This C.C came before us for final hearing, in the presence of Sri M. Durgaiah, Advocate for the complainant; Sri G. Sita Rama Rao, Advocate for opposite party No.1 and 3; and of Sri B. Tirumal Rao, Advocate for opposite party No.4; opposite party No.2 notice not returned; Upon perusing the material papers on record; upon hearing, and having stood over for consideration, this Forum passed the following:-

O R D E R

(Per Sri R. Kiran Kumar, Member)

This complaint is filed under section 12-A of the Consumer Protection Act, 1986.  2.

2.       The averments made in the complaint are that the complainant has worked as corporate employee, designated as Project Engineer in the Wipro Technologies, survey No.203/1, Manikonda Village, Gachibowli, Hyderabad during the period from 27-08-2007 to 22-06-2009 and she has taken corporate policy No.4016/0001719, MA-ID 4001512943 of Health Insurance from opposite party No.1 for indemnity of Rs.2,00,000/- policy through employer and the opposite party No.2 is a co-associate / investigator, opposite party No.3 is a branch office at Khammam town and District and opposite party No.4 is one of the networking hospitals of opposite party No.1, where the complainant has taken treatment.  The complainant submitted that the premium will be deducted from the monthly salary of the complainant through the employer by an agreement from the date of appointment is a strict policy system to indemnify the expenditures on medical treatment of the policy given by the opposite parties.  The complainant further submitted that while she has been working in the said Wipro Technologies, she has suffered with mild fever on 19-03-2009 in the evening hours, she had travelled from Hyderabad to khammam on that evening she reached at Khammam around 9:30 night hours, since she was being suffering from serious fever she has joined in the hospital of opposite party No.4 and seeing her serious condition, the duty Doctor G. Venkateswarlu admitted her in to ICU and conducted necessary tests and tests revealed that she has been suffering from platelets count down in her Blood and she was under the observation on treatment of the doctors for 10 days from 19-03-2009 to 29-03-2009 and the hospital charged Rs.91,959/- and after payment, the complainant discharged from the hospital along with all material papers. 

          The complainant further submitted that she had submitted all hospital payment bills  to the opposite party No.1 through employer Wipro Technologies for reimbursement of aforesaid amount of Rs.91,959/-, but the opposite party No.2 not acted properly and their acts all are perverse to the material papers submitted by the complainant and they made table investigation report for the denial of the claim and consequently the opposite party no.1 come to denied, complainants right to reimbursement claim amount of Rs.91,959/- by reason of opposite parties own sake on cheating ground without applying their mind on material papers saying the reason that complainant was on duty on 19-03-2009 up to 4:30 PM.  The complainant further submitted that by the time when she had joined the hospital by her relative to save her life in the emergency circumstances, she is not in a position to find the cyber café to obtain the e-health card and thereby to submit the same to hospital authorities at the time of joining.  The complainant further submitted that the assess of joining timings in the hospital is criteria but not the opposite parties self styled thinking of flimsy grounds whims and fancies opposed to public policy and the reasons stated by the opposite parties are quite illegal.  The complainant further submitted that the opposite parties acts are intended to cause loss to the complainant against the security benefits of insurance policy and they are in return illegally commented ‘fraudulent’ against the complaint on her repeated contacts with the opposite parties.  The complainant further submitted that as the opposite parties caused untold mental agony, physical pain and intended to cause economical loss to her claim of Rs.91,959/-, she filed this complaint for Rs.1,00,000/- as compensation from the opposite parties for their non response, nonpayment of amounts for said bill pertaining her treatment, delayed vexatious allegations by denying claim.  The complainant further submitted that as the opposite parties failed to settle the claim she got issued the notice on 03-08-2009 calling upon the opposite parties to pay the claim amount, inspite of receipt of said notice the opposite party No.1 did not choose to issue reply notice and the opposite party No.2 issued a false reply notice dt. 16-09-2009 intended to opposite the name of complainant as such the complainant filed this present complaint.

3.       On behalf of the complainant the following documents have been filed and marked as Ex.A1 to A7.

Ex.A-1:-Photocopy of policy No.4016/0001719, MA-ID 4001512943, Emp No. 151236 along with claim acknowledgement letter.

Ex.A-2:-Photocopy of Prescription by Dr. G. Venkateswarlu, Sri Raksha Hospitals, Khammam along with medical bills (Nos.11)

Ex.A-3:-Photocopy of Diagnostic Reports (Nos.17).

Ex.A-4:-Photocopy of Patient Discharge Summary.

Ex.A-5:-Photocopy of acceptance of Resignation letter issued by Wipro Technologies, dt. 22-06-2009.

Ex.A-6:-Office copy of legal notice.

Ex.A-7:-Photocopy of Daily Delivery Sheet (DRS), dt.05-08-2009 served against opposite party No.1.

Ex.A-8:-Photocopy of Courier Receipt, (Nos. 2) dt. 03-08-2009.

Ex.A-9:-Photocopy of ION statement, dt. 08-06-2009 issued by Medi Assist India TPA Pvt. Ltd.

Ex.A-10:-Photocopy of reply issued by Medi Assist India TPA Pvt. Ltd., dt. 16-09-2009.

Ex.A-11:- Photocopy of List of Cashless Hospitals in Khammam Area.

4.       On receipt of the notice, the opposite parties appeared through their counsel and filed counter.  In their counter opposite party No.1 and 3 submitted that the insurance police between the insurer and the insured represents a contract between the parties, since the insurer undertakes to compensate the loss suffered by the insured on account of risk covered by the insurance policy, the terms of the agreement have to be strict construed to determine the extent of liability of the insurer and the insured cannot claim anything more than what is covered by the insurance policy.  The opposite parties further submitted that insurance is a contract of indemnity, it has to be viewed as a normal contract as per the Indian Contract Act, any violation of the insurance contract by the parties to the contract of Insurance, the contract becomes void and in such an event the insurance company would not be liable to answer the claim of the complainant.  The opposite party No.1 and 3 denied all the averments made by the complainant in her complaint.  The opposite party No.1 and 3 further submitted that the complainant obtained policy at the office of opposite party No.1, which is at Hyderabad, it clearly shows that the entire transaction took place at Hyderabad, as such the complainant is not entitled to file this complaint before this Forum, as such the Forum has no jurisdiction to entertain this complaint and prayed to dismiss the complaint without going into merits. The opposite party No.1 and 3 further submitted that as per the version of the complainant, she alleged have to took treatment for 10 days i.e. from 19-03-2009 to 29-03-2009, but the records clearly shows that the complainant attended duty on 19-03-2009 up to 4:30 PM, she failed to explain at what time, she fell ill on 19-03-2009 and what time she admitted in the hospital, it clearly shows that the complainant suppressed the material facts and filed the complaint with a mollified intension to have wrongful gain from the opposite parties,  the complaint against opposite parties is a vexatious one and hence the same is prayed to dismiss with exemplary costs.

5.       On behalf of the opposite parties No.1 and 3 the following documents are filed and marked as Exhibits B1 to B

Ex.B-1:- True Copy of Group Health (Floater) Insurance Policy.

Ex.B-2:- Letter addressed by Medi Assist India TPF Pvt. Ltd., to opposite party No.1, dt. 09-08-2010.

Ex.B-3:- Photocopy of Daily Attendance Report (15-03-2009 to 30-03-2009) of Emp No.151236 at Manikonda 2.

Ex.B-4:- Certified copy of Admission History and Physical Assessment Form, issued by opposite party No.4.

Ex.B-5:- Inpatient Medical Chart, issued by opposite party No.4.

Ex.B-6:- Patient Discharge Summary, issued by Sri Raksha Hospitals, Khammam.

6.       The opposite party No.4 in their counter admitted that the complainant was admitted as in-patient in the hospital of the opposite party No.4 on 19-03-2009 at 10:00 AM and she was discharged on 29-03-2009, in this regard the hospital has issued discharge summary and medical bills for her treatment as in-patient.  The opposite party No.4 further submitted that the other averments made in complaint are not within their per view and they were made as proforma party and prayed to dismiss the complaint with exemplary costs.  

7.       On behalf of the opposite party No.4 ICU/MLC Case Sheet with IP No.966, pertaining to SK. Hussain, R/o. Khammam is filed and the same is marked as exhibit B7.

8.            Written arguments of complainant and opposite party No.1 filed.

9.            Heard Oral Arguments.

10.     Upon perusing the material papers on record, now the point that arose for consideration is,

Whether the complainant is entitled for the claim?

Point:-

          The case of the complainant is that, she has worked as corporate employee, designated as Project Engineer in the Wipro Technologies,  Hyderabad during the period from 27-08-2007 to 22-06-2009, during that period she has taken corporate policy No.4016/0001719, MA-ID 4001512943 of Health Insurance from opposite party No.1 for indemnity of Rs.2,00,000/- policy through employer and the opposite party No.2 is a     co-associate / investigator.  According to the complainant, she had suffered with mild fever on 19-03-2009, in the evening hours, she travelled from Hyderabad to khammam and reached at Khammam at around 9:30 night hours, since she is being suffering from serious fever, has joined in the hospital of opposite party No.4 and seeing the duty Doctor G. Venkateswarlu admitted her in to ICU and conducted necessary tests, tests revealed that she has been suffering from platelets count down in her Blood and she is under the observation for 10 days from 19-03-2009 to 29-03-2009 and the hospital charged Rs.91,959/- and after payment, the complainant discharged from the hospital. 

          According to the complainant, she had submitted her claim through her employer employer Wipro Technologies to opposite party No.1 for reimbursement of the claim amount, but the opposite party No.2 not acted properly and made table investigation report for the denial of the claim, saying the reasons that the complainant was on duty on 19-03-2009 up to 4:30 PM.  As the opposite parties rejected the claim of the complainant in flimsy grounds caused mental agony and economical loss to her a claim of Rs.91,959/-, as such the complainant approached the Forum for redressal. 

In this case counsel for opposite party No.1 and 3 filed exhibits B-1 to B-7  wherein, exhibit B-3 is the daily attendance report from 15-03-2009 to 30-03-2009 pertaining to complainant, as per exhibit B-3 the complainant (151236) is in Manikonda-2 on 19-03-2009 from 09:08 hours to 19:11 hours and also on 26-03-2009 from 10:25 hours to 14:44 hours.  As per exhibit B-4, she has been admitted as inpatient in ICU Ward at 10:30 AM on 19-03-2009 vide IP/ID No.966 and also as per medication and treatment record she is admitted as in-patient at 11:00 AM on 19-03-2009.  After observing the above record, Forum issued notice to opposite party No.4 directed to produce the entire treatment record in original i.e. case sheet, discharge summary etc., pertaining to Sindu Rasuru Bhaskaradu vide IP.No.966, dt. 19-03-2009. Receiving notice from this Forum the opposite party No.4 appeared and filed counter, stating that the complainant was admitted as inpatient in the hospital of opposite party No.4 on 19-03-2009 at 10:00AM and she was discharged on 29-03-2009, in this regard the hospital has issued discharge summary and medical bills for the treatment as in-patient. And also the opposite party No.4 filed (exhibit B7) ICU/MLC case sheet IP No.966 dt, 18-03-2009 pertaining to one SK. Hussain, R/o. Khammam. 

From the material and documents available on record, we observed that the complainant failed to produce the original ICU/MLC case Sheet which is necessary to settle her claim.  Also the complainant failed to disprove the contention and documents filed by the opposite party No.1, 3 and 4.  As per the original ICU/MLC IP.No.966 (Exhibit B-7) submitted by the opposite party No.4 the complainant had not taken treatment in the hospital of opposite party No.4.  From the above we observed that the complainant filed vexatious complaint for wrongful gain from the opposite party No.1 insurance company by producing false documents.  In Haryana Urban Development Authority & Anr. Vs. Vasundara Cooperative Group House Society Ltd., III (2014) CPJ 86 (NC) the Hon’ble National Commission observed that vexatious and unnecessary litigations clogging wheels of justice, for too long making it difficult for courts and tribunals to provide easy and speedy access to justice to bonafide and needy litigants.  It appears to us that the only intention of the complainant is just to grab money from the opposite party No.1, under these circumstances, this point is answered against the complainant.

8.       In the result, the complaint is dismissed with costs.  The complainant is directed to pay an amount of Rs.10,000/- to the opposite party No.1 for the vexatious complaint, within one month from today, failing which the amount shall carry interest @ 9% per annum till realization.

          Typed to dictation, corrected and pronounced by us in the Open Forum on this the 30^th day of August, 2016.

FAC President         Member

District Consumer Forum

KHAMMAM

APPENDIX OF EVIDENCE

WITNESSES EXAMINED:-

For Complainant:-                                                     For Opposite party:-   

       -None-                                                                           -None-

DOCUMENTS MARKED:-

For Complainant:-                                                     For Opposite party:-   

FAC President        Member

District Consumer Forum

KHAMMAM