IN THE TAMIL NADU STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI Present: Hon’ble Thiru Justice R.SUBBIAH ... PRESIDENT Thiru.R.VENKATESAPERUMAL … MEMBER F.A. No.146 of 2018 (Against the Order, dated 26.04.2018, in C.C. No.195 of 2014, on the file of the DCDRF, Chennai-North Orders pronounced on: 10.08.2022 Oriental Insurance Co. Ltd., rep. by its Regional Manager, P.B. No.1877, U.I.L Building, IV Floor, No.4, Esplanade, Chennai 600 108. … Appellant/Opposite Party.

vs.

P.Dhanesh, No.118, Anna Pillai Street, 4^th Floor, Sowcarpet, Chennai 600 079. … Respondent/Complainant For Appellant : M/s.Elveera Ravindran For Respondents : M/s.V.Balaji/Amicus Curiae This First Appeal came up for final hearing on 20.04.2022 and, after hearing the arguments of the counsels and perusing the materials on record and having stood over for consideration till this day, this Commission passes the following:- O R D E R R.Subbiah, J. President .

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Aggrieved by the Order, dated 26.04.2018, passed by the DCDRF, Chennai-North, in C.C. No.195 of 2014, whereby, the District Forum partly allowed the complaint filed by the respondent herein by directing the Opposite Party/Insurance Company to pay to him a sum of Rs.1,76,555/- towards the medical expenses and Rs.50,000/- towards compensation for mental agony, besides Rs.5,000/- towards litigation expenses, the Insurance Company has filed the present appeal.

2. For the sake of convenience, the parties shall be referred to in the course of this order, as per their respective rankings before the District Forum.

In brief, the case of the complainant, as given in the complaint filed before the District Forum, is as follows:-

The complainant is the holder of an Individual Mediclaim Policy issued by the OP and since 1999, he has been renewing it from time to time without any default. He migrated from Individual Mediclaim to Happy Family Floater Policy (in short HFP) with effect from 22.01.2010 and it also mentions the number of the previous Policy. The Complainant was continuously renewing the same as and when due for renewal and at no point of time, he did suffer from any pre-existing disease since the inception of the policy in 1999. While so, he was admitted in Apollo Hospital, Chennai, on 17.07.2013, to get treatment for Acyanotic Congenital Heart Disease Ostium Secundum ASD, but, he was denied cashless claim from the OP’s Third Party Agent (TPA)/M/s.MD India Health Care Services TPA Pvt. Ltd., vide letter, dated 18.07.2013, addressed to Apollo Hospitals stating “Cashless Hospitalization denied under Exclusion 4.8 as convalescence, general debility, rest cure, congenital external disease or defects or anomalies, sterility, infertility, sub fertility, venereal disease, intentional self injury … not covered under the Policy". The complainant had settled the hospital dues from his own sources and thereafter, he lodged a claim with the OP’s TPA for reimbursement of the said medical expenditure. But, the OP denied the claim on the ground that the TPA had written another letter dated 27.07.2013, to the Branch that the claim falls under exclusion clause No.4.8 of the Policy. This time, the said clause is quoted to mention also the ‘internal disease’ which suggests that the TPA is not sure about the policy wordings and terms & conditions. Aggrieved by the same, the complainant sent a letter, dated 20.08.2013, to the head office of the OP and by reply, dated 03.10.2013, it was stated that the Insurance Company stands by the decision of the TPA and that, if not satisfied therewith, he can very well approach the Insurance Ombudsman. Since the complainant did not receive treatment for any pre- existing disease, he is entitled for the claim amount, hence, he issued the legal notice, dated 07.11.2013, for which, no reply was given. Thereafter, he wrote a letter, dated 17.12.2013 to the Insurance Ombudsman, however, the said authority, only awarded a sum of Rs.20,000/- as ex gratia. The complainant took steps seeking the Ins