.	Xerox
Ex.A4	22.11.2008	Letter of Tambaram Consumer Protection society.	Xerox
Ex.A5	27.07.2007	Letter of Tambaram Consumer Protection society.	Xerox
Ex.A6	05.06.2007	Letter of Tambaram Consumer Protection society.	Xerox
Ex.A7	26.06.2007	Advocate Notice of the opposite party	Xerox
Ex.A8	22.04.2007	Letter of Tambaram Consumer Protection society.	Xerox
Ex.A9	17.05.2007	Letter of Apollo Hospitals confirming the necessity of admission of the patient.	Xerox
Ex.A10	22.04.2007	Letter of Tambaram Consumer Protection society.	Xerox
Ex.A11	23.03.2007	Letter of Insured to the Tambaram Consumer Protection Society.	Xerox
Ex.A12	28.11.2005	Letter of insured contesting the rejection of the claim by the opposite party.	Xerox
Ex.A13	28.09.2005	Letter of the opposite party to the insured rejecting the claim.	Xerox
Ex.A14	25.08.2005	Letter of Dr.K.Sriram to the opposite party.	Xerox
Ex.A15	04.07.2004	Bills  of the insured etc.,	Xerox
Ex.A16	03.07.2004	Discharge summary given by the Apollo Hospitals, Chennai	Xerox

 

List of documents filed by the opposite party:-

 

No documents

 

 

VINODH KUMAR                                                                                                               R.V.R.DEENADAYALAN

         MEMBER                                                                                                                              PRESIDENT