Before the District Forum: Kurnool
Presen lt: Sri K.V.H Prasad, B.A., LL.B., President
Sri R. Ramachandra Reddy, B.Com., LL.B., Member
Wednesday the 31st day of May, 2006
C.D No.39/2004
K. Anand, S/o. Sowrappa,
Aged about 59 years,
R/o. D.No. 7/96,
Sampath Nagar, S.A.P
Camp (Post), Kurnool. . . . Complainant
-Vs-
1. The Divisional Manager,
The Oriental Insurance Co., Ltd.,
Branch Office at Bhupal Complex,
Kurnool.
2. The General Manager,
The District Co-Operative Central-
Bank Ltd., Kurnool. . . . Opposite parties
This complaint coming on this day for Orders in the presence of Sri P. Siva Sudarshan, Advocate, Kurnool for complainant, Sri V.V. Krishnama Raju, Advocate, Kurnool for opposite party No.1 and Sri K. Ramakrishna Rao, 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 Sri.K.V.H.Prasad, Hon’ble President)
1. This case of the complainant is filed under section 12 of C.P Act seeking direction on the opposite parties to pay to the complainant Rs.21,727/- towards reimbursement of the expenditure incurred in undergoing eye operation being covered under medi claim group insurance policy, and 9% interest there on from the date of the complaint, Rs.1,500/- towards mental agony suffered by the complainant and costs of this case, alleging that he took group medical claim policy No.432100/900/0/48/678/2002 dated 23-3-2002 as the employee of the second opposite party for the year 2002-03 and underwent a surgery to his right eye on 20-12-2002 in L.V.Prasad Eye Institute, Hyderabad incurring expenditure of Rs.21,727.46ps and preferred claim through opposite party No.2 for reimbursement of said expenditure by opposite party No.1 under the said policy and the opposite party No.1 repudiated the said claim on 4-2-2003 giving intimation to opposite party No.2 without any cogent reasons and the opposite parties kept silent to the legal notice dated 10-3-2004 and the liability of the opposite party No.2, as employer of the complainant though whom the said group insurance medi claim policy was obtained – holds joint and several liability with the opposite party No.1.
2. In pursuance of the receipt of the notice of this Forum as to the case of the complainant the opposite parties caused their appearance though their counsels and filed written version denying any of their liability to the complainant’s claim and there by seeking the dismissal of the case with costs.
3. The written version of the opposite party No.1 even though admit the complainant as one of the beneficiary under said group insurance medi claim policy covering up to Rs.30,000/- but allege that as per the investigation of Dr.A.V.Rathnam the complainant was found suffering with pre existing disease of Gradual Reduction of vision of both distance and near vision since last 10 years to taking the policy and advise to left eye operation in 2001 and under going by pass surgery in 2001 and so not covered under the policy and hence the same was intimated to the complainant and the notice dated 29-3-2003 of the complainant was suitable replied and the repudiation of the claim was made as the complainant suppressed said fact as to his pre existing disease and such a suppression of pre existing disease is not covered under terms and conditions of said policy and hence the complainant is not entitled to the reimbursement sought.
4. The written version of the opposite party No.2 even though admit the complainant as covered under group insurance medi claim as its employee and the complainant under going said surgery to his right eye incurring said expenditure, deny any of its nexus with repudiation of claim made by the opposite party No.1 as it has done of its job of processing for obtaining group insurance medi claim policy on its employee and forwarded the claim preferred by the complainant and so there by deny any deficiency on its part and so seeks dismissal of the complainant case with costs.
5. In substantiation of the contentions while complainant side has relied upon the documentary record in Ex.A1 to A20 besides his sworn affidavit and replies to the interrogatories exchanged, the opposite party side as relied upon the sworn affidavit of the opposite party No.1 and replies exchanged to the interrogatories.
6. Hence the point for consideration is whether the deficiency alleged against the opposite party is made out making out the liability of the opposite party to the complainant’s claim.
7. The Ex.A1 is the appointment slip dated 6-8-2002 issued by L.V.Prasad Eye Institute, Hyderabad giving the date of appointment to the complainant with Dr.Subhadra Jalali on to 31st October 2002, collecting Rs.125/- as charge under Ex.A2. The Ex.A3 is prescription for optithrocin eye ointment to the complainant. The Ex.A4 envisages the diagnosis of current medication, investigation and normal values assessed by the said institute to find out the physical fitness of the complainant for conducting surgery. The Ex.A5 is the receipt for Rs.475/- received by said hospital from the complainant towards medical consultation and certain investigations mentioned therein. The Ex.A6 is the document which envisages the pre surgery medication instructions of said hospital to the complainant, the Ex.A7 is the receipt issued by said hospital for receipt of Rs.21,000/- from the complainant on 20-12-2002 towards various prescription charges mentioned there under vide detailed particulars furnished in Ex.A8. The Ex.A9 is the prescription as to use of the medicines (eye drops) indicated therein. The Ex.A10& A11 are the bills for Rs.49.50ps and 36.70ps for purchase of medicines mentioned there under. The Ex.A12 is the mode prescribed by said hospital for use of medicines mentioned there in to the complainant. The Ex.A13 is the bill for Rs.33/- for purchase of medicines by the complainant. The Ex.A14 is the certificate issued by said hospital certifying the operation conducted to the complainant’s right eye on 20-12-2002 and advising rest of 8 days from there on. The Ex.A15 is the claim form submitted by the complainant on 9-1-2003 to the opposite party No.1 with all the necessary particulars through opposite party No.2 and Ex.A16 is the covering letter of the opposite party No.2 through which the claim of the complainant was forwarded to opposite party No.1 and the Ex.A17 is the reminder issued by the opposite party No.2 to opposite party No.1 requesting for early settlement of complainant’s claim.
8. The complainant under going said opthomolgical surgery to his right eye incurring expenditure being not denied by the opposite party, as it questions only its entitleness to the complainant under clause 4-1 of the terms and conditions of said policy, the above said exhibits remains proved as to the material consisted therein.
9. The opposite party No.1 alleges that the claim of the complainant falls under clause 4-1 of the terms and conditions of the policy as the complainant was suffering from gradual reduction of visions both distance and near since last 10 years but it has not substantiated the said with any cogent material except filing an unattested xerox of letter dated 24-2-2003 of Dr.A.V.Rathnam addressed to the opposite party No.1 which says that as per records of L.V.Prasad Eye Institute the complainant was with complaint of gradual reduction in visions both distance and near for past 10 years and the condition worsened in the last one year and patient gave history of consulting opthomologist two years back and diagnosis of catract to left eye and advice surgery and the patient under going by-pass surgery 1998 and surgery to left eye two years ago to said day and so recommending for repudiation of claim.
10. In substantiation of said material mentioned in supra letter of Dr.A.V.Rathnam neither the author of said letter was examined nor any of his affidavit is filed affording an opportunity to the complainant to test the varsity of said document nor any such record alleged in said letter filed on which the author of said letter have incorporated his findings as to the past medical history of the complainant. Neither the investigation report of complainant made by Dr.A.K.Bansal – which forms the part of Ex.A15 sounds any pre existing diseases medical history of the complainant. Hence there appears any cogent material with the opposite party No.1 to believe any pre existing disease of the complainant by the time of taking said policy to bring him under scope of alleged clause 4-1 of the terms and conditions of said policy.
11. Further the so called letter of Dr.A.V.Rathnam is not specific of the eye with which the complainant was suffered from said complaint of reduction in vision of both distance and near to credit it to the right of the complainant to which the later has under went opthomolgical surgery in L.V. Prasad Eye Institute, Hyderabad.
12. Hence there appears neither any justification to said Dr.A.V.Rathnam to recommend for repudiation of the complainant's claim nor to the opposite partyNo.1 to justify the repudiation of the complainant’s claim it made in Ex.A18.
13. The Ex.A18 repudiation of claim dated 4-2-2003 addressed to opposite party No.2 by opposite party No.1 as marks its copy to the complainant there appears any justification to the complainant in causing Ex.A19 and A20 to the opposite parties 1 and 2 especially when the repudiation of the claim was definite in Ex.A18 and makes clear that no further correspondence in that regard can be entertained and so also any relevancy lies with the alleged reply dated 19-4-2004 of opposite party to the notice in Ex.A20.
14. As there appears no justification for repudiation of the complainant’s claim by the opposite party No.1 in the absence of any cogent proof as to the existence of any pre existing disease to the complainant by the time of obtaining said policy and its intentional concealment by the complainant from revealing while taking said policy, the complainant is not only remaining entitled for the reimbursement of the incurred medical expenditure he has in under going surgery to his right eye in L.V.Prasad Eye Institute but also to compensation for the mental agony he suffered at the wrongful repudiation of the claim and to the costs of this case as he was driven by opposite party No.1 to the Forum for redressal of his consumer grievances arising out of the deficiency in service of the opposite party No.1.
15. As there appears any material as to any deficient service conduct of the opposite party No.2 at the complainant as he has done his duty of submitting the claim of the complainant properly to the opposite party No.1, the case against the opposite party No.2 is dismissed.
16. Consequently, the case of the complainant is allowed directing the opposite party No.1 to pay to the complainant Rs.21,727/- the incurred medical expenditure of said surgery to his right eye, and an amount of Rs.10,000/- as compensation for mental agony and Rs.3,000/- as costs of this litigation within a month of the receipt of this order. In default the opposite party No.1 shall pay the supra awarded amount with 9% interest per annum from there till realization.
Dictated to the stenographer, transcribed by him, corrected and pronounced by us in the Open Forum this the 31st day of May, 2006.
PRESIDENT MEMBER
APPENDIX OF EVIDENCE
Witnesses Examined
For the Complainant: Nil For the opposite parties: Nil
List of Exhibits Marked for the complainant:-
Ex A.1 Appointment Slip, dt 6.8.2002 issued by L.V. Prasad, Eye Institute,
Hyderabad, for Rs.125/-.
Ex A.2 Bill – Cum – Receipt for payment of Rs.125/-, dt 31.10.2002.
Ex A.3 Prescription of L.V. Prasad Eye Institute.
Ex A.4 Physical Fitness Form, dt 12 .12.2002.
Ex A.5 Payment of receipt of Rs.475/- for Ex A.4.
Ex A.6 Medication Instructions dt 20.12.2002.
Ex A.7 Receipt, dt 20.12.2002 for Rs.21,000/-.
Ex A.8 Details of Treatment for Rs.21,000/-.
Ex A.9 Eye drops prescription, dt 21.12.2002.
Ex A.10 Bill for purchase of prescription of Ex A.9 dt 20.12.02 for Rs.49.50p.
Ex A.11 Bill for purchase of prescription medicines of Ex A.9.
Ex A.12 Prescription for the use of Eye Drops.
Ex A.13 Bill for purchase of Medicines on Ex A.12.
Ex A.14 Certificate in respect of Eye Operation issued by L.V. Prasad, dt 6.1.03.
Ex A.15 Office Copy of Medi-claim Application send to OP No.1 through
OP No.2.
Ex A.16 Letter, dt 9.1.2003 addressed to OP No.1 through OP. NO.2.
Ex A.17 Letter, dt 11.1.2003 addressed by OP No.2 to OP No.1.
Ex A.18 Claim repudiation issued by OP No.1 addressed to OP No.2, dt 4.2.03.
Ex A.19 Letter of complainant addressed to opposite party No.1, dt 10.3.03.
Ex A.20 Office Copy of Legal notice to opposite parties with postal
acknowledgements (2) dt 10.3.2004.
List of Exhibits marked for the opposite parties: Nil
PRESIDENT MEMBER
Copy to :-
1. Sri P. Siva Sudarshan, Advocate, Kurnool.
2. Sri V.V. Krishnama Raju, Advocate, Kurnool.
3. Sri K. Ramakrishna Rao, Advocate, Kurnool.
Copy was made ready on:
Copy was dispatched on:
Copy was delivered to parties:
