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 28th day of November, 2006
CC No. 138/2006
P.C. Eswara Reddy, S/o. P.V. Subba Reddy, Age 64 years,
Plot No. 201, Chandra Apartments, Sapthagiri Nagar, Kurnool.
. . . Complainant
-Vs-
1.The Branch Manager,
Andhra Bank, Budhawar Pet Branch, Kurnool.
2.The Divisional Manager, United India Insurance Company Ltd.,
Divisional Office - IV, 2nd floor, Posnett Bhavan, Tilak Road, Hyderabad. . . . Opposite parties
This complaint coming on this day for orders in the presence of Sri P. Siva Sudarshan, Advocate, Kurnool for complainant and opposite parties No.1 and 2 called absent set exparte, and stood over for consideration till this day the forum made the following:-
O R D E R
(As per Smt C.Preethi, Hon’ble Lady Member)
1. This consumer complaint of the complainant is filed under section 11 and 12 of C.P. Act, 1986, seeking a direction on opposite parties to pay Rs. 11,984/- towards reimbursement of medical expenses with 24% interest per annum, Rs. 10,000/- towards mental agony, costs of the complaint and any other relief or reliefs which the complainant is entitle in the circumstances of the case.
2. The brief facts of the complainant’s case is that the complainant is the holder of AB Arogyadaan /SB account introduced by opposite party No.1 and 2. The complainant joined the said scheme on 14.7.2004 by paying Rs.838/- towards premium and a policy bearing No. 050400/48/04/00350 for Rs.50,000/- was issued by opposite party No.2. As per the policy conditions if the policy holder incurred hospitalization expenses for illness/ decease or injury sustained, the opposite party No.2 has to reimburse the said hospitalization expenses. The complainant joined Care Hospital, Banjara Hills, Hyderabad for treatment of Heart decease on 24.2.2005, after discharge from the hospital, the complainant submitted claim form along with required documents to opposite party No.2 for reimbursement, but the opposite party No.2 on 11.3.2005 replied stating that the present hospitalization is for management of an ailment which is related to a pre existing condition clause 4.1. Hence, they did not consider the claim of the complainant and repudiated the same. The complainant submits that as per policy conditions he is entitle for reimbursement and the opposite parties without any valid reason repudiated his claim and hence, resort to the forum for redressal.
3. In substantiation of his case the complainant relied on the following documents Viz (1) certificate of insurance issued by opposite party No.2 to the complainant (2) attested xerox copy of consultation receipt of Care Hospital dated 23.2.2005 (3) attested xerox copy of out patient bill dated 23.2.2005 (4) attested xerox copy of receipt dated 24.2.2005 (5) attested xerox copy of receipt dated 25.2.2005 (6) attested xerox copy of cash memo dated 25.2.2005 (7) attested xerox copy of out patient bill cum receipt dt 27.2.2005 (8) attested xerox copy of care hospital bill (9) repudiation letter dated 11.3.2005 and (10) discharge summary card issued by Care Hospital, besides to the sworn affidavit of the complainant in reiteration of his complaint averments and the above documents are marked as Ex A.1 to A.10 for its appreciation in this case.
4. The opposite parties in spite of receipt of notice as to this case of the complainant did not appear before the Forum and remained absent thought out the case proceedings and were made exparte?:
5. Hence, the point for consideration is to what relief the complainant is entitled alleging deficiency of service on part of opposite parties:-
6. It is a case of the complainant that on14.11.2004 he joined AB Arogyadaan/ SB Account introduced by opposite party No.1 and 2 and paid Rs.838/- towards premium and the certificate of insurance was issued by opposite party No.2 vide Ex A.1, the policy commenced from 16.7.2004 to 8.6.2005. Thereafter, on 24.2.2005 the complainant was hospitalized at Care Hospital and taken treatment for Heart decease for two days as in patient. The Ex A.10 is the discharge summary issued by Care Hospital to the complainant mentioning the admission date as 24.2.2005 and discharge date as 26.2.2005 and the complainant has taken treatment for the said period from Dr A.V. Anjaneyulu. Thereafter, the complainant submitted claim form along with relevant documents to opposite party No.2 for reimbursement of expenses incurred during the said treatment at Care Hospital totaling Rs.11,984/-. But the dismay of the complainant the opposite parties vide Ex A.9 letter dated 11.3.2005 repudiated the claim of the complainant stating the present hospitalization is for management of an ailment which is related to a pre existing condition clause 4.1. The said clause 4.1 as mentioned in the policy issued to the complainant vide Ex A.1 says that Domiciliary/out patient treatment, but pre existing decease as mentioned in the reputation letter (Ex A.9) is not mentioned there, hence, the reputation by the opposite parties is baseless and untenable and cannot be taken into consideration. The Ex A.2 is the attested xerox copy of consultation fee dated 23.2.2005 for Rs.225/-. The Ex A.3, Ex A.4, Ex A.5 and Ex A.8 are the attested xerox copies of bills issued by Care Hospital for Rs.860/-, Rs.7,500/-, Rs.444/- respectively. The Ex A.6 is the attested xerox copy of Cash memo dated 25.2.2005 as to the purchase of medicines worth Rs.130.55/- by the complainant. The Ex A.7 is the attested xerox copy of out patient bill cum receipt dated 27.2.2005 for Rs. 1,000/- issued by Care Hospital towards CD recording. The above material as not rebutted by opposite parties hence, they remain admitted. The material placed by the complainant in uni-tone says that he has incurred expenditure of Rs.11,984/- towards medical expenses and as per Ex A.1 (certificate of insurance) the opposite party No.2 has to reimburse the said amount incurred by the complainant, hence the opposite party No.2 is liable to pay to the complainant the incurred Hospitalization expenses. As opposite party No.2 driven the complainant to the Forum for redressal the complainant is entitle to costs of Rs.500/-. As no cause of action is made out against to opposite party No.1 the case against opposite party No.1 is dismissed.
7. In the result, the complaint is allowed directing the opposite party No.2 to pay to the complainant Rs.11,984/- with 9% interest from the date complaint i.e 13.10.2006 till realization along with costs of Rs.500/- within a month of receipt of this order.
Dictated to the Stenographer, transcribed by him, corrected and pronounced in the Open bench this the 28th day of November, 2006.
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
Witnesses Examined
For the complainant :Nil For the opposite parties :Nil
List of exhibits marked for the complainant:-
Ex A.1 Certificate of Insurance policy copy, period of Insurance from 16.7.04.
Ex A.2 Attested xerox copy of consultation receipt of Care Hospital dt 23.2.05
for Rs. 225/-.
Ex A.3 Attested xerox copy of Out Patient bill cum receipt dt 23.2.2005 for
Rs.860/-.
Ex A.4 Attested xerox copy of receipt dt 24.2.2005 issued by Care Hospital for
Rs.7,500/- as advance for I.A treatment.
Ex A.5 Attested xerox copy of receipt dt 25.2.2005 issued by Care Hospital for Rs.
444/- towards final settlement.
Ex A.6 Attested xerox copy of cash memo dt 25.2.2005 as to the purchase of
medicines wroth of Rs.130.55/-.
Ex A.7 Attested xerox copy of Out Patient bill cum receipt dt 27.2.2005 for
Rs.1,000/- issued by Care Hospital towards C.D recording.
Ex A.8 Attested xerox copy of Care Hospital bill under various head.
Ex A.9 Repudiation letter, dt 11.3.2005 on the reason of Pre existing condition
clause 4.1.
Ex A.10 Discharge summary card issued by Care Hospital.
List of exhibits marked for the opposite parties:- Nil
MEMBER PRESIDENT
Copy to:-
1.Sri P. Siva Sudarshan, Advocate, Kurnool.
2.The Branch Manager, Andhra Bank, Budhawar Pet Branch, Kurnool.
3.The Divisional Manager, United India Insurance Company Ltd., Divisional Office – IV, 2nd floor, Posnett Bhavan, Tilak Road, Hyderabad.
Copy was made ready on:
Copy was dispatched on:
Copy was delivered to parties:
