Tamil Nadu

South Chennai

CC/234/2013

S.Abdhul Basheer - Complainant(s)

Versus

TTK Healthcare TPA Pvt Ltd., - Opp.Party(s)

T.V.Lakshmanan

22 Dec 2021

ORDER

                                                                                                                                                                 Date of Complaint Filed: 04.07.2013

                                                                                                                                                                 Date of Reservation: 23.11.2021

                                                                                                                                                                 Date of Order: 22.12.2021

                                                                                                       

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.234/2013

 

TUESDAY, THE 22^nd DAY OF DECEMBER 2021

                                

Mr.S.Abdul Basheer,

(Customer ID:7H 3818440),

34/17, First Seaward, Valmiki Nagar,

Thiruvanmiyur, Chennai-41.

(Now at CT6, Vinoth Viruksha Apartments,

No.106, Gangai Amman Nagar Extn.,

Nolambur, Magappair – East, Chennai -107.                                  .. Complainants.                                                           

                                                                                ..Versus..

1.The Manager,

   TTK Healthcare TPA Private Limited,

   Anmol palani’88, L2, G.N.Chetty Road,

   T.Nagar, Chennai – 600 017.

 

2.The Manager,

    The New India Assurance Company Limited,

    45, Moore Street, 5^th Floor, Chennai -1.                              ..  Opposite parties.

******

Counsel for the complainant                            : Mr.T.V. Lakshmanan, Adv.

Counsel for the opposite parties                     : M/s.S.Radha Devi., Advocate.

 

On perusal of both side records and having heard the oral argument of opposite parties 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 a sum of Rs.51,348/- towards deficiency in service and mental agony to the complainant.

2. In order to prove the case, on the side of the complainant proof affidavit submitted as his evidence, documents Ex.A1 to Ex.A27 were marked, written argument not filed and also oral argument not adduced   While so, on the side of the opposite parties proof affidavit submitted as their evidence, documents Ex.B1 to Ex.B3 were marked and written argument filed.  

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

The complainant has taken MEDICLAIM POLICY with the 2^nd opposite party insurance company.  The complainant has renewed policy from the year 2005 to 2012 regularly.  The last renewal date is 22.03.2012.  Therefore the period is from 22.03.2012 to 22.03.2013. 

4. The complainant has been suffering “Non Flow Limiting CAD” and has been taking inpatient treatment in IRUDHAYAM hospital private limited, NAGARCOIL from the year 2008 onwards periodically.  During July 2012 the complainant went for medical checkup and he was asked to get admitted in the hospital for treatment.  Accordingly he admitted on 23.07.2012, underwent treatment and got discharge on 25.07.2012.  The complainant made a claim for a sum of Rs.21,709/- on 11.08.2012 enclosing all the relevant paper and records in support of the claim. But on 05.09.2012 the claim was repudiated as that the treatment was for “Coronary artery disease” and the given treatment was possible on OPD basis.  Complainant attempted to explain the whole situation by letter dated 06.12.2012 as his claim was allowed for the previous years and the treatment has been periodically given.  But by letter dated 20.12.2012 again the claim was repudiated and the reason stated in the letter of the 1^st opposite party is totally against the policy terms and conditions. Hence this complaint is filed.

5. Written Version of the opposite parties in brief:-

It is true that the complainant had taken MEDICLAIM policy from the 2^nd opposite party.  The opposite parties further state that the complainant had the habit of admitting himself in the hospital for treatment of “CORONARY ARTERY DISEASE’ now and then which does not require hospitalization and get MEDICLAIM from the opposite parties.

6. The opposite parties states that the complainant was admitted and treated periodically as in patient treatment for ‘Non Flow Limiting CAD” in IRUDAYAM Hospital private limited NAGARCOIL from the year 2008.  On 23^rd July 2012 the complainant underwent treatment for “CORONARY ARTERY DISEASE” from 23.07.2012 to 25.07.2012.  On scrutiny of the claim documents submitted by the complainant the opposite parties came to know that treatment for said Non Flow Limiting CAD was possible on OPD and investigation was done on PPD basis.  The complainant wantonly admitted in the hospital where there is possibility for treating the said disease as OPD and in order to extract money from the opposite parties he was admitted himself.  It is crystal clear that the complainant is treated as in patient where there is no necessity.  The opposite parties further states that the claim was repudiated through letter dated 05.09.2013 and by subsequent letter 20.12.2012 as per the terms and conditions of the policy.

7. As per the terms and conditions of the MEDICLAIM policy, the treatment taken as OPD is not covered under policy.  The opposite parties on verification found that the treatment under went by the complainant does not require hospitalization and he can very well be treated as outpatient.  In order to comply with the necessary requirements of policy conditions and to extract money from the opposite parties the complainant was admitted as in patient for which, no hospitalization is required.  The opposite parties further states that the medical expert was also appointed to adduce opinion with regards to the settlement of claim  and the medical expert also opined that hospitalization was not warranted for the said treatment and hence recommended for denial of MEDICLAIM.  Further Medical expert also opined that due to advancement in medical technology it is not necessary to be treated as in patient for the said disease.  The opposite party further states that the complainant was admitted in the IRUDAYAM Hospital Private limited mainly for investigation.  In the terms and conditions of the MEDICLAIM policy it is clearly mentioned 24 hours hospitalization is necessary to get claim under MEDICLAIM.  The complainant can be treated as outpatient for such ‘”CORONARY ARTERY DISEASE” instead of inpatient treatment at the above said hospital.  Therefore the complainant is not entitled to get any claim and it was repudiated for correct reason. Hence it is requested to dismiss this complaint.

8.The points for consideration are:-

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

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

3) To what relief the complainant is entitled to?

9. Point No.1:-

It is an admitted that the complainant had taken MEDICLAIM POLICY from the 2^nd opposite party.  It is admitted that the complainant underwent treatment for “Coronary artery disease” from 23.07.2012 to 25.12.2012. According to the opposite party that the treatment for the said Non Flow Limiting CAD was possible as an OPD.  Further medical expert also opined that due to advancement in medical technology it is not necessary to be treated as inpatient for the said disease. Therefore it is stated that the claim of the complainant was rightly repudiated. On perusal of Ex.B1 the letter given by a medical expert who is the Vidal health, third party administer dated 09.01.2004 it is found that patient is a known case of CAD.  Patient admitted with C/O of chest pain, palpitation since three months, underwent diagnostic investigation and conservator management (oral medication). Based on submitted documents, this claim is repudiated for below said reasons.

“It is not an emergency hospitalization and moreover,

During hospitalization only oral drugs given to the patient which is possible on OPD.

During hospitalization along with oral drugs, investigations done to the patient (ECG, 3D, vasculgrapny, metabolic profile and cardiac profile) which is also possible on OPD.

As this treatment does not need admission as only oral drugs and investigations are done which is possible on OPD”.

10. The above opinion was given by Dr.Kubenthrian,BHMS,.  So many cardiologists are available to give opinion in respect of the claim made by the complainant but the expert opinion was obtained by homeopathic doctor. Since no expert opinion obtained from a qualified cardiologist, the opinion relied by the opposite party is not acceptable one.  Hence we found that the 2^nd opposite party is committed deficiency in service on his part. Accordingly point No.1 is answered.

11. Point Nos.2&3:-

We have discussed and decided that the 2^nd opposite party is committed deficiency in service on his part.  Hence the 2^nd opposite party is liable to pay the claim amount of Rs.21,709/- to the complainant along with a sum of Rs.10,000/- towards compensation for the mental agony caused to the complainant.  Further the complainant is entitled a sum of Rs.5,000/-  towards litigation expenses.  The 1^st opposite party is only a third administrator.  Hence he is not liable to pay any compensation to the complainant. Accordingly point Nos.2&3 are answered.

In the result, this complaint is allowed in part.  The 2^nd opposite party is hereby directed to pay a sum of Rs.21,709/-(Rupees twenty one thousand seven hundred and nine only) towards the insurance claim amount of the complainant and to pay a sum of Rs. 10,000/-  (Rupees ten thousand only) towards compensation for the mental agony caused to the complainant.  It is further directed to pay a sum of Rs.5,000/- (Rupees five thousand only) towards litigation expenses to the complainant.

The 2^nd opposite party is directed to pay the above accrued amounts within three months from the date of this order failing which, the complainant is entitled to recover the same with interest at the rate of 9% per annum from the date of this order to the date of realization of the amount. This complaint is dismissed as against the 1^st opposite party.

Dictated to steno-typist, transcribed and typed by him, corrected and pronounced by us in the open commission, on this the 22^nd day of December 2021.

 

VINODH KUMAR                                                                  R.V.R.DEENADAYALAN

         MEMBER                                                                             PRESIDENT

 

List of documents filed by the complainant:-

Ex.A1	19.08.2008	Discharge summary for the claim of the year 2008.	Xerox
Ex.A2	23.08.2008	Medical certificate for the claim of the year 2008.	Xerox
Ex.A3	25.08.2008	Authorisation given by the complainant to the 1st op for the claim of the year 2008.	Xerox
Ex.A4	05.09.2008	Claim form.	Xerox
Ex.A5	12.11.2008	Medicalaim computation for the year 2008	Xerox
Ex.A6	19.11.2008	Claim settlement advice for the claim	Xerox
Ex.A7	25.10.2009	Discharge summary	Xerox
Ex.A8	25.10.2009	Medical certificate for the claim of the year 2009	Xerox
Ex.A9	12.11.2009	Authorisation given by the complainant to the 1st op for the claim of the year 2009.	Xerox
Ex.A10	12.11.2009	Claim form for the claim of year 2009	Xerox
Ex.A11	15.12.2009	Mediclaim computation for the year 2009	Xerox
Ex.A12	18.12.2009	Claim settlement advice for the claim year 2009.	Xerox
Ex.A13	29.06.2011	Discharge summary for the claim of the year 2011	Xerox
Ex.A14	29.06.2001	Medical certificate for the claim of the year 2011.	Xerox
Ex.A15	11.07.2011	Authorisation given by the complainant to the 1st op for the claim of the year 2011.	Xerox
Ex.A16	11.07.2011	Claim form for the claim of year 2011.	Xerox
Ex.A17	15.07.2011	Claim form for the claim of year 2011/	Xerox
Ex.A18	11.08.2011	Claim settlement advice for the claim year 2011.	Xerox
Ex.A19	25.07.2012	Discharge summary for the claim of the year 2012.	Xerox
Ex.A20	25.07.2012	Medical certificate for the claim of the year 2011.	Xerox
Ex.A21	11.08.2012	Authorization given by the complainant to the 1st op for the claim of the year 2011.	Xerox
Ex.A22	11.08.2012	Claim form for the claim of year 2012 (Hospitalization)	Xerox
Ex.A23	15.09.2012	Rejection by the 1st op of the complainant’s hospitalization claim for 2012.	Xerox
Ex.A24	30.09.2012	Claim form for the claim of year 2012 (Post Hospitalization)	Xerox
Ex.A25	06.12.2012	Letter issues by the complainant to the 1st opposite party.	Xerox
Ex.A26	20.12.2012	1st opposite party’s rejection letter.	Xerox
Ex.A27	……………..	Mediclaim policy (2007)	Xerox
List of documents filed by the opposite parties:-

 

Ex.B1	...........	Letter given by medical expert.	Xerox
Ex.B2	………………	Complaint copy CC.No.78/2008	Xerox
Ex.B3	…………..	Order copy CC.No.78/2008	Xerox

 

 

 

VINODH KUMAR                                                                  R.V.R.DEENADAYALAN

         MEMBER                                                                             PRESIDENT