State Consumer Disputes Redressal Commission
The Oriental Insurance Co. Ltd., ... vs S.V.K.Thampi, No.2069/18, Jeevan ... on 20 April, 2012
THE TAMILNADU STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI
THE TAMILNADU STATE
CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI. (BENCH -I)
Present: Thiru.A.K.Annamalai, Presiding
Judicial Member
Thiru.S.Sambandam, Member.
F.A.No.539/2011
[Against order in C.C.No.60/2009 on the file
of the DCDRF, Chennai (North)]
FRIDAY, THE
20th DAY OF APRIL
2012.
The Oriental Insurance Co.
Ltd.,
Oriental House,
N9.A. 25/27, Asaf Ali Road,
New Delhi 110 002. .. Appellant/1st opposite
party
/Vs/
1. S.V.K.Thampi,
No.2069/18, Jeevan Bhima Nagar,
Anna Nagar, Western Extension,
Chennai 600 101. .. 1st Respondent/Complainant
2. Medical
T.P.A.Services (I) Limited,
Flat No.10, Paul Mansions,
6B, Bishop Lefroy Road,
Kolkatta 700 020. ..
2nd Respondent/2nd opposite party
3. Appollo
First Med Hospitals,
No.154, Poonamallee High Road,
Chennai 600 010. .. 3rd Respondent/3rd
opposite party
The 1st
Respondent as complainant filed a complaint before the District Forum, against
the opposite parties praying for the direction to the opposite parties to pay a
sum of Rs.71,288/- together with interest at 18% p.a from 5.2.2007 till date of
realization in full, to pay a sum of Rs.1,00,000/- towards deficiency in
service, to pay a sum of Rs.1,00,000/- towards damages and compensation for the
mental trauma, pain and suffering undergone by the complainant, to pay cost. The District Forum allowed the complaint,
against the said order, this appeal is preferred praying to set aside the order
of the District Forum dated 10.3.2011 in C.C.No.60/2009.
The appeal coming
before us for hearing finally on 9.4.2012, upon hearing the arguments of both
sides and perused the documents, written submissions as well as the order of
the District Forum, this Commission made the following order :-
Counsel
for Appellant/1st Opposite party
: M/s.Nageswaran & Narichania, Adv.
Counsel
for 1st Respondent/Complainant : M/s.F.X.A.F.Denny, Advocate.
Counsel
for 2nd Respondent/2nd opposite party : M/s.Elveera
Ravindran, Advocate.
Counsel
for 3rd Respondent/3rd opposite party : Served
absent.
ORDER
A.K.ANNAMALAI, PRESIDING JUDICIAL MEMBER
1. 1st opposite party is the appellant.
2. The complainant had taken mediclaim policy with the 1st opposite party from the year 1999.
During October 2006 since the complainant developed pain in the lower abdomen on 23.12.06 he had consultation with 3rd opposite party and he was advised for direct inguinal reducible hernia operation and accordingly he got admitted on 29.12.2006 and undergone surgery on the same date. At the time of admission he was initially granted medical expenses for Rs.22,000/- through the 2nd opposite party and after treatment when the complainant claimed the actual expenses for the treatment from the 1st and 2nd opposite parties by submitting necessary documents in March 2007, 2nd opposite party by letter dated 19.2.07 repudiated the claim by stating some flimsy reasons and thereby earlier approval of Rs.22,000/- was also withdrawn and it was stated the complainant was suffering from ailment for the past 15 years as per the report of the 3rd opposite party and thereby the claim was repudiated which compelled the complainant to come forward with the consumer complaint claiming relief for payment of Rs.71,288/- incurred for the treatment and Rs.1,00,000/- each towards deficiency of service and for damages mental agony, pain and sufferings and for costs.
3. The opposite parties denied the allegations of the complainant in their return version. The 1st opposite party contended admitting the details of mediclaim policy and on receipt of form-I, from the 3rd opposite party, the 2nd opposite party sanctioned a sum of Rs.22,000/- as initial amount towards cashless facility and subsequently after receipt of all claim papers the 2nd opposite party forwarded the same to the Adjudication department and on that basis due to contradictions regarding the details in the documents the complainant was suffering from ailment for the last 3 months and 15 years and when the complainant was addressed the complainant sent a notice claiming the amount and compensation without any explanation for the contradiction and the claim was rejected on the basis of terms and conditions of the policy.
4. The 2nd opposite party also contended the claim was time barred and the complainant was not able to give proper explanation regarding the period of treatment and suppressed the material facts. 3rd opposite party contended that the complainant was admitted on 29.12.06 and he was diagnosed for bilateral inguinal hernia underwent a laparoscopy surgery with mesh repair done by Dr.Ravindran Kumaren.
The complainant was suffering from the ailment only for the past 3 months and it was wrongly recorded in the records as 15 years which is human error committed by the hospital staff.
Hence the complaint to be dismissed.
5. Based on both sides materials and after an enquiry the District Forum gave a finding that all the 3 opposite parties are deficiency in service and directed the 1st opposite party to pay a sum of Rs.71,288/- with 9% interest to the complainant from the date of complaint and also to pay a sum of Rs.25,000/- as compensation for mental agony and Rs.5,000/- as costs and also directed the 3rd opposite party to pay Rs.25,000/- to the complainant for mental agony and sufferings. No order was passed against 2nd opposite party.
6. Aggrieved by the impugned order the 1st opposite party alone has come forward with this appeal and in the grounds of appeal it is contended that the claim for approval under mediclaim policy is subject to the decision of the claim adjudication department the panel doctors of the head office of the 2nd opposite party and as per the terms and conditions of the policy the claim was repudiated since there were clear contradictions between the two discharge summary documents submitted by the complainant regarding the duration of ailment and the complainant had not taken to clarify the discrepancy in spite of the letter sent by the 2nd opposite party and as per the clause 4 of exclusion of policy on the basis of pre-existing disease which was suppressed claim was repudiated. When the error was committed by the 3rd opposite party on the basis of the reports of 3rd opposite party, 2nd and 1st opposite parties acted they cannot be blamed and there are no deficiency on their part in this regard and thereby the appeal to be allowed.
7. While considering both sides arguments, averments and contentions, it is the admitted case of both sides that the complainant undergone treatment with the 3rd opposite party for his inguinal reducible Hernia and for the same he has claimed the insured amount from the 1st opposite party through the 2nd opposite party for a sum of Rs.71,288/-.
But the 1st and 2nd opposite parties repudiated the claim stating that the complainant was having pre-existing disease for more than 15 years as on the date of admission with the 3rd opposite party and thereby by suppressing the same the policy was taken. Hence the claim was repudiated. For this the 1st and 2nd opposite parties relied upon the documents under Exhibits B25 to B27. Exhibit B25 is the letter sent by the 2nd opposite party to the 3rd opposite party calling for details relating to the treatment of the complainant along with policy copy and other investigating reports. On that basis, copy of the policy under Exhibit B26 was sent and this was not in dispute. Under Exhibit B27, the discharge summary issued by the 3rd opposite party which is dated as 29.12.06 relates to the complainant and the date of admission is mentioned as 29.12.06 date of surgery mentioned as 28.12.06 and date of discharge mentioned as 31.12.06 and under the history of complaints it is stated complaints of painless reducible swelling in the left groin to scrotum 15 years and under the head summary. The complainant admitted with complaints of painless reducible left scrotal swelling for past 11 years was evaluated he was taken up for laporascopy hernia mess repair on 29.12.06 and in the subsequent pages in the details regarding general information under the history of presenting complaints it is mentioned painless reducible swelling extending to scrotum -3 months.
Under Exhibit B28 which is the actual repudiation letter sent by the 2nd opposite party to the complainant it is stated the original cashless request was approved when the commencement of ailment was declared to be 3 months in form 1. However the discharge summary documented that the member was suffering from the ailment since last 15 years we hereby withdraw the DP approval of Rs.22,000/-.
In this case as it is a prima facie case of suppression of facts on the part of hospital. From these observations it is clear only on the basis of the discharge summary the claim was repudiated. Whereas the very same discharge summary filed by the complainant under Exhibit A1 it entirely differs with Exhibit B27 normally which should not be so, if really the 3rd opposite party had furnished the same with all relevant details preparing then and there; Under Exhibit A1 date of admission and date of surgery and date of discharge are mentioned as 29.12.2006, 29.12.2006 and 31.12.06 respectively. Regarding the history of presenting the complaint it is mentioned as painless reducible swelling in the left groin extending to scrotum-3 months.
Under the head summary it was mentioned the patient was evaluated left inguinal hernia taken up for hernia mess repair on 29.12.06 and in the subsequent page other details are given including advise of discharge on these basis alone the complainant could have claimed the mediclaim amount and he was not provided with any other documents by the 3rd opposite party at the time of claim and those documents were all directly received by the 2nd opposite party from 3rd opposite party and sent it to the adjudication department for consideration of claim.
8. The 3rd opposite party admitted in their written version and as well as in the proof affidavit that the complainant was actually having history of the complaint only for 3 months prior to the date of admission for surgery and inadvertently in the records it was mentioned as for 15 years and on perusal of Exhibit B27 it is found that the record was prepared in reckless manner even the dates relating to the surgery admission etc., were all mentioned in a hub hazard without any cogency manner and regarding the history of patient it was wrongly mentioned in 3 different periods as 3 months 15 years and 11 years etc., and in those circumstances because of those lethargic attitude in preparing the document without proper care and given to the insurance company on that basis alone claim to be approved which caused the complainant to get the repudiation of claim as well as mental agony. The 3rd opposite party in the proof affidavit filed has stated in para 6 as follows :-
I state that a perusal of the case sheet would show that it has been clearly recorded both in the admission record and the discharge summary that the complainant was suffering from the ailment only for 3 months.
However, in the hand written record under the caption course in the Hospital and discussion, it has been inadvertently recorded that the patient was suffering from this ailment for the past 15 years. This is apparently an error which had crept in at the time of wring this record by the concerned doctor.
From this admission it is clear while in the course of discussion in the hospital regarding the treatment it has been inadvertently recorded that the patient was suffering from the ailment for the past 15 years in stead of 3 months. Hence only because of the 3rd opposite partys negligence and deficiency of service the complainant was made to suffer and when the claim was repudiated by the 1st opposite party on the basis of the records submitted by 3rd opposite party through the 2nd opposite party, the 1st opposite party cannot have any deficiency in their service even though was expected to be more vigilance and careful in scrutinizing the medical records and cross checking the same with the 3rd opposite party.
9. In those circumstances even though the District Forum came to the conclusion that all the 3 opposite parties are deficiency in service without passing any award against 2nd opposite party allowed the complaint against 1st and 3rd opposite parties alone and the 1st opposite party was directed apart from the payment of Rs.71,288/- with interest, compensation of Rs.25,000/- also for mental agony of the complainant even though there was no deficiency of service and Rs.5,000/- as costs and Rs.25,000/- as compensation by 3rd opposite party were directed. In view of the foregoing discussions and reasons as stated we are o the view that the 1st opposite party need not have been penalized by ordering compensation also when there was no deficiency of service on their part, while considering the claim of the complainant on the basis of records submitted through 2nd and 3rd opposite parties. In those circumstances except for the same and otherwise the order of the District Forum to be retained.
10. In the result, the appeal is allowed in part by modifying the order of the District Forum as follows :- The award of Rs.25,000/- towards compensation for mental agony suffered by the complainant and his family members payable by the 1st opposite party to the complainant alone is hereby reduced to Rs.5,000/- alone. In other respects the order of the District Forum is hereby confirmed including the rate of interest payable on the sum of Rs.71,288/- towards the claim from the date of complaint till date of realization.
No order as to costs in this appeal.
S.SAMBANDAM, A.K.ANNAMALAI, MEMBER PRESIDING JUDICIAL MEMBER INDEX : YES / NO sg/B-I/aka/Ori.
Ins.
10. In the result, the appeal is allowed in part by modifying the order of the District Forum as follows :- The award of Rs.25,000/- towards compensation for mental agony suffered by the complainant and his family members payable by the 1st opposite party to the complainant alone is hereby set aside. In other respects the order of the District Forum is hereby confirmed including the rate of interest payable on the sum of Rs.71,288/- towards the claim from the date of complaint till date of realization. No order as to costs in this appeal.
S.SAMBANDAM, A.K.ANNAMALAI, MEMBER PRESIDING JUDICIAL MEMBER INDEX : YES / NO sg/B-I/aka/Ori.
Ins.