IN THE CONSUMER DISPUTES REDRESSAL COMMISSION ERNAKULAM
Dated this the 30th day September 2022 Filed on: 24/11/2017
PRESENT:
Shri.D.B.Binu President
Shri.V.Ramachandran Member
Smt.Sreevidhia T.N. Member
C.C.No.470/2017
Complainant :
Janardanan M.K., Manalil House, Makkanai, Mannam P.O.,
N Paravur-683 520
(By Party-in-person)
Vs.
Opposite parties :
1. Branch Manager, Medi Assist Insurance TPA Pvt. Ltd,, 4th Floor, Chicago Plaza, Rajaji Road, Ernakulam-682 035
2) Branch Manager, National Insurance Co. Ltd., Main Road,
Paravur-683 513
(O.ps rep. by Adv.P.G.Ganappan, Anjali, Thrikkakara P.O., Cochin-682 021)
O R D E R
D.B.Binu, President.
A brief statement of facts of this complaint is as stated below:
The complaint was filed under section 12 of the Consumer Protection Act, 1986.The complainant’s case in brief is that the complainant is a Senior citizen and he has been purchasing Mediclaim Policy from Opp. Party No.2) for the last 17 years and the last policy No. was 571002/48/16/8500001811. As per Policy conditions Opp. Party No.1) who is the TPA of Opp. Party 2) is fully responsible for settling the claims in case of hospitalization treatment. On 17.1.2016 the complainant met with a Motor Vehicle Accident-causing multiple fractures on his right hand and the complainant had to undergo surgery on the same day at Sree Narayana Institute of Medical Science, Manjaly, N. Paravur. As per the policy conditions Opp. Party No.1 had to settle the medical bill before discharge. But against the total medical bill of Rs.36,490/- Opp. Party No.1 approved only Rs.35,130/- and the complainant had to pay the balance payment of Rs.1360 directly to the hospital before getting discharged. Many of the items against which Opp. Party denied the payments are either treatment charges or medicine charges and as per policy conditions expenses TPA has no right to deny such expenses. As per Clause No.1 of Policy conditions Policy Holder is entitled to get Pre & Post hospitalization expenses for 2 months. The complainant had lodged the claim for Rs. 1470/- on 28.4.2017 for pre-& post hospitalisation expenses. In spite of repeated reminders by e-mail & letters resting with letter dated 22.7.2017 Opp. party No.1) has neither settled the claim nor informed the complainant as per which clause of Policy conditions of his claim was denied /rejected. Even his complaint dated 31.8.2017 to the Grievance Cell of Insurance Company has not yielded any result. As per policy conditions, the complainant is eligible for hospitalisation expenses up to Rs.75,000/- (Rs.50,000/- + non-claim bonus of Rs.25,000/- in a year and hence non-payment of Rs.2830/- by the Opp. Parties is uncalled for and illegal and defeat the very purpose for which one purchase the policy. There is gross negligence on the part of the Opp. Parties. Also, there was deficiency of service on the part of Opp. Party. The complainant has suffered a loss of Rs.2830/-, in addition humiliation, harassment and mental torture by the acts of Opp. Parties.
2) Notice
Notice was issued from the Commission to the opposite parties and the opposite parties received the notice, entered appearance and filed their versions.
3) Version of the Opposite Party 1
This O.P. is the Third-Party Administrator of the 2nd O.P. National Insurance Co. Ltd. The 2 Op issued a National Mediclaim Policy in favour of the Complainant subject to terms and conditions of the Policy and genuineness of the Claim. As per the terms and conditions of the Policy the 2nd OP is liable to pay medical expenses alone.
In respect of the treatment undergone by the Complainant in the Road Traffic Accident occurred on 17-01-2017, this OP received a Claim from the Complainant for an amount of Rs.36,490/-. The Claim was processed by this OP and as per the terms and conditions of the Policy the same was settled for an amount of Rs.35,130/- and deducted an amount of Rs. 1,360/- as non-medical expenses.
The allegation in the Complaint that "many of the items against which OP denied the payment are either treatment charges or medicine charges is not correct and against the true facts stated above. In respect of the Post Hospitalization expenses a 2nd Claim for an amount of Rs.1,470/- was also received from the Complainant. This OP after processing the 2nd Claim an amount of Rs.890/- was transferred in the Complainant's Bank Account on 17-08-2017 and non-medical an amount of Rs.580/- was deducted. The eligible medical expenses as per the terms and conditions of the policy was already paid and the non-medical expenses alone were deducted by this OP and accordingly there is no deficiency of service on the part of the Opposite Parties. The attempt of the Complainant is to extract some amount from the opposite parties in any way.
4) Version of the Opposite Party 2
This OP issued National Mediclaim Policy in favour of the Complainant for a sum insured amount of Rs.50,000/- and Cumulative Bonus of Rs.25,000/- for the period from 12-09-2016 to 11-09-2017. The liability if any of this OP is subject to the terms and conditions of the Policy and the genuineness of the Claim if any made. As per the terms and conditions of the policy this OP is liable to pay medical expenses alone. In respect of the Road Traffic Accident injuries sustained on 17-01-2017and treatment undergone by the Complainant, this OP's TPA., the 1 OP received a Claim from the Complainant for an amount of Rs.36,490/-. The Claim was processed by the TPA. And as per terms and conditions of the Policy settled the claim for an amount of Rs.35,130/- and deducted an amount of Rs.1,360/- as non -medical expenses. The allegation in the complaint that "many of the items against which OP denied the payment are either treatment charges or medicine charges" is not correct and against the true facts as stated above. In respect of the Post hospitalization expenses a 2nd Claim for an amount of Rs.1,470 was also received from the Complainant. Prior to processing the 2nd Claim by the TPA and taken a decision on merit the Complainant challenged the same processing the 2nd Claim it found that out of the Claim amount of Rs.1,470/- the also in the above Complaint. After Complainant is eligible for an amount of Rs.890/- and deducting an amount of Rs.580/- as non-medical. The eligible amount as per the terms and conditions of the policy was already paid and the non-medical expenses alone were deducted by the Opposite Parties and accordingly there is no deficiency of service on the part of the Opposite Parties.
5) Evidence
The proof affidavit was filed by the Complainant along with 9 documents. Documents. Exhibit A1 to A9 marked.
EXHIBIT A1- The copy of the policy No. was 571002/48/16/8500001811.
EXHIBIT A2- Policy conditions
EXHIBIT A3- the claim Form
EXHIBIT A4- The complainant had lodged the claim.
EXHIBIT A5- letter dated 22.7.2017
EXHIBIT A6- copy of the complaint dated 31.8.2017 to the Grievance Cell of Insurance Company.
EXHIBIT A7- copy of the newspaper reports.
EXHIBIT A8- copy of the newspaper report.
EXHIBIT A9- copy of the driving licence.
6) The main points to be analysed in this case are as follows:
I) Whether the complaint is maintainable or not?
II) Whether there is any deficiency in service or unfair trade practice from the side of the opposite party to the complainant?
III) If so, whether the complainant is entitled to get any relief from the side of the opposite party?
IV) Costs of the proceedings if any?
The issues mentioned above are considered together and is answered as follows. The complaint is maintainable as the Consumer Protection Act, 1986. In the above case the Complainant has produced EXHIBIT A1 to A9.
On verification of the facts furnished by the complainant along with the documents produced as evidences and also since, the opposite party has not produced any documents from their side to substantiate and establish that the non medical charges shall not be paid as alleged by the complainant this Commission is reached into the following observation.
The complainant have established his case on merit in the absence of any contra evidence for the side of the opposite party and therefore point No. (I) is found in favour of the complainant.
Hence point Nos.(II) and (III) are decided accordingly.
ORDERS
1) The opposite parties are directed to reimburse an amount of Rs.2,830/- to the complainant being the total amount of the bill.
2) Considering the nature of this complaint no amount is ordered as compensation.
3) To pay an amount of Rs.2000/- to the complainant as cost of proceedings.
All these amount shall be paid by the opposite parties within one month from the date of receipt of a copy of this order.
Pronounced in the open Commission this the 30th day of September 2022.
Sd/-
D.B.Binu, President
Sd/-
V.Ramachandran, Member
Sd/-
Sreevidhia T.N., Member
Forwarded by Order
Assistant Registrar
APPENDIX
EXHIBIT A1- The copy of the policy No. was 571002/48/16/8500001811.
EXHIBIT A2- Policy conditions
EXHIBIT A3- the claim Form
EXHIBIT A4- The complainant had lodged the claim.
EXHIBIT A5- letter dated 22.7.2017
EXHIBIT A6- copy of the complaint dated 31.8.2017 to the Grievance Cell of Insurance Company.
EXHIBIT A7- copy of the newspaper reports.
EXHIBIT A8- copy of the newspaper report.
EXHIBIT A9- copy of the driving licence.
Forwarded by Order
Assistant Registrar
C.C.No.470/2017
order dated 30.09.2022
