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.

Saturday, 31^st May 2014

CONSUMER COMPLAINT No.  54/ 2013

Samudrala Raghuramaiah, S/o Late Pedda Subbaiah,

aged 68 years, Hindu, Business, Residing at D.No. 14/204,

Sastry Nagar, Badvel town, Kadapa District.                             Complainant.

Vs.

1)   The New India Assurance Co. Ltd., Rep. by its

      Divisional Manager, Divisional Officer,

      Nagarajupeta, Kadapa city.

2)   M/s Good Health Plan Ltd., Rep. by its Manager,

      Plot No. 49, Nagarjuna Hills, Panjagutta,

      Hyderabad – 500 082.                                                       Respondents.

This complaint coming on this day for final hearing on 30-5-2014 in the presence of Sri M.D. Alikhan, Advocate for complainant and Sri D.V.S. Prasad, Advocate for Respondents and upon perusing the material papers on record, the Forum made the following:-

O R D E R

(Per Smt. K. Sireesha, President FAC),

1.             Complaint filed under section 12 of the C.P. Act 1986.

2.             The brief facts of the complaint are as follows:-   The complainant and his wife Lakshmi Kanthamma, have been paying the premium since 2007 under Janata Medi claim policy (Hospitalization Benefit Policy) from the R1, who inturn appoint 3^rd party administrator (T.P.A) for dealing the claim of the policy holders under the above captioned policy.  

3.             The complainant obtained policy bearing No. 611200341106000000066 valid from 2-2-2014 to 01-2-2013 issued by the R1 under Janata Medi claim policy for himself and his wife S. Lakshmi Kanthamma.  The complainant is suffering with diabetic, which was disclosed to R1, who collected additional premium of Rs. 460/- for diabetes and that the complainant paid total premium of Rs. 4,826/- under the above policy.  The R1 appointed the R2 as 3^rd party administrator (TPA) for dealing the above policy.  The R2 has sent an identity card for the complainant and his wife. 

4.             The complainant was suffering with burning sensation and pain in both the legs for the past 2 months, pain in both hands, tightness of chest and difficulty in breathing, as such the complainant went to Dr. Mohan’s Diabetic Specialist Center, Chennai on 1-10-2012  and the doctors after due Diagnosis, advised the complainant to join as inpatient in their hospital for curing the problem and the complainant admitted in the above hospital as advised by the doctors.  The complainant got admitted in the said hospital on 01-10-2012 and got discharged on 3-10-2012.  The complainant took the required treatment with Dr. Vignesh and Dr. Parthasarathy.  During the course of the complainant’s admission as inpatient, several tests were conducted as advised by the doctors and purchased medicines, as prescribed and the complainant spent Rs. 2,104/- towards medicines, Rs. 2,962/- was spent towards diagnosis tests, Rs. 790/- was paid on 1-10-2012 vide bill No. 2959.  The said hospital charged                           Rs. 18,090/- as inpatient bill for the treatment taken by the complainant vide bill No. 29458 dt. 3-10-2012.  The complainant intimated his inpatient treatment to the R2 while he was under treatment.  After discharge from the hospital, the complainant intimated his treatment to the R1, who issued a claim form which was duly filled by the complaint by enclosing all the original bills referred above and the R1 inturn sent the same to the R2 for settlement of claim. 

5.             The complainant approached the R1 and contracted the R2 over phone for settlement of his claim but the respondents are very adamant and failed to settle the genuine claim and the respondents are postponing the settlement for one or other reasons.  There is deficiency of service on the part of the respondents who failed to settle the claim.  The complainant has no other option except to approach this Hon’ble forum. 

6.             The cause of action arose when the R1 issued policy bearing No. 61120034110600000066 valid from 2-2-2012 to 01-2-2013 under Janatha Medi claim policy (Hospitalization benefit policy) for the complainant and his wife Lakshmikanthamma and that the R1 collected additional premium of Rs. 460/- for the Diabetic disease suffering by the complainant and that the complainant paid premium of Rs. 4,826/- under the said policy and that the R1 appointed R2 has their TPA for the above said policy and that the complainant was suffering with burning sensation and pain in both the legs for the past 2 months, pain in both the hands, tightness of chest and difficulty in breathing as such he approached Dr. Mohan Diabetic Specialization Centre, Chennai on 01-10-2012 and that the complainant on the advice of the doctors admitted as inpatient on 01-10-2012 and discharged on 3-10-2012 and during the said period of inpatient treatment, several tests were conducted by the hospital which was charged Rs. 2,962/- and that medicines for Rs. 2,104/- were purchased and that Rs. 790/- was paid on 1-10-2012 vide bill No. 2952 and that the final bill was issued by the hospital for Rs. 18,090/- and that the complainant intimated inpatient treatment to both the respondents and that a claim form issued by the respondent No. 1 was submitted by the complainant along with all the original bills referred above, who in turn sent the same to R2 and that both the respondents failed to respond for the genuine claim of the complainant and that there is deficiency of service on the part of the respondents, which all took place within the territorial jurisdiction of this Hon’ble forum to try this complaint.   A court fee of Rs. 100/- is paid through I.P.O.

7.             Therefore, prayed that the Hon’ble forum may be pleased to pass an order in favour of the complainant and against the respondents jointly and severally (a) to  pay Rs. 23,946/- which the complainant spent towards his inpatient treatment during the period 01-10-2012 to 3-10-2013 at Dr. Mohan, Diabetes specialties Center, Chennai, (b) to pay Rs. 50,000/- towards mental agony, (c) to pay costs of this complaint and for such other reliefs or reliefs as the Hon’ble forum deems fit and proper in the circumstances of the complaint in the interest of justice.

8.             Counter filed by R1 and the same was adopted by R2 with memo.   The complaint filed by the complainant is neither just nor maintainable either in law or on facts.   

9.             The complainant is put to strict proof of all the allegations made in the complaint except those that are not specifically admitted herein.

10.            It is true that the complainant obtained the policy bearing No. 611200/34/11/06/00000066 valid from 2-2-2012 to 01-2-2013 under Janatha Medi claim policy for himself and his wife.  This respondent appointed R2 has 3^rd party Administrator (TPA for dealing the above policy, who is alone bestowed with the responsibility o9f issuing identity cards, correspondence with the insured  cases of any claim and it settlement.  Except obtaining the premium and issuance of policy by this respondent, all other subsequent incidents are all dealt and looked after by R2. 

11.            It is true that the complainant approached this respondent for settlement of his claim with regard to his inpatient treatment at Dr. Mohan’s Diabetic Specialist Centre, Chennai for burning sensation and pain in both his legs, thereupon this respondent issued claim form which was got filed and the relevant bills were submitted to this respondent and inturn all the same were forwarded to R2 for settlement of the claim.

12.            It is submitted that the R2 scrutinized the documents furnished by the complainant and the nature of treatment given at Dr. Mohan’s Diabetes Specialist Centre, Chennai opined and concluded that the treatment given during hospitalization can be given as outpatient treatment and that there is no need or necessity to take the treatment as inpatient and spent such amount as claimed.

13.            This respondent intimated the above fact to the complainant that the treatment which he took can be taken as outpatient treatment and that for the said reason his claim is not maintainable. 

14.            It is submitted that only for the purpose of reimbursement and having aware of the existence of the above said policy the complainant though not necessary took treatment as inpatient, in spite which the treatment can be obtained as outpatient.

15.            It is submitted that there is deficiency of service on the part of this respondents and the non-maintainability of the claim of the complainant was informed, inspite which the present complaint is filed only two defame.

16.            Viewed from any angle there are no merits in this complaint and is not entitled for the prayers sought.   Therefore prayed that the Hon’ble court may be pleased to dismiss the complaint in the interest of justice.

17.            On the basis of the above pleadings the following points are settled for determination. 

1. Whether the complainant is entitled to the relief as prayed by him or not?
2. Whether there is negligence or deficiency of service on the part of the Respondent?
3. To what relief?

18.            On behalf of the complainant Ex. A1 to A8 were marked.

19.            Point Nos. 1 & 2.   It is true that the complainant obtained policy bearing No. 611200/34/11/06/00000066 valid from 2-2-2012 to 01-2-2013 under Janatha Medi claim policy for himself and his wife from R1 under Ex. A1.   The respondent being issued original identity card in favour of the complainant under Ex. A2.   It is very clear from Ex. A3 that the complainant had admitted at Dr. Mohan’s Diabetic Specialist Center, Chennai on 1-10-2012 and discharged on 3-10-2012.  Ex. A4 and A5 are original bills of the complainant from the hospital.  Ex. A6 is the claim form submitted by the complainant to the respondents.  Ex. A7 clearly shows that the complainant had spent amount as inpatient in the hospital.  Ex. A8 is also original bill filed by the complainant which was issued by the hospital.  From the above all documentary evidence it is very clear that the complainant had admitted Dr. Mohan’s Diabetic Specialist Center, Chennai for his illness and had treated there from 01-10-2012 to                      3-10-2012.  The hospital had provided the original bills to the complainant.   The complainant properly produced the same to the respondents for settlement of his claim but the respondents did not turned up.  Generally nobody will have interest to join in the hospital as inpatient without any illness.  If any treatment will be available as outpatient everybody will willing for that treatment only.   So from all the above documents it is very clear that the complainant had admitted in the hospital for his ailment and he was treated there properly and he submitted all original bills.  The respondents utterly failed to perform their duty for settlement of the claim.  So there is deficiency of service and negligence on the part of the respondents 1 & 2 jointly and severally.  At the same time the complainant is eligible for compensation as prayed by him. 

20.            Point No. 3 In the result, the complaint is allowed, directing the respondents 1 & 2 to pay an amount of Rs. 23,946/- (Rupees Twenty Three Thousand Nine Hundred and Forty Six Only) towards the inpatient treatment costs, Pay Rs. 10,000/- towards mental agony (Rupees Ten Thousand Only), pay Rs. 2,000/- towards costs (Rupees two thousands only) of the complaint to the complainant, within 45 days of date of receipt of orders.

                Dictated to the Stenographer, transcribed by him, corrected and pronounced by us in the open Forum, this the 31^st May 2014

MEMBER                                                                                PRESIDENT FAC

APPENDIX OF EVIDENCE

Witnesses examined.

For Complainant        NIL                                   For Respondents :     NIL      

Exhibits marked for Complainant  : -

Ex. A1       P/c of policy bearing No. 611200341106000000066 valid from                           

                2-2-2012 to 1-2-2013 issued by R1.

Ex. A2       Original identity card issued by the R2 in favour of the complainant. 

Ex. A3       P/c of the discharge summary issued by Dr. Mohan’s Diabetic

                Specialties Centre, Chennai.

Ex. A4       P/c of inpatient bill No. 29485, dt. 3-10-2012 for Rs. 18,090/-.

Ex. A5       P/c of bill dt. 3-10-2012 for Rs. 2,104/-.

Ex. A6       P/c of claim form.

Ex. A7       P/c of check list dt. 3-10-2012.

Ex. A8       P/c of bill dt. 01-10-2012 for Rs. 790/-.

Exhibits marked for Respondents: -                 NIL  

MEMBER                                                                               PRESIDENT FAC

Copy to :-

1. Sri M.D. Ali Khan, Advocate for complainant.
2. Sri D.V.S. Prasad, Advocate for Respondents.

B.V.P.