Tamil Nadu

South Chennai

CC/55/2020

Jesudasan paul, - Complainant(s)

Versus

The Regional Manager New India Assurance Company Limited, - Opp.Party(s)

J.Chellappa

26 May 2023

ORDER

  Date of Complaint Filed:12.03.2020

  Date of Reservation     :03.05.2023

  Date of Order              :26.05.2023

          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.55/2020

 FRIDAY,THE 26^th DAY OF MAY 2023

Jesudasan Paul, ME(USA)

No.1, 9^th Trust Cross Street,

R.A.Puram,

Chennal 600028 .

E-Mail:Jdj028@gmail.com

Land Line:2464 0810

Mobile : 9445357052.                                                      .. Complainant.

-Vs-

1. The Regional Manager,

New India Assurance Company Limited, Bengaluru,

 DO3 Mahalaxmi Chambers 2^nd Floor,

 M.G Road.

Bengaluru 560001.

Ph: 08025584443/25584479.

E-Mail: nia.670300@newindia.co.in

CIN No:U99999MH1919GO1000526.

 

2. The Manager,

Vidal Health Insurance TPA Pvt.Ltd.,

Annol Palanal, 2^ndFloor,

88 G.N. Chetty Road,

T'Nagar, Chennal 600017,

E-Mail:help@vidalhealthtpa.com.                                   .. Opposite Parties.

* * * * *

Counsel for the Complainant            : M/s. J. Chellappa

 

Counsel for 1^st Opposite Party          : M/s. S. Dhakshnamoorthy

 

Counsel for the 2^nd Opposite Party   : Exparte on 27.05.2022

 

On perusal of records and upon treating the written arguments as oral arguments of the Complainant on endorsement made by the Complainant and hearing the oral arguments of the counsel for 1^st Opposite Party this Commission delivered the following:

ORDER

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

(i)     The Complainant has filed this complaint as against the Opposite Parties under section 12 of the Consumer Protection Act, 1986 and prays to pay a sum of Rs.1,00,000/- towards deficiency of service along with a sum of Rs.10,910/- incurred towards outpatient hospitalization treatment at the CSI Kalyani General Hospital, Chennai which is their listed Hospital for causing untold misery and hardship and financial loss to a senior citizen.

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

1.     The Complainant submitted that he was covered under the New India Flexigroup Mediclaim Policy with 1^st Opposite Party, from 1.11.2017 upto 31.10.2020 and paid a sum of Rs.86,206 under their Medicialm Policy to meet his hospitalization expenses as and when incurred by him towards inpatient/outpatient treatment in their approved hospital for a sum of Rs.5 lakhs.

2.     Earlier covered under Mediclaim Policy with United India Insurance Company, commencing from 1.11.2009 to 31.10.2017 and remitted a total sum of Rs.1,82,000, to cover hospitalization expenses when Incurred by him  and the same is administered in collaboration with Canara Bank. After termination of contract with United India Insurance Company, The New India Assurance Company has taken over the Mediclaim Policy and had renewed the existing Cancomfort Insurance policy holders with them. Accordingly, they have renewed his existing policy with the New India Assurance Company and renamed it as New India Assurance Group Mediclaim Policy for Can Card holders like him and being administered through Canara Bank.

3.     He currently incurred a sum of Rs.10,910/- towards outpatient treatment for Balaopti/Circumcision at CSI Kalyani General Hospital, Chennai, on 11.1.2020, which is a listed hospital by the 1^stOpposite Party.

4.     He had sent a letter dated 21.1.2020 to 1^stOpposite Party by RPAD  requesting them to settle the amount of Rs.10,910/-  at the earliest along with the Original official receipts (3 nos.) issued by the said Hospital per details furnished, which was not settled by the 1^st Opposite Party. He undergone the surgery with Apollo Hospital, they would have charged a minimum Rs. 1 lakh.

5.     The 1^st Opposite Party and their TPA namely 2^nd Opposite Party is bent upon harassing policy holders who are Senior Citizens in not settling the meager amount of claim speedily incurred towards outpatient surgery by Senior Citizen which tantamount to abuse of process of law and totaling to travesty of justice.

6.     His Counsel, Mr.J.Chellappa has sent a legal notice by RPAD on 04.03.2020.(Exhibit 9, Page 7), to pay the hospital expenses and cost.   He had also filed C.C.No.59/2019, towards deficiency of service against Opposite Party 1 & 2 for not paying the hospitalization expenses of Rs.8,305 towards outpatient treatment incurred by the Complainant for Excision Lipoma at CSI Kalyani General Hospital and the Honb'le Forum was pleased to pass an order directing the Opposite Parties 1 and 2 jointly and severally to pay a sum of Rs.8,305/- towards Hospitalization expenses, Rs.15,000/- towards compensation for mental agony and Rs.10,000/- towards cost to the Complainant and payment is awaited from Opposite Party. Hence this complaint is filed for the deficiency of service of the opposite parties

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

7.     This Opposite Party submitted that the complaint is made alleging non settlement of the claim arising out of the policy covered under "New India Flexi Group Mediclaim Policy" issued vide Policy Certificate No.670300/2019-2020/00095 issued for the period from 01/11/2019 to 31/10/2020 for a Sum insured of Rs.5,00,000/-. During the currency of this Policy period, the Complainant has lodged a claim for a sum of Rs.10,910/- for the treatment under gone by him in CSI Kalyani Hospital.

8.     The complaint along with the Claim form has submitted only 3 cash receipts which shows as under:

1. Urology Consultation- Rs.250/-

2. Surgery Charges- Rs.10,000/-

3. Drug Charges- Rs.660/-

Except these 3 cash receipts, the Complainant has not produced any treatment records as to the surgery undergone by him. Further, he has not produced even the doctor's prescription as to the consultation and drugs prescribed by the doctor. No surgery would have been done without any documentary record and further even for drugs administered to the Complainant, there would be necessarily a prescription by the doctor.

9.     This Opposite Party submitted that the 2^nd Opposite Party, the Third Party Administrator who process the claim had vide their mail dated 18.02.2020 has sought for the details and breakup for the cash bill of Rs.10,000/- paid for "Surgery Charges". The Complainant chose not to respond to the said request and instead proceeded to file this complaint before this Honourable forum.

10.    This Opposite Party vide their email dated 02.06.2020 have given a detailed reply to the Legal notice sent by the Complainant through his counsel Mr. J.Chellapa vide mail dated May 25, 2020. In the said mail, the Opposite Party has clearly explained the requirements of the documents and further the efforts put forth by the Opposite Parties is trying to obtain details from the Hospital. But neither the Complainant nor the Hospital came forward in sharing the documents sought by the Opposite Parties for processing of the Claim.

11.    The duty to submit the required documents, by the insured/complaint, at the time of lodging a claim has been expressly stated in Clause 5.3 of the Policy's terms and conditions expressly.  Hence, due to willful failure on the part the Complainant, Opposite Parties were unable to process the claim. The Opposite Parties have acted as per the terms and conditions of the Policy. That there is no deficiency in service and thus this Complaint deserves no fate other than outright dismissal.

III. The 2^nd Opposite Party was set ex parte:

        Notice was sent to the 2^ndOpposite Party and was duly served to the 2^nd Opposite Party. Despite the notice being served to the 2^nd Opposite Party they failed to appear before this Commission either in person or by  Advocate on the hearing date and not filed any written version on their side.  Hence the 2^nd Opposite Party was called absent and set ex-parte. Subsequently, the case was proceeded to be heard on merits.

IV. The Complainant has filed his proof affidavit and Written Arguments,  in support of his claim in the complaint and has filed documents which are marked as Ex.A-1 to A-9. The 1^st Opposite Party had submitted its proof affidavit and Written Arguments. On the side of 1^st Opposite Party documents were marked as Ex.B-1 to Ex.B-3.

 

V. Points for Consideration:-

 

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

2. Whether the Complainant is entitled for reliefs claimed?

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

Point Nos. 1 to 3 :-

12.    The undisputed facts are that the Complainant is holding a “New India Flexi Group Mediclaim Policy” vide Policy Certificate No.670300/2019-2020/00095 issued for the period from 01/11/2019 to 31/10/2020 for a Sum insured of Rs.5,00,000/-. It is also not in dispute that during the subsistence of the policy the Complainant had made a claim for Rs.10,910/- for the treatment undergone by the Complainant in CSI Kalyani Hospital. The dispute arose on the non settlement of the claim arising out of the said policy by the opposite parties.

13.    The Complainant had taken the New India Flexi group Mediclaim Policy from 1^st Opposite Party, and paid a sum of  Rs.86,206/- towards premium amounts from 1.11.2017 upto 31.10.2020 which is also evident from Ex.A 1 to A 3, and the sum assured is Rs.5,00,000/-. The Complainant had undergone outpatient treatment for Balaopti/Circumcision at CSI Kalyani General Hospital, Chennai, on 11.1.2020 as per Ex.A 4 and incurred a sum of Rs.10,910/- as per Exs.A 6 to 8. The Complainant had sent a letter dated 21.1.2020 to opposite parties Ex.A 5, requesting them to settle the amount of Rs.10,910/- enclosing the  receipts issued by the said Hospital which was not settled by the 1^st Opposite Party.

14.    The Opposite party contended that Complainant along with the Claim form has submitted only 3 cash receipts  towards Urology Consultation- Rs.250/-,  Surgery Charges- Rs.10,000/- and  Drug Charges- Rs.660/-. Except those 3 cash receipts, the Complainant has not produced any treatment records as to the surgery undergone by him, the doctor's prescription as to the consultation and drugs prescribed by the doctor. As per Ex.B 1, the e - mail dated 18.02.2020, the 2^nd Opposite Party, the Third Party Administrator who process the claim had sought for the details and breakup for the cash bill of Rs.10,000/- paid for "Surgery Charges". According to the 1^st opposite party the Complainant had not chosen to produce the details. However it is seen from Ex.B 2 which is the legal notice issued by the Complainant stating that he had already furnished documents required by the 2^nd opposite party and called upon the opposite parties to pay the surgery expenses for which the opposite party had given a reply mail as seen from Ex.B 2, explaining the requirements of the documents and their efforts to obtain details from the Hospital.

Clause 5.3 of the New India Flexi Group Mediclaim Policy is extracted hereunder:

“…… Final claim along with hospital receipted original Bills/Cash memos, claim form and documents as listed in the claim form below should be submitted to the Policy issuing Office/TPA not later than 30 days of discharge from the hospital. The insured may also be required to give the Company/TPA such additional information and assistance as the Company/TPA may require in dealing with the claim.

a. Bill, Recipt and Discharge Certificate / card from the Hospital

b. Cash Memos from the Hospitals / Chemists, supported by proper prescriptions

c. ….

d. Surgeon’s certificate stating nature of operation performed and Surgeons’ bill and receipt.”

It is seen that the Complainant had not produced the details of treatments undergone by him at the Kalyani Hospital as required by the opposite parties.

Moreover Clause 4.4.2 under the head Permanent Exclusions, any medical expenses incurred for or arising out of Circumcission, cosmetic or aesthetic treatment, plastic surgery unless required to treat injury or illness are excluded. It is admitted by the Complainant that he had undergone treatment for circumcision for which medical expenses he has made claim to the opposite parties. As the treatment taken by the Complainant falls under the category of Permanent Exclusions the Complainant is not entitled for the claim amount as the Complainant had failed to establish that the surgery is necessary to treat any injury or illness in order to substantiate his claim.

 

15.    It is pertinent to note that the order passed in C.C.No.59/2019 filed by the Complainant earlier before this Commission directing the opposite parties therein to pay a sum of Rs.8,305/- towards Hospitalization expenses, Rs.15,000 towards compensation for mental agony and Rs.10,000 towards cost to the Complainant has no relevancy to the present case.

16.    Upon considering the discussions made above and in the facts and circumstances of the case it is clear that the Complainant has failed to provide documents as required by the opposite parties, due to which the Opposite Parties were unable to process the claim and also as the treatment undergone by the Complainant falls under the exclusion clause of the Policy terms and conditions which is binding upon the Complainant, he is not entitled for the claim amount and also the Complainant had failed to prove that there is any deficiency in service or unfair practice on the part of the opposite parties as alleged in the Complaint. The Complainant is not entitled for the relief claimed or for any other relief(s). Accordingly the points are answered.

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

Dictated to Steno-Typist, transcribed and typed by her, corrected and pronounced by us in the Open Commission, on 26^th of  May 2023.

 

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                    B.JIJAA

      MEMBER II                         MEMBER I                        PRESIDENT

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

 

Ex.A1	01.11.2019	Policy End date – 31.10.2020. Amount paid Rs.33,154
Ex.A2	01.11.2018	Policy end date 31.10.2019. Amount paid Rs.25,523
Ex.A3	01.11.2017	Policy end date 31.10.2018. amount paid Rs.26,523
Ex.A4	17.01.2020	Cashless Hospitalization policy part C in 4 pages of TPA
Ex.A5	21.01.2020	From Jesudasan Paul to Vidal Insurance with copy to New India Assurance Company
Ex.A6	10.01.2020	Receipt No.P485604 for Rs.250 from Kalyani Hospital
Ex.A7	11.01.2020	Bill No.RC326218 towards outpatient surgery charges for Rs.10,000
Ex.A8	11.01.2020	Bill No.RC326293 towards drug charges for Rs.660
Ex.A9	04.03.2020	Legal notice from Counsel Mr.J.Chellappa sent by RPAD to Opposite Party 1 & 2

 

 

List of documents filed on the side of the 1^st Opposite Party:-

Ex.B1	18.02.2020	Mail communication sent to Complainant
Ex.B2	02.06.2020	Reply sent by the Opposite Party to the Legal Notice sent by the Complainant
Ex.B3	01.11.2019	Certificate and terms and conditions

 

List of documents filed on the side of the 2^nd Opposite Party:-

 

 

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                    B.JIJAA

      MEMBER II                          MEMBER I                            PRESIDENT