BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
KADAPA Y.S.R DISTRICT
PRESENT SMT. K. SIREESHA, B.L., PRESIDENT FAC
SRI M.V.R. SHARMA, MEMBER.
Wednesday, 3rd September 2014
CONSUMER COMPLAINT No. 67 / 2013
V. Praveen Kumar, S/o V. Subba Rao, aged 42 years,
Hindu, Residing at D.No. 3/114, Nagarajupeta,
Kadapa city & District. ….. Complainant.
Vs.
1. The New India Assurance Co. Ltd., Rep. by its
Divisional Manager, Divisional Office, Sai Towers,
Sri Hari Rao Street, 1st floor, Nagarajupeta,
Kadapa city & District.
2. Good Health Plan Ltd., H.O. Plot No. 49,
Nagarjuna Hills, Panjagutta, Hyderabad, A.P.
Rep. by its M.D. ….. Opposite parties.
This complaint is coming before us for final hearing on 28-8-2014 and perusing complaint and other material papers on record and on hearing the arguments of Sri Md. Ali Khan, Advocate for complainant and Sri K. Guru Murthy, Advocate for O.P.1 and O.P.2 called absent and set exparte on 5-2-2014 and the matter is having stood over for consideration this day, the Forum made the following:-
O R D E R
(Per Sri M.V.R. Sharma, Member),
1. This Complaint is filed under section 12 of the Consumer Protection Act 1986 requesting this forum to direct the Opposite parties:-
(a) To pay Rs. 49,259/- which was disallowed by the opposite parties.
(b) To pay Rs. 50,741/- towards deficiency of service and also for the mental agony suffered by the complainant.
(c) Award cost of this complaint
2. The complainant filed the complaint and stated that the complainant paid premium since 2007 under Mediclaim for a sum of Rs. 1,00,000/- to the O.P.1, who inturn appointed 3rd party administrator (PPA) i.e. O.P.2 and O.P. 2 dealing the claims of the mediclaim policy. The complainant paid premium of Rs. 1633/- and the O.P.1 issued bearing policy No. 61120034110100000181 for a period of 8-12-2011 to 7-12-2012. The complainant admitted as in patient at KOTAKAL ARYAVAIDYAL SALA AYURVEDIC HOSPITAL AND RESEARCH CENTER, KOTTAKAL, Kerala during the subsistence of the policy from 30-4-2011 to 30-5-2011 and spent an amount of Rs. 67,239/- towards hospitalization and he informed to the O.P’s and submitted all the relevant documents to O.P.2 and O.P.2 disallowed Rs. 11,304/- and send a cheque bearing No. 794878, dt. 12-9-2011 for Rs. 55,988/- as against the claim of Rs. 67,293/-.
3. The complainant further stated that he paid Rs. 2,079/- as premium towards continuation of the above policy for the period of 8-12-2012 to 7-12-2013 to O.P.1 and the O.P.1 issued policy bearing No. 61120034120100000187 for a sum of Rs. 1.00,000/- under mediclaim policy (hospitalization benefit policy). After that he felt ill and got admitted as in patient KOTAKAL ARYAVAIDYAL SALA AYURVEDIC HOSPITAL AND RESEARCH CENTER, KOTTAKAL, Kerala from 29-2-2012 to 29-3-2012 and spent Rs. 75,049/- towards hospitalization and the said hospital issued bill bearing No. 4319, dt. 29-3-2012. The complainant informed his sickness and incurring of hospitalization charges to both O.P’s, after his discharge he submitted the original bill and other supported documents for processing and settlement of the claim. The O.P.2 astonishingly settled the claim for Rs. 25,000/- and sent a cheque bearing No. 223889, dt. 29-5-2012 as against the claim of Rs. 74,259/- thereby disallowed a huge amount of Rs. 49,259/-. Soon after the receipt of the above said cheque the complainant contacted O.P.1 by placing his grievance in settlement of claim and the O.P.1 gave evasively replies and stated that they are not responsible for the settlement of claim and O.P. 2 is only competent to settle the claim.
4. The complainant also stated that he addressed a letter to O.P. 2 on 9-6-2012 by disallowing of Rs. 49,259/- under the heads of (1) room rent, (2) medicines, (3) procedures and (4) miscellaneous. But the complainant not received any reply and contacted several times to O.P.2 by phone for disallowing the huge amount was not disallowed in the previous year. But the O.P. 2 also gave evasive replies. Hence, this complaint.
5. After registered the case notices were issued to O.P’s and the same is served to them. The O.P.1 filed counter and O.P.2 called absent and set exparte.
6. The O.P.1 filed counter and admitted that the complainant paying the premium since 2007 under mediclaim policy for an assured sum of Rs. 1,00,000/- from O.P.1, in turn appointed 3rd party administrator (PPA) i.e. O.P.2 for dealing claims of the policy holders under IRDA (3rd party administrators Health Services) Regulation 2001 and also admitted the O.P.2 was settled complainant’s claim for hospitalization for Rs. 55,989/- as against the claimed amount of Rs. 67,296/- as per norms of settlement under the policy No.61120034110100000181 for the period from 8-12-2011 to 7-12-2012.
7. The O.P.1 also admitted that the another policy was issued to the complainant, policy bearing No. 61120034120100000187 for the period from 8-12-2012 to 7-12-2013 for an assured sum of Rs. 1,00,000/- under mediclaim policy. Again the complainant submitted a claim to O.P.2 against the admission into the hospital between 29-2-2012 to 29-3-2012 the claim of the complainant was registered vide claim No. 61690 after scrutiny and as per the policy norm expenses incurred for ayurvedic treatment. The admissible expenditure for ayurvedic treatment is up to 25% of sum insured. In this case maximum admissible amount is paid i.e. as the assured sum is Rs. 1,00,000/- out of which 25% i.e. 25,000/- is settled and paid to the complainant. The O.P.2 sent a cheque bearing No. 223889, dt. 29-5-2012 for Rs. 25,000/- only as against the claim of Rs. 74,259/- thereby disallowed amount of Rs. 49,259/- as per rules. The reason for difference amount among settled amount two claims is that the SI for the policy period 09-11-2010 to 08-11-2011 is Rs. 2,00,000/- (+Rs.27,500/- C.B) but for the policy period 09-11-2011 to 08-11-2012 SI is Rs. 1,00,000/- only (No CB) so the claim is settled as per norms 25% SI i.e. 25,000/- only. Therefore, this O.P. humbly prays that the Hon’ble forum may be pleased to dismiss the complaint in the interest of justice.
8. To prove his case the complainant filed an affidavit along with documents which are marked as Ex. A1 to A7 and Ex. B1 is marked on behalf of O.P.1.
9. On the basis of the above pleadings the following points are settled for determination.
i. Whether the complainant is eligible for compensation as prayed by him?
ii. Whether there is negligence or deficiency of service on the part of opposite parties?
iii. To what relief?
10. Point Nos. 1 & 2. The contention of the complainant is that the complainant paid premium of Rs. 1,633/- since 2007 under mediclaim policy for a sum of Rs. 1,00,000/- to the O.P.1, who inturn appointed 3rd party administrator (PPA) i.e. O.P.2 and O.P.2 dealing the claims of the Mediclaim policy. O.P.1 issued policy bearing No. 61120034110100000181 for a period from 8-12-2011 to 7-12-2012 and the complainant admitted as inpatient at KOTAKAL ARYAVAIDYAL SALA AYURVEDIC HOSPITAL AND RESEARCH CENTER, KOTTAKAL, Kerala. During the subsistence of the policy 30-4-2011 to 30-5-2011 and spent an amount of Rs. 67,293/- towards hospitalization and he submitted all the relevant documents to O.P.2 and the O.P.2 disallowed Rs. 11,304/- and sent a cheque bearing No. 794878 for Rs. 55,988/- as against the claim of Rs. 67,293/- and the complainant paid Rs. 2,079/- as premium towards continuation of the aforesaid policy for the period from 8-12-2012 to 7-12-2013 to O.P.1 and O.P.1 issued policy bearing No. 61120034120100000187 for a sum of Rs. 1,00,000/- under mediclaim policy. After that, he felt ill and got admitted as inpatient aforesaid hospital from 29-2-2012 to 29-3-2012 and spent Rs. 75,049/- towards hospitalization. The complainant submitted original bill and other support documents for processing and settlement of the claim. The O.P.2 astonishingly settled the claim for Rs. 25,000/- and sent a cheque as against the claim of Rs. 74,259/- thereby disallowed a huge amount of Rs. 49,259/-.
11. On the other hand the main contention of the O.P1 is that the admissible expenditure for ayurvedic treatment up to 25% of sum assured. In this case maximum admissible amount is paid i.e. as the assured sum is Rs. 1,00,000/- out of which 25% i.e. 25,000/- is settled and paid to the complainant. The O.P.2 sent a cheque for Rs. 25,000/- only as against the claim of Rs. 74,259/- thereby disallowed an amount of Rs. 49,259/- as per rules. Another contention of O.P.1 is that the reason for difference amount among settled amount of two claims is that the S.I for the policy period 09-11-2010 to 8-11-2011, Rs. 2,00,000/- (Rs. 27,000/- C.B) but the policy period 9-11-2011 to 8-11-2012 S.I is Rs. 1,00,000/- only (no C.B). So the claim is settled as per norms 25% S.I i.e. Rs. 25,000/- only.
12. It is an admitted fact that the complainant paid an amount of Rs. 1,633/- premium under mediclaim for a sum of Rs. 1,00,000/- to the O.P.1 as seen from Ex. A1 and the complainant admitted as in patient at aforesaid hospital and spent an amount of Rs. 67,293/- as seen Ex. A2. As seen Ex. A3 the O.P.2 settled the claim for Rs. 55,988/- to the complainant. As seen Ex. A4 it is clearly shows that the complainant paid Rs. 2,079/- towards premium and continuation of the policy for the period from 8-12-2012 to 7-12-2013 to O.P.1 for a sum of Rs. 1,00,000/- under the mediclaim policy and he admitted in the aforesaid hospital from 29-2-2012 to 29-3-2012. As seen under Ex. A5. As seen Ex. A6 the O.P.2 settled the claim for Rs. 25,000/- against the claim of Rs. 74,259/- thereby disallowed an amount of Rs. 49,259/-.
13. In this case the main contention of the complainant is that he paid premium of Rs. 1,633/- for mediclaim policy for a sum of Rs. 1,00,000/- policy bearing No. 61120034110100000181 and he admitted in the above said hospital and incurred Rs. 67,239/- towards hospitalization and the O.P.2 settled the claim of Rs. 55,989/-, which is disallowed amount of room rent and miscellaneous. After that the complainant paid Rs. 2,079/- towards premium and continuation of the aforesaid policy for a sum of Rs. 1,00,000/- and he admitted in the same above hospital and he spent Rs. 75,049/- towards hospitalization and the O.P.2 settled the claim for Rs. 25,000/- as against the claim of Rs. 74,259/- thereby disallowed a huge amount of Rs. 49,259/-. In this regard the O.P.1 stated that in the counter that the reason for the difference of amount settled two claims is that the S.I for the policy period from 9-11-2010 to 8-11-2011 is Rs. 2,00,000/- but the policy period from 9-11-2011 to 8-11-2011 is Rs. 1,00,000/-. So the claim is settled as per norms of 25%. As seen Ex. B1 mediclaim policy 2007 mentioned the terms and conditions are same and have not changed for both claims. In this regard, we have observed Ex. A1 and Ex. A4 is clear that the policy sum assured of Rs. 1,00,000/- and it is also noticed that in the first policy i.e. Ex. A3 the O.P.2 disallowed only room rent and miscellaneous and medicine by hospital disallowed only Rs. 18/-, which is the total bill of Rs. 11,117/-. As seen Ex. A6, we have observed that the O.P.2 disallowed Room rent miscellaneous, medicine by hospital procedures. The procedures which is not mentioned in the first claimed policy and not disallowed any procedure amount and also disallowed total medicine by hospital amount of Rs. 17,537/- which is incurred by the complainant.
14. As above discussion, we are opined that the O.P’s not justified to the complainant by disallowing the medicine by hospital and procedures which is not disallowed in the first claim. Hence, the contention of the O.P’s not tenable. As such the answer is in favour of the complainant. The complainant is eligible for medicines by hospital and procedure amount under Ex. A6.
15. Point No. 3 In the result, the complaint is allowed, directing the opposite parties 1 & 2 to pay Rs. 31,022/- towards medicines and procedures bill (Rs. 17,537/- + Rs. 13,485/-) to the complainant, pay Rs. 5,000/- towards deficiency of service and mental agony, pay Rs. 2,000/- towards cost of the complaint to the complainant, within 45 days of date of receipt of the orders.
Dictated to the Stenographer, transcribed by him, corrected and pronounced by us in the open Forum, this the 3rd September, 2014
MEMBER PRESIDENT FAC
APPENDIX OF EVIDENCE
Witnesses examined.
For Complainant NIL For Respondents : NIL
Exhibits marked for Complainant: -
Ex. A1 P/c of previous policy 31120034110100000181 for the period from
8-12-2011 to 07-12-2012.
Ex. A2 P/c of previous hospitalization bill No. 651, dt. 29-5-2011.
Ex. A3 P/c of settlement claim in respect of bill No. 651, dt. 13-9-2011.
Ex. A4 P/c of present policy 61120034120100000187 for the period from
8-12-2012 to 7-12-2013 for a assured sum of Rs. 1,00,000/- under
Mediclaim policy (hospitalization benefit policy).
Ex. A5 P/c of Hospitalization bill No. 4319, dt. 28-3-2012 for Rs. 74,259/-.
Ex. A6 P/c of settlement claim in respect of bill No. 4319, dt. 28-3-2012
for Rs. 25,000/- as against total bill of Rs. 74,259/-.
Ex. A7 P/c of letter addressed by the complainant to respondent No. 2,
dt. 9-6-2012.
Exhibits marked for Opposite parties: -
Ex. B1 Copy of medical policy (2007) issued by the New India Assurance Co. Ltd.,
Mumbai.
MEMBER PRESIDENT FAC
Copy to :-
1) Sri Md. Ali Khan, Advocate for complainant.
2) Sri K. Guru Murthy, Advocate for O.P.1.
3) Good Health Plan Ltd., H.O. Plot No. 49, Nagarjuna Hills, Panjagutta, Hyderabad, A.P. Rep. by its M.D
B.V.P.
