BEFORE THE DISTRICT FORUM: KURNOOL
Present: Sri K.V.H.Prasad, B.A., LL.B., President
And
Smt. C.Preethi, M.A., LL.B., Member
Tuesday the 10th day of April, 2007
C.C. No.124/2006
V. Subramanyam, S/o. Late V.Rama Swamy, Aged about 45 years, Teacher,
R/o. H.No.81-5A, Raghavendra Nagar, Near I.T.C Company, Kurnool
…Complainant
-Vs-
1. The Branch Manager, Andhra Bank,
G.P.R. Engineering College Extension, Counter Branch, Kurnool.
2. The Divisional Manager,
M/s. United India Insurance Company Limited,Kurnool.
…Opposite parties
This complaint coming on this day for orders in the presence of Sri. S. Sivaramakrishna Prasad, Advocate, Kurnool for complainant, and Sri. M.Sanjeeva Reddy, Advocate, Kurnool for opposite parties No.1 and Sri. D.Yella Reddy, Advocate, Kurnool for opposite party No. 2 and stood over for consideration till this day, the Forum made the following:-
O R D E R
(As per Smt. C.Preethi, Member)
1. This consumer complaint of the complainant is filed U/S 12 of C.P. Act., 1986 seeking a direction on the opposite parties to pay Rs.1,00,000/- under AB Arogyadaan scheme vide policy bearing No.050400/48/05/00551/with 18% interest per annum, Rs.25,000/- towards mental agony, costs of the complaint and any other relief or reliefs which the complainant is entitled in the circumstances of the case.
2. The brief facts of the complainant’s case is that the complainant is the account holder bearing No. ASB 20425 of opposite party No.1 which introduced a scheme called AB Arogyadaan to facilitates his customers who will be hospitalized due to ill health and the complainant paid Rs.888/- towards the scheme for assured sum of Rs.50,000/- and opposite party No.1 issued a card bearing No.HAV0000155653 covering all the family members of the complainant. The complainant joined the scheme on 05-8-04 to 08-6-05. The said policy was the renewed for a period from 09-6-05 to 08-6-05 by paying Rs.1,822/- to the dismay of the complainant he got some heart complication and joined Usha Mullapudi Cardiac Centre, Hyderabad which is notified by opposite parties. Immediately the hospital authorities intimated the admission of complainant & opposite party replied dated:01-8-05 denying their liability since the ailment falls under the 1st year exclusive pre existing disease and the complainant was forced to pay hospital charges of Rs.1,63,333/-. After discharge the complainant addressed a letter dt:30-8-05, along with originals opposite party No.2 denied their liability. The attitude of opposite parties in rejecting the claim of the complainant is amounting to deficiency of service by opposite parties to the complainant. Hence resorted to the forum for redressal.
3. In support of his case the complainant relied on the following documents viz:(1)original savings account passbook A/c No.ASB 20425 of V.V.Subramanyam (2)original health card issued by AB Arogyadaan for a period of 07-6-05 to 08-6-06 (3)office copy of letter dated:30-8-05 addressed by complainant to authorize official of F.H.P.L and (4) attested xerox copy of discharged summary of complainant issued by Usha Medical Cardiac Center dated:15-8-05, besides to the sworn affidavit of the complainant in reiteration of his complaint averments and the above documents are marked as Ex.A1 to A4 for its appreciation in this case. The complainant caused interrogatories to opposite party No.2 and suitablely replied to the interrogatories caused by opposite party No.2.
4. In pursuance to the notice of this forum as to this case of the complainant the opposite parties appeared through their standing counsel and filed their written version. The written version of opposite party No.1 admits the complainant as beneficiary under AB Arogyadaan claim and denies the other averments of the complaint and further submits that it has not received any medi claim from the complainant and it has no responsibility in payment of amount to the complainant and it is opposite party No.2 which has to settle the claim and opposite party No.1 acted as a facilitator between the complainant and opposite party No.2 and further alleges that there is no deficiency of service on part of opposite party No.1 and seeks for the dismissal of complaint with costs.
5. The written version of opposite party No.2 admits the complainant as a beneficiary under AB Arogyadaan group Mediclaim policy bearing No.050400/48/05/00551 and submits that the complainant suppressed true facts and filed this complaint. It further submits that the policy holder under Mediclaim policy will be covered for a period of year as per terms and conditions of the policy. It further says that as per condition No.4 standard exclusion as per Mediclaim policy does not cover the following clauses 4 (1) pre-existing diseases (2)pre existing diseases are not payable under policy. Further this exclusion is deleted after three consecutive and continuous claim free policies under AB Arogyadaan and there is no claim/hospitalization for the pre existing ailment during three years of insurance i.e., each policy period comprising of 365 days. The medical records submitted by the complainant says that he was first admitted in Kurnool heart and care center on 11-6-05 and discharged of 12-6-05 and he was suffering from congenital bicuspid aoric, -valve, severe-arotic, stenosis. Hence, the claim of the complainant falls within the first year of the policy inception (with in 365 days) and during the second admission at Usha Mullapudi Cardiac Center, Hyderabad, the complainant under went valve replacement on 02-8-05. The Divisional Manager United India Company, Hyderabad has appointed a 3rd party administrator (Hyderabad limited) consisting of panel of doctors to process the mediclaims and the opposite party No.2 referred the claim of the complainant with all documents to the 3rd party administrator for settlement and 3rd party administrator after considering the documents of hospitalization opined that the claim of the complainant does not fall under the perview of the policy as the claim falls under first year exclusion clause of the said policy. Hence the claim of the complainant was rejected.
6. It lastly submits that the complainant knows the disease which he was suffering and with malafide intentions by suppressing the disease got the medi claim policy and hence he did not suffer any mental agony and he is not entitle to any amount claimed and seeks for the dismissal of complaint with costs.
7. In substantiations of their case the opposite parties relied on the following documents viz: (1)attested xerox copy of medi claim policy bearing no.050400/48/04/41/00000350 for a period commencing from 09-6-04, to 08-6-05 issued to opposite party No.1 (2)policy terms and conditions (3)renewal master policy for the period from 096-6-05 to 08-6-06 (4)certificate of insurance – AB Arogyadaan group – medi claim insurance for a period from 05-8-04 to 08-6-05 for assured sum of Rs.50,000/- (5)certificate of insurance – AB Arogyadaan group for a period from 09-6-05 to 08-6-06 for assured sum of Rs.1,00,000/- besides to the sworn affidavit of opposite party No.2 in reiteration of his complaint written version averments and the above documents are marked as Ex.B1 to B5 for its appreciation in this case. The opposite party No.2 caused interrogatories to the complainant and suitablely replied to the interrogatories caused by complainant.
8. Hence, the point for consideration is to what relief the complainant is entitled alleging deficiency of service:?
9. It is not in dispute that the complainant has taken certificate of insurance AB Arogyadaan group Medi claim policy vide Ex.B4 for period commencing from 05-8-04 to 8-6-05 for assured sum of Rs.50,000/- and said policy is renewed vide Ex.B5 for a sum of Rs.1,00,000/- for a period from
09-6-05 to 08-6-05. The master policy is issued by opposite party No.2 to opposite party No.1 vide Ex.B1 and the said master policy is renewed vide Ex.B3 and it is not in dispute that the complainant under went valve replacement surgery at Usha Mullapudi Cardiac Center and was discharged of 15-8-05 vide Ex.A4 and incurred expenses of Rs.1,63,333/-. When the complainant put forth the claim for incurred expenses under the policy it was repudiated on the reason that the claim of the complainant fall under the exclusion clause 4 (1) pre existing disease and the complainant suppressed true facts of his treatment at Kurnool Heart and care center from 11-6-05 to 12-6-05 and latter of under went Aortac involve replacement of 2-8-05 at Usha Mullapudi Cardiac Center, Hyderabad and the said treatment falls under first year excluded clause under said policy. Condition No.(4) of Ex.B5 which are dealing with standard execution as per medical excludes the coverage of insurance for the first time of the insurance cover to the disease mentioned therein, and it entitles the payment to the diseases mentioned therein after insurance cover for 365 days under AB Arogyadaan provided those diseases were not pre existing at the time of taking the insurance policy for the first time. As the master policy holder of Arogyadaan group medi claim insurance policy being opposite party No.1 (Andhra Bank) and complainant as member joined the said scheme, he is a mere beneficiary. The opposite party No.1 is only having a privy of insurance of its member with opposite party No.,2. From the Ex.B4 the period of insurance is from 05-8-04 to 8-6-05, the master policy in Ex.B1 was issued in favour of opposite party No.1 by opposite party No.2 covering the period from 09-6-04 to 08-6-05 (Midnight) and Ex.B3 is the renewed master policy in favour of opposite party No.1 was also issued for a period of one year commencing from 09-6-05 to 08-6-05. As the Ex.B4 certificate of insurance in the name of the complainant covers from 05-8-04 to 08-6-05 and the master policy in Ex.B1 also concludes on 08-6-05 only. The period of insurance of beneficiary member runs from the above EX.B1 with a period of insurance of master policy holder irrespective of his joining. As the period of insurance in Ex.B5 is concerning with the complainant is for the some period as the master policy in Ex.B3 covers, it goes without any further say that the period of insurance of the beneficiary member of said policy is co-existent with that of his master policy holder. As the Ex.B4 is earlier certificate of insurance covers a period of 11 months, only which is concluding with the period of its master policy holder of opposite party No.1. It appears that there is no individual practice of opposite party No.2 to issue certificate of insurance to the beneficiary members of master policy of opposite party No.1 of irrespective of the period of insurance of the master policy. The 365 days insurance cover under AB Arogyadaan is mentioned in 4 (4) of Ex.B5 is to be under stood as certificate of insurance covered under master policy and not individual certificate of insurance of beneficiary member. Simply because the period of insurance of every beneficiary members joining the scheme of the master policy is synchronizing with the period of the conclusion of said master policy. In this case as a certificate of insurance in Ex.B5 of the complainant as beneficiary member of the master policy is covering for the same period as the master policy in Ex.B3 covers. The scheme of the complainant is not hit by 4 (4) of Ex.B5 to get any exclusion from its honouring by opposite party No.2.
10. The opposite party No.2 further alleged that the complainant has taken treatment at Kurnool Heart & brain centre from 11-6-05 to 12-6-05 but did placed any cogent supporting material documents what so ever on record which could substantiative the said allegations. Further the opposite parties are not denying the operation under gone by the complainant at Usha Mullapudi Cardiac Center and the complainant incurred expenses of Rs.1,63,333/-.
11. Having regard to over all consideration there is no hesitation to hole that the opposite parties have miserable failed to substantiate their contentions. Therefore, in these circumstances the repudiation of claim by the opposite party is wholly arbitrary unreasonable and unjust and amounts to deficiency in service of their part.
12. To sum up in the light of the above discussions in having regard to such circumstances it is common knowledge that in case of valve replacement surgery in hospital like Usha Mullapudi Cardiac Center one has to incur a lot of expenditure and the alleged expenditure alleged to have been incurred by the complainant neither be considered exclusive nor unreasonable . Therefore, the complainant is entitled to the assured sum of Rs.1,00,000/- under the policy issued by opposite party No.2. As no case is made out against opposite party No.1the case against opposite party No.1 is dismissed.
13 In the result the case against opposite party No.1 is dismissed and the allowed against the opposite party No.2 directing opposite party No.2 to pay to the complainant Rs.1,00,000/- with 9% interest from the date of filing of this case i.e., 29-8-06 till realization along with costs of Rs.2,000/- within a month of receipt of this order.
Dictated to the Stenographer transcribed by him, corrected and pronounced in the Open bench on this the 10th day of April, 2007.
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
Witnesses Examined
For the Complainant: Nil For the Opposite Parties: Nil
List of Exhibits marked for the complainant:-
Ex.A1 original savings Account pass book A/c. No.ASB 20425 of
V.V.Subramanyam.
Ex.A2 original Health card issued by AB Arogyadaan for period from 09-6-2005
to 08-6-06.
Ex.A3 office copy of letter, Dt:30-8-05 addressed by complainant to Authorized
official of F.H.P.L.
Ex.A4 Attested xerox copy of Discharge summary of complaint issued by Usha
Mullapudi Cardiac Center Dt:15-8-2005.
List of Exhibits marked for the opposite parties:-
Ex.B1 Attested copy of Group Mediclaim policy bearing
No.050400/48/04/41/00000350 period from 09-6-04 to 08-6-05 issued
to opposite party No.1.
Ex.B2 policy terms & conditions.
Ex.B3 Renewed Master policy for the period from 09-6-05 to 08-6-06.
Ex.B4 certificate of Insurance AB Arogyadaan Group Mediclaim Insurance
policy for the period from 05-8-04 to 08-6-05.
Ex.B5 Certificate of Insurance AB Arogyadaan Group Mediclaim Insurance
policy for the period from 09-6-05 to 08-6-06, for an assured sum of
Rs.1,00,000/-.
Ex.B6 Repudiation of letter, Dt:08-11-06 addressed to the complainant.
Ex.B7 panel Report, Dt:26-10-06 as to the claim of the complainant.
MEMBER PRESIDENT
Copy to:
1. V. Subramanyam, S/o. Late V.Rama Swamy, Aged about 45 years, Teacher,
R/o. H.No.81-5A, Raghavendra Nagar,Near I.T.C Company, Kurnool.
2. Sri. S.Siva Rama Krishna Prasad, Advocate, Kurnool.
3. The Branch Manager, Andhra Bank, G.P.R. Engineering College Extension,
Counter Branch, Kurnool.
4. Sri. M.Sanjeeva Reddy, Advocate, Kurnool.
5. The Divisional Manager, M/s. United India Insurance Company Limited,
Kurnool.
6. Sri. D.Yella Reddy, Advocate, Kurnool.
Copy was made ready on:
Copy was dispatched on:
Copy was delivered to parties:
