Andhra Pradesh

Nellore

CC/74/2017

Darsi Rajesh, S/o. Subrahmanyam - Complainant(s)

Versus

1. The Family Health plan (TPA) Limited, Rep. by Its Managing Director - Opp.Party(s)

G.V.L.Nagamani

02 Apr 2018

ORDER

Date of Filing     :03-07-2017

                                                                             Date of Disposal:02-04-2018

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM:NELLORE

Monday, this the   2^nd  day of   APRIL, 2018

 

          Present: Sri Sk.Mohd.Ismail, M.A., LL.B., President

                        Sri A. Prabhakar Gupta, Member

 

C.C.No.74/2017

Darsi Rajesh,

S/o.Subrahmanyam,

Hindu, Male, Aged about 30 years,

Residing at D.No.28/3/1678, Mypadu Road,

Simhapuri Colony,

Nellore.                                                                                       ..… Complainant       

                                                             Vs.

 

1.	The Family Health Plan (TPA) Limited, Represented by it’s Managing Director, Ground Floor, Srinilaya Cyber Spazio, Road No.2, Banjara Hills, Hyderbad-500 034, Telangana State.
2.	The Senior Divisional Manager, The New India Assurance Company Limited, 3-1-2/A, First Floor, State Bank of Hyderabad, Habsiguda, Hyderabad  500007.
3.	The Manager, The New India Assurance Company Limited, Subedarpet, Nellore.                                                            ..…Opposite parties

                                                             .

          This complaint is coming before us  for hearing in the presence of                Sri G.V.L. Nagamani, advocate for the complainant and                                                 opposite party No.1 appeared in person, opposite party No.2 remained absent and Sri I.V. Ramasastry and Sri G. Srinivasulu, advocate for the                                                       opposite party No.3  and having stood over for consideration till this day and this Forum passed the following:

ORDER

                       (ORDER BY  Sri.Sk.MOHD.ISMAIL, PRESIDENT)

             The complainant filed the complaint  against the opposite parties  1 to 3   and to direct the opposite parties 1 to 3  to pay Rs.35,203.53 Ps. (44,003.53Ps.  -   8,800=00Ps.) towards the balance of insurance claim amount with interest at            12% p.a. from the date of operation i.e., on 30-08-2016 till the date of realization, Rs.50,000/- towards compensation and damages for deficiency  in service, negligence, unfair trade practice committed by opposite parties, costs and submits to allow the  complaint with costs.

             2.    The brief averments of the complaint are as follows that:-the  the complainant  has been working as Home Guard 102 under the control of Superintendent of  Police, Nellore.   The  complainant is having group insurance policy bearing No.3101341604 00000002.   The policy period commencing from 09-06-2016 to 08-06-2017.  As per the terms of the policy, if any illness suffered the complainant and his family members medical expenses  will be reimbursed by the opposite parties.

             The complainant further submitted that  the complainant suddenly  became sick and approached   Sai Deekshitha Clinic, Nellore and  there to the Vijaya Hospital, Nellore on 29-08-2016 and upon examinations and investigations, the doctors decided  that the  complainant need surgical   operation in Nasal Region to remove the congestions and advised him to join as inpatient to undergo surgery.  The complainant immediately informed  the same to the opposite parties and taken permission and as per the advise of the doctors the complainant admitted in the said Vijaya  Hospital, Nellore on 30-08-2016  for surgical operation and for  Nasal Congestion with  mild   Facial pains.   The complainant undergone operation on 30-08-2106 and incurred Rs.44,003.52 Ps.  towards medical charges, expenses etc.,  The complainant discharged on 31-08-2016.  The complainant upon discharge from the hospital, submitted  the claim alongwith all original  bills  and  receipts etc., as required by opposite parties, to the opposite parties   through the employer of the complainant and requested to settle the claim.  But after several approaches and requests, the opposite parties  sent a cheque for Rs.8,800/-  on 08-03-2017 instead of full amount of Rs.44,003.52Ps.    The complainant submitted that the opposite parties negligently and willfully settled for a very meager amount of Rs.8,800/- instead of Rs.44,003.52Ps.  which is against the terms and conditions of the insurance policy.

            The complainant submitted that  it is the legal and bounden duty of the  opposite parties   to pay the entire amount  of expenditure   i.e.,   Rs.44,003.52 Ps. 

 

as per terms and conditions of the policy having collected insurance   premium and policy was issued.  Having agreed to   reimburse the entire amount,  paying meager amount  constitutes the gross negligence, deficiency in service and unfair trade practice and also violation of terms and conditions of the policy.  Due to that the  complainant  suffered lot of mental agony, distress and also financial loss.  So, the opposite parties are not only liable to pay the entire claim amount of                           Rs.44,003.53 Ps. after deducting Rs.8,800/- with interest, but also  liable to pay damages to the complainant.  So, the complainant  got issued legal notice dated 13-03-2017  to the opposite party No.1 demanding to pay the entire claim amount.  Having received the same the opposite party No.1 kept quite   and even the opposite parties did not choose to give reply and hence submits to allow the complaint with costs.

           3.      On behalf of the opposite party No1 reply / written version  filed with the following averments that:-  based  on the  submitted available medical documents and as per the applicable policy conditions of the Group Medi Claim Policy of ADDL. DGP-HG-AP, complainant’s medi claim  was  processed as per eligible billed amount.

             The opposite party No.1  submitted that the complainant has submitted the Claim for an amount of Rs.44,003.53 for reimbursement, we being the TPA  are obligated to process the claim as per the terms and conditions  of the policy,  after due verification of the submitted documents.

Complainant’s eligibility  as per the Policy  conditions are:

1.  Room, boarding and nursing charges eligibility as per the policy is @ 1% of Sum Insured per day and the same has been mentioned in group mediclaim policy under Clause 2.1.
2. ICU  eligibility as per the policy is @ 2% of Sum Insured per day and the same has been mentioned in group medi claim policy under clause 2.2.
3. All other charges except above mentioned clauses of 2.1  &  2.2 of  hospitalization expenses are covers under clause 2.3 & 2.4.
4. The amount payable under clause 2.3 & 2.4 shall  be at the rate  applicable to the entitled Room  Category with the exception of Medicines as per the group medi claim policy conditions.

 

            The opposite party No.1 further submitted that  the complainant availed  Single Room-AC   and the charges are Rs.2,500/- which includes nursing charges per day.  The complainant’s eligibility is  Rs.500/- per day including nursing charges, the claim was processed based on the eligible room limit of the claimant.

 

          The opposite party No.1 further submitted that  the total claim was processed based on the room eligibility in accordance with other charges proportionally excluding  medicines.  The details of calculations are as follows:

 

1.  Rs.2,000/-  Exceeding the room & nursing charges as per the policy terms and conditions  has  been deducted.

 

2. Rs.2,000/-  Exceeding  the ICU &  extra  ICU charges for Rs.1,000/- has been deducted as per the policy terms and conditions.

 

3. Rs.4,000/- Assistant Charges not indicated anywhere  in the treatment record and the same has been deducted.

 

4. Rs.153/-  Betadin Charges are not payable.

 

5. Rs.250/-  Report not submitted for X-Ray, hence the same was deducted.

 

6. Rs.1,900/-  and Rs.1,100/-  breakup’s   for Laboratory charges were not provided, hence the  same was not paid.

 

7. Rs.16,400/-, Rs.4,800/- and Rs.1,600/- has been deducted under proportionate  clause accordance with room rent eligibility as per the policy terms and conditions.

However, we being the  Third Pay Administrator appointed by the  Insurance Company for processing the claims under the policy issued by them, we confirm that there is no negligence and there is no any unfair trade was committed by the opposite party No.1 against the  complainant’s claim  and hence submits to dismiss the complaint with costs.

4.On behalf  of the opposite party No.2 , no written version was filed.

 

5. On behalf of the opposite party No.3,  no written version was filed.

 

            6.        The opposite party No.3 filed I.A.No.22/2018 under Section-151 of C.P.C. to receive the written version on  behalf of opposite party No.3  and following the  decisions reported in AIR  2016 Supreme Court, 1986 as the  opposite party No.3  did not file written version within 45 days.  The petition filed by the opposite party No.3 to receive the written version  beyond  45 days was dismissed without costs.

            7.       On behalf of  the complainant, the affidavit  of P.W.1  filed and Exs.A1 to  A6 were marked.

            8.        On behalf of the opposite party No.1, the affidavit of R.W.1 filed and Exs.B1 to B3 were marked.

            9.         On behalf of the opposite party No.2, no evidence was adduced and no documents were marked.

            10.          On behalf of the opposite party No.3, the affidavit of R.W.2  filed and Exs.B4 to B7  were marked.

           11.         Written arguments on behalf of the complainant filed.

            12.          Written arguments on behalf of the opposite parties  1 and 2 not filed.

           13.          Written arguments on  behalf of the opposite party No.3 filed.

            14.           Perused the written arguments filed on behalf of the complainant and  opposite party No.3.

           15.        Now the points for consideration are:

           (1)          Whether  the complaint filed by the complainant under Section-12

                       of the Consumer Protection Act, 1986  alleging   deficiency of

                       service against  the opposite parties 1 to 3 is maintainable?

           (2)        To what relief, the complainant is entitled?

 

           16.            POINT No.1:The learned  counsel for the  complainant submits by relying upon the evidence of P.W.1  and  Exs.A1 to  A6 that the complainant  who is working as  Home Guard  under the controller of Superintendent of Police, Nellore giving group insurance policy bearing No.310134160400000002 commencing from 09-06-2016  to 08-06-2017 and when the complainant  admitted in Vijaya Hospital, Nellore on 30-08-2016  for surgical operation and in  Nasal Congestion with mild Facial pains and the complainant   was undergone surgery on 30-08-2106 and  incurred  medical expenditure  of Rs.44,003.52 ps.   and after  discharge, the complainant submitted  vouchers to the opposite parties 1 to 3 for the payment of the hospital expenses but the opposite parties sent  a cheque for Rs.8,800/-  on 08-03-2017 instead of  full amount of Rs.44,003.52 Ps.  and as the opposite parties 1 to 3  failed to pay the entire medical expenses, it amounts to deficiency of service and inspite of  several  demands, the opposite parties 1 to 3 failed to pay the entire due amount.  The complainant filed this complaint against the opposite parties 1 to 3 to direct the  opposite parties  1 to 3  to pay   he balance of Rs.35,203.53 Ps. (44,003.53   -   8,800.00)  and submits  to allow the complaint with costs.

          On the other hand, the learned  counsel for the opposite party No.1 submits by relying upon the evidence of R.W.1  and Exs.B1 to B3  that  as per the terms and conditions  of Ex.B1, the opposite party No.1 and 3  paid the amount of Rs.8,800/- to the complainant and the terms of Ex.B1 is binding on the complainant and as the opposite parties 1 to 3 paid  to the amount of Rs.8,800/-  as per the  terms and conditions of Ex.B1 and as there is deficiency of service, he submits that  the complaint filed by the complainant against the  opposite party No.1 is not maintainable and submits for the dismissal of the complaint with costs.

          The learned counsel for the  opposite party No.3 submits by relying upon the evidence of  R.W.2 and Exs.B4 to B7 that as per the terms of Ex.B1, the opposite party paid the entire amount and hence as there is no deficiency of service on the part of the opposite party No.3, he submits  that the complaint filed by the complainant against  the  opposite party No.3 is not maintainable and submits for the dismissal of the complaint with costs.

           In view of the arguments submitted by the learned counsels for the  both parties and as seen from the contention of the opposite parties 1 and 2    that as per the terms and conditions under Ex.B1, the  opposite party was paid the hospital expenses as per terms of Ex.B1.  The evidence of R.W.1  at page-2 reads as follows:

I submit that, the complainant has submitted the claim documents for an amount of Rs.44,003.53 Ps. for reimbursement, we being the TPA  (Third Party Administrator) are obligated to process the claim as per the terms and conditions of the policy, after due verification of the submitted documents.            I submit that, the complainant’s  claim was processed with below policy conditions as per eligibility of group medi claim policy.  Complainant’s Sum Insured is Rs.50,000/- (Fifty thousand only) per year and claim need to be processed as per  below conditions: Room, boarding and nursing charges eligibility as per the policy is @ 1% of Sum Insured per day and the same has been mentioned in group medi  claim policy under Clause 2.1. ICU eligibility as per the policy is @ 2% of Sum Insured per day and the same has been mentioned in group medi claim policy under clause 2.2. All other charges except above mentioned clauses of 2.1 & 2.2 of hospitalization expenses are covers under  clause 2.3 & 2.4. The amount payable   under clause 2.3 & 2.4 shall be at the rate  applicable to the entitled Room Category with the exception of Medicines as per the group medi claim  policy conditions.

           Complainant’s Room  eligibility as per the policy is @ 1% (Room) &  @ 2% (ICU) of Sum Insured, which comes to Rs.500/-  per day.  Complainant has availed / Opted  Single AC room @ 2500/- per day, which is a higher category than his eligibility.  We have restricted the Room charges from  Rs2,500/-  to Rs.500/-  per day as per  clause 2.1 and all other charges other than Room &  ICU (Clause 2.1 & 2.2)  with exception of Medicines / Pharmacy was restricted accordance with Room rent eligibility as per clause 2.3 & 2.4.

 

          The affidavit of R.W.2  (opposite party No.3)  at para-3 reads as follows:         

I submit that the complainant unfortunately fell ill underwent surgery for his  Sinusitis  Nasal congestion problem  and discharged, later submitted claim documents for reimbursement of charges of Rs.4,400-53 Ps. for his treatment at opposite party No.1 office.  Basing on the available medical bills and documents submitted as  per the applicable policy conditions  of the Group Mediclaim Policy of ADDL-DGP-Hg-AP., complainant’s  mediclaim was processed as per the eligible billed amount.  The member eligibility as per the policy condition is Room, boarding and nursing charges eligibility as per the policy is  at  the rate 1% of sum insured per day and the same has been mentioned in group mediclaim policy under Clause 2.1; ICU  eligibility has per the policy is at 2% of sum insured per day and the same has been mentioned in group mediclaim policy under Clause 2.2; All other charges except above mentioned clauses of 2.1  and 2.2  of hospitalization expenses are covered under clauses 2.3 and 2.4; The amount payable under clause 2.3  and 2.4 shall be at the  rate  applicable to the entitled room category with the   exception of medicines   as per the group medicalim policy conditions. The member has availed single room AC  and the charges are Rs.2,500/- which includes nursing charges per day and the eligibility isRs.500/- per day.

 

           The affidavit of R.W.2  (opposite party No.3) at para-4 reads as follows:-

 

          I submit that opposite party No.1 processed the total claim  based on the eligible room limit of the member (complainant) in accordance with  other charges proportionally excluding  medicines.  The details of calculation are as follows:

 

Rs.2,000/- - Exceeding the room and nursing charges as per the policy terms  and conditions has been   deducted (eligibility is Rs.500/- per day including nursing charges); Rs.2,000/- - Exceeding the ICU  and extra ICU charges for Rs.1,000/- has been deducted; Rs.4,000/- - Assistance Surgeon charges not indicated; Rs.153/-  - Betadine charges are not payable; Rs.250/- - Report was not submitted for X-Ray. Rs.1,900/- and Rs.1,100/-  - Breakeups for laboratory charges  were not provided hence the same was not paid; Rs.16,400/-, Rs.4,800/- and Rs.1,600/- has been deducted under proportionate clause accordance  with  room rent eligibility as per the policy terms and conditions.

 

           The affidavit of R.W.2  (opposite party No.3) at para-5 reads as follows:-

 

 

        I submit that the opposite party No.1 approved the eligible billed amount as per the claim billing sheet claim Id:1240143 as follows:

 

Service name	Claimed Rs.	Disallowed Rs.	Approved Rs.	Remarks
Room	2500	2000	500	Exceeding the room and nursing charges as  per the policy.
ICU	3000	3000	0	Exceeding the ICU  limit as per policy and Rs.1,000/- not payable ICU  extra charged.
Doctor Charges	24,500	20,400	4,100	Rs.4,000/- not indicated for Assistance  charges, Rs.16,000/- restriction as per entitled room category @ 80%; Rs.400/- restriction as per entitled room category @ 80%.
Pharmacy	2753	153	2,600	Betadine charges Rs.153/- not payable.
Lab	3,250	3,250	0	Rs.250/- - no report for X-ray; Rs.1900/- no breakup for CT – PNS; Rs.1100/- - no breakup for lab.
OT charges	6000	4,800	1,200	Rs.4,800/- restriction as per entitled room category @ 80%
Others	2000	1,600	400	Rs.1,600/- restriction as per entitled room category @ 80%
Total	44003	35,203	8,800

 

Sanction Amount:    Rs.8,800/-

Payable Amount:     Rs.8,800/-

Net Paid Amount:    Rs.8,800/-

 

         As per the evidence  of R.W.1  and  2 and the terms and conditions  of Ex.B1, the complainant is not entitled for the  entire medical expenses which was paid by the complainant.

 

In   Oriental Insurance Company Limited and another Vs. Target Plywood Industries Limited reported in                                2009 CTJ 821 (SC)  =  2009 (7)  SCC 759

 

Wherein the Hon’ble Apex Court held that  the terms of the policy  have to be strictly construed  to determine the  extent of Law.  The insured cannot claim anything more than what is covered by the policy.”

 

In   General Assurance Society Limited Vs. Chandumall Jain  and another reported in 1966 (3) SCR 500 =  AIR 1996 SC 164

 

Wherein the  Hon’ble Apex  Court held that  “ it is  settled Law with the terms  of the contract have to be strictly  read and natural meaning  be given to it.  No outside  said  number sought   unless the  meaning of ambiguous.”

             Following the above decisions as the opposite parties paid the medical expenses  of Rs.8,800/- as per the terms and conditions of Ex.B1, we are of the opinion that there is no deficiency of service on the part of the opposite parties  and hence the complaint filed by the complainant against the opposite parties 1 to 3 is not maintainable  and the same has to be dismissed.

             By relying upon the above decisions and the discussion made above,  we answer this point against the complainant and in favour of the opposite parties                    1 to 3.

 

            17.   POINT No.2:In view of our  answering on point No.1 against the complainant and in favour  of the opposite parties 1 to 3, the complaint filed by the complainants against opposite parties 1 to 3 is not maintainable and the same has to be  dismissed.

            In the result, the complaint is dismissed but in the circumstances, no costs.

          Dictated to Stenographer, transcribed by her corrected  and pronounced by us in the open  Forum, this the  2^nd  day of   APRIL, 2018.

 

          Sd/-                                                                                       Sd/-

      MEMBER                                                                         PRESIDENT

                            

                                      APPENDIX OF EVIDENCE

 

Witnesses Examined for the complainant

 

P.W.1  -

24-01-2018

Sri Darsi Rajesh, S/o.Subrahmanyam, Nellore (affidavit filed)

 

Witnesses Examined for the opposite parties

 

R.W.1  -	06-02-2018	Sri Ch.Manohar Babu, Sr.Executive at Family Health Plan Insurance TPA Limited, R/o.Vijayawada (affidavit filed).
R.W.2  -	06-02-2018	Sri K.V. Sobhanadri, S/o.Late Eswarudu, Deputy Manager, New India Assurance Company Limited,  Ongole (affidavit filed)

 

                           EXHIBITS MARKED FOR THE COMPLAINANT

Ex.A1  -	-	Photostat copy of Home Guard Identity Card  in favour of complainant issued by the Government of Andhra Pradesh.
Ex.A2  -	-	Identity Card issued by the  opposite parties 2 and 3 in policy No.61310134160400000002  in favour of complainant.
Ex.A3  -	-	Photostat copies of  prescription in favour of complainant issued by  Sai Deekshitha Clinic on                29-08-2016 and  Case Summary and Discharge Summary.
Ex.A4  -	-	One Advance Receipt No.6983 for Rs.5,000/-, photostat copies of cash receipt No.222,                      dated 31-08-2016 for Rs.44,003.52/-, Final bill,  Bill No.SL 6520, dated 30-08-2016  for Rs.577.22Ps. issued by the Vijaya Krishna Medical & Fancy, Nellore-1, Cash bill No.150, dated 29-08-2016, CT Scan of Paranasal Sinuses dated 29-08-2016,   receipt No.86/dated 29-08-2016 in Maruthi Digital X-Ray, Nellore for Rs.250/-. Cash bill  dated 29-08-2016 for Rs.1,100/- and Lab Report dated 29-08-2016.
Ex.A5  -	13-03-2017	Legal notice from  complainant’s advocate to the  opposite party No.1 alongwith postal receipt and acknowledgement.
Ex.A6  -	-	Photostat copies of prescription slips on 30-08-2016 (one prescription) and  four prescriptions on                    31-08-2106

 

                         EXHIBITS MARKED FOR THE OPPOSITE PARTIES

Ex.B1  -	-	Photostat copy of  Standard Group Mediclaim Policy (2007).
Ex.B2  -	-	Photostat copy of policy issued by  opposite parties 2 and 3
Ex.B3  -	-	Photostat copy of Policy Schedule issued by opposite parties 2 and 3
Ex.B4  -	29-08-2017	Photostat copy of mail.
Ex.B5  -	-	Photostat copy of  Claim Biling Schedule.
Ex.B6  -	-	Photostat copy of Policy Schedule issued by opposite parties 2 and 3
Ex.B7  -	-	Photostat copy of  Standard Group Mediclaim Policy (2007).

 

                                                                                                             Id/-

                                                                                                      PRESIDENT

 

Copies to:

 

1.	Smt G.V.L. Nagamani, Advocate, Nellore.
2.	The Family Health Plan (TPA) Limited, Represented by it’s Managing          Director, Ground Floor, Srinilaya Cyber Spazio, Road No.2, Banjara Hills,Hyderbad-500 034, Telangana State.
3.	The Senior Divisional Manager, The New India Assurance Company      Limited, 3-1-2/A, First Floor, State Bank of Hyderabad, Habsiguda, Hyderabad  500007.
4.	Sri I.V. Ramasastry and Sri G. Srinivasulu, Advocates, Nellore

 

Date when free copy was issued: