Andhra Pradesh

Nellore

CC/76/2016

Jetty Syam Sundar Reddy,s/o of Balarama Reddy - Complainant(s)

Versus

1. United India Insurance Co Ltd, rep by its Chairman - Opp.Party(s)

G.Babulu

25 Jul 2017

ORDER

Date of filing        :  20-07-2016

Date of Disposal   :  25-07-2017

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

           :: NELLORE ::

                                                       

Tuesday, this the 25th day of JULY, 2017.

 

  PRESENT:  Sri V.C. Gunnaiah, B.Com., M.L, President(FAC)

                              Sri K.Umamaheswara Rao, M.A., B.L.,  Member.                                

                              Sri M.Subbarayudu Naidu, B.Com.,B.L., LL.M, Member

                             

C.C.No.76/2016        

 

J.Syam Sundar Reddy,

(Jetty Syamsundar Reddy),

S/o.Balarama Reddy,

Aged about 55 years,

Hindu, advocate

Residing at Padapa dugupadu village,

Nellore District.                                                                    ….   Complainant

 

Vs.

                                                                           

                                                              

1.  United India Insurance Co. Ltd.,

 represented by its Chairman,

 24, Whites Road, Chennai 600014.

 

2. United India Insurance Co. Ltd.,

Represented by its branch manager, Nellore

GNT Road, OPP: Bollineni hospital,

Nellore.

 

3. Vidal Health TPA Pvt. Ltd.

Represented by its Managing Director,

First Floor, Tower No.2,

SJR I Park, EPIP Zone,

Whitefield, Bangalore – 560066.                           … Opposite parties

 

This matter coming on 17-07-2017  before us for final hearing in the presence of  Sri G.Babulu, Advocate  for the complainant and                         Sri P.V.Mallikarjuna Rao, Advocate for the 1^st and 2^nd opposite parties and the 3^rd opposite party remained absent and having stood over for consideration till this day, this Forum passed the following:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          

 

ORDER                                                                                                                                                                                                                                                             

(By Sri V.C. Gunnaiah, B.Com., M.L., President(FAC)

 

 

1.     The complainant filed this complaint under section 12 of Consumer Protection Act, 1986 to direct the opposite parties to pay an amount of        Rs.6,66,700/- with interest 18percent p.a., from 16-07-2016 till realization towards medical bills and compensation and to pay costs of this complaint.

 

2.  The averments of the complaint in brevity are as follows:

 

The complainant purchased health insurance policy for self and his family members from the opposite parties, initially for a period of one year from 28-09-1985 and thereafter it was renewed from time to time under the policy No.151242814P104945753 and it was valid upto     30-09-2016 for a sum of Rs.2,75,000/- to the complainant.  But, the complainant suddenly fell ill on 30-07-2015 and went to the Yasodha Hospitals, Hyderabad which is one of the preferred provider network hospitals of the opposite parties.  The complainant underwent medical tests and spent an amount of Rs.6,819/- for tests and medicines and the opposite parties are liable to pay the said amount.  The doctors of Yasodha diagnosed the problem as right renal calculi, hipher tension, diabetes and the doctors advised the complainant to undergo RIGHT RIRS plus LASER LITHOTRIPSY plus D J STENTING.  The hospital sent for a request to the 3^rd opposite party on 02-08-2015 for  pre-authorization approval for cashless treatment of the complainant and 3^rd opposite party has given cashless approval on 03-08-2015 for an amount of Rs.49,000/- stating that RIRS charges and laser assisted surgeries and are not payable, final claim will be settled as per their agreed tariff. The hospital authorities raised invoice ICO86626 for Rs.99,287/- and after giving credit amount of Rs.49,000/- paid by the T.P.A.(3^rd opposite party), the complainant paid Rs.50,000/- from his pocket and Rs.287/- was given as discount by the hospital. Again, the complainant also joined in the same hospital on 04-09-2015 and spent total amount of Rs.20,473/- for removal of the stent already fixed at the time of operation but the opposite party paid Rs.19,316/- and failed to pay the balance of Rs.1,157/-. The complainant submitted the claim for the remaining total amount of Rs.57,976/-but the opposite parties have not paid the above amount and caused lot of mental agony and suffering. Thus, there is deficiency in service on the part of the opposite parties for settling the claim of the complainant. Therefore, the complainant is entitled for Rs.57,976/- and interest thereon and to pay Rs.5,00,000/- for mental agony.  Hence, the complaint for the above reliefs.

 

 

 

2. The opposite parties have not chosen to file their written version inspite of given ample time by this Forum.

 

3.  The complainant filed his affidavit in support of his case and got marked Exs.A1 to A12.  The 2^nd opposite party though not filed their written version, filed their affidavit and got marked Exs.B1 to B4.  The complainant and the 2^nd opposite party filed their written arguments. 

 

4.  Heard arguments on both sides and perused the pleadings of complainant, affidavits filed by the both parties, their documents and written arguments of complainant and the 2^nd opposite party.

 

5.   The points that arise for determinations are:

       1) Is there any deficiency in service on the part of the opposite parties,

           in settling the claim of the complainant, as pleaded?

        2) Whether the complainant is entitled for the reliefs sought for?

        3) To what relief?

 

6.   POINTS 1 AND 2:  Learned counsel for the complainant contended that the complainant has medical insurance  for a sum of Rs.2,75,000/- as per Ex.A1 and he took treatment in Yashoda hospitals and bill was Rs.99,287/- but the opposite parties paid only Rs.49,000/-.  Therefore, he is entitled for Rs.50,000/- paid  by him to the hospital authorities, apart from Rs.1,157/- paid to the same hospital when he went to the hospital for review thus totally he entitled Rs.57,976/- apart from compensation for loss of deficiency.  He also contended that there is no reason given by the opposite parties to restrict his claim only to Rs.49,000/-.    Therefore, he is entitled for the total claim of his treatment.

 

7.  Per contra, learned counsel for the 2^nd opposite party contended that there is no deficiency in service on the part of the opposite parties, as they paid Rs.49,000/- to the hospital authorities as per the approval and as per the policy conditions under Ex.A1 and the other part of invoice is rejected.  Therefore, they are not liable to pay an amount claimed by the complainant.  Hence, the complaint is liable to be dismissed.

 

8.  In this case, it is not in dispute that the complainant obtained medi-claim policy from the opposite parties as per Ex.A1 and issued by opposite parties.  It is also not in dispute between parties that the complainant suffered with ill-health and he took treatment in the Yashoda hospital, Hyderabad on 30-07-2015 and incurred expenses to the tune of Rs.99,287/- as per  Ex.A7 invoice issued by the hospital.  Ex.A9 is another invoice dated 04-09-2015, wherein the complainant incurred an expenditure of Rs.20,473/- for removal of stent, after operation, in this regard the opposite party paid Rs.19,316/-  and failed to pay Rs.1,157/-.

 

9.  However, case of the complainant here in is, though he incurred Rs.99,287/- on 15-08-2015 as per Ex.A7 as per medical expenses, the 3^rd opposite party has given approval only for Rs.49,000/- and paid the same to hospital.  But, he (complainant) paid Rs.50,000/- from his pocket to the hospital and Rs.287/- was given  as discount by the hospital to the complainant.  He also paid from his pocket Rs.1,157/- on 04-09-2015 as the opposite party paid Rs.19,316/- only out of the bill amount of Rs.20,473/-.  The complainant filed Exs.A1 to A11 to prove how he admitted in the hospital, incurred expenses to the amounts claimed by him. 

 

10.   A perusal of the above documents, Exs.A7, A8, A9, A10 and A11 clearly and categorically goes to show that the complainant incurred expenses of Rs.99,287/- under Ex.A7 invoice and Rs.20,473/- as per Ex.A9 invoice but the opposite party No.3 approved and paid Rs.49,000/- under Ex.A7 and invoice Rs.19,316/- under Ex.A9 invoice but not paid  the remaining amounts.  The argument of opposite party in this regard is that as per Ex.A1 policy terms and conditions, the invoices under Ex.A7 and Ex.A9 were approved to that extent and paid.    Hence, the remaining part is rejected.

 

11.  But, a perusal of Ex.A1, does not disclose exemption of treatment given to the complainant in this case as contended by the opposite party.  There is no reason given by the 3^rd opposite party to approve only for Rs.49,000/- though invoice Ex.A7 was for Rs.99,287/-.  So, also no reason was given for excluding Rs.1,157/- from the amount under Ex.A9 invoice dated             04-09-2015.  Therefore, would not see any merit in the contention of opposite parties to reduce the amounts from the purview of the Ex.A1 policy.  Admittedly, the opposite parties collected premium from the complainant to the tune of Rs.6,100/-. The sum assured was Rs.2,75,000/-.  The policy was valid on the date, when the complainant was hospitalized and took treatment.  Since, there was valid insurance coverage to the complainant as per the policy terms and conditions under Ex.A1 for the treatment given to him by the hospital authorities the complainant is entitled for reimbursement of the medical claim from the opposite parties as per the invoice under Exs.A7 and A9 fully.  The total amount due by the opposite parties is Rs.57,976/-.  But, the opposite parties without assigning any reason rejected the claim of the complainant.  Therefore, we hold that there is deficiency in service on the part of the opposite parties in not honoring the invoices amounts under Exs.A7 and A9 in its entirety.  Therefore, the complainant is entitled for the amounts paid from his pocket to the hospital authorities under Exs.A7 and A9 and the opposite parties are liable to pay the remaining amount of Rs.57,976/- as claimed by the complainant with interest @9% p.a. from the date of filing of this complaint, apart from, compensation of Rs.10,000/- for mental agony and Rs.5,000/- towards costs of this complaint.  Accordingly,  points 1 and 2 are answered in favour of the complainant.

 

POINT NO.3: In the result, the complaint is allowed in part, directing the opposite parties 1 to 3 jointly and severally to pay Rs.57,976/- (Rupees seven thousand nine hundred and seventy six only)  with interest  9 percent (nine) p.a., from the date of the complaint i.e., 20-07-2016 till the date of realization and shall also pay Rs.10,000/- (Rupees ten thousand only) towards mental agony and Rs.5,000/- (Rupees five thousand only) towards costs of the complaint to the complainant within 45 days from the date of the receipt of the order.  Rest of the claim of complainant is dismissed without costs.

Dictated to the Stenographer, transcribed by her and corrected and pronounced by us in the Open Forum this the 25th day of  JULY, 2017.    

 

                Sd/-                             Sd/-                                      Sd/-

         MEMBER                          MEMBER                      PRESIDENT (FAC)

 

  APPENDIX OF EVIDENCE

 WITNESSES EXAMINED FOR COMPLAINANT:

 

PW1

18-01-2017

:

J.Syam Sundar Reddy, S/o.Balarama Reddy, aged 55 years, Hindu, advocate, and residing at Pedapadugupadu Village, Nellore District.

 

WITNESSES EXAMINED FOR OPPOSITE PARTIES:

 

RW1

28-02-2017

Srikalyan CH, S/o.Siva Ram Prasad, Hindu, aged 24 years, working as Administrative Officer in M/s. United India Insurance Company Limited, Nellore.

                                                                       

EXHIBITS MARKED FOR COMPLAINANT:

 

Ex.A1		:	Attested copy of Individual Health Insurance policy bearing No.151204284P104945753 issued by the United India Insurance Company Ltd., to the J.Syamsundara Reddy (complainant).
Ex.A2	30-07-2015	:	Copy of Initial prescription and report given by Yashoda hospital in favour of complainant.
Ex.A3	30-07-2015	:	Copy of receipt No.ORE65327/15 issued by Yashoda Hospital in favour of complainant.
Ex.A4	31-07-2015	:	Copy of Cash Memo bill No.C041053 issued by Lakshmi Medicals, inside Yashoda Hospital, Hyderabad in favour of complainant.
Ex.A5	31-07-2015	:	Copy of Cash Memo bill No.C008513 issued by Lakshmi Medicals, inside Yashoda Hospital, Hyderabad in favour of complainant.
Ex.A6	03-08 -2015	:	Copy of Pre-authorization approval letter addressed by VIDAL HEALTH third party administrator to the Yashoda Super Specialty Hospital, Hyderabad.
Ex.A7	03-08-2015	:	Attested copy of  invoice No.ICO86626 for total amount of Rs.99,287/- issued by Yashoda Super Specialty Hospital, Hyderabad in favour of the complainant along with pharmacy details.
Ex.A8	05-08-2015	:	Copy of Discharge summary issued by Yashoda Super Specialty Hospital, Hyderabad in favour of the complainant
Ex.A9		:	Attested copy of invoice No.ICO87625 for total amount of Rs.20,473/- issued by Yashoda Super Specialty Hospital, Hyderabad in favour of the complainant along with description copy.
Ex.A10	04-09-2015	:	Copy of In-patient deposit receipt issued by Yashoda Super Specialty Hospital, Hyderabad in favour of the complainant.
Ex.A11	04-09-2015	:	Copy of discharge summary issued by Yashoda Super Specialty Hospital, Hyderabad in favour of the complainant.
Ex.A12	01-04-2016	:	Copy of legal notice got issued by the counsel for the complainant to the second opposite party along with, original postal receipt and acknowledgement.

 

EXHIBITS MARKED FOR OPPOSITE PARTIES:   

 

Ex.B1		:	Attested copy of the conditions under Group Medi-claim Insurance Policy No.1512042814P104945753 issued by the United India Insurance Company Ltd., to the J.Syamsundara Reddy (complainant) and 3 others (complainant’s family members) for the period from 01-10-2014 to 30-09-2015.
Ex.B2	09-05-2016	:	Copy of cashless claim approval letter along with the Medi-claim computation issued by VIDAL HEALTH third party administrator, to the complainant.
Ex.B3	09-05-2016	:	Photo copy of the PRE-AUTHORIZATION Approval Letter to Yashoda Super Specialty Hospital Hyderabad from the VIDAL HEALTH third party Administrator.
Ex.B4		:	Photo copy of the claim denial letter to the complainant from the 3rd opposite party.

                

            

 

                                                                           Id/-

                                                                PRESIDENT (FAC)

 

Copies to:

 

1. Sri G.Babulu and Sri  N.Surendra Reddy, Advocates,

16-2-227A, Pogathota, Nellore – 524 001.

 

2. Sri P.V.Mallikarjuna Reddy, Advocate, 24/2/1456,

Milterey Colony, 1^st Line, Dargamitta, Nellore – 524 004.

 

3. Vidal Health TPA Pvt. Ltd., represented by its Managing Director,

First Floor, Tower No.2, SJR I Park, EPIP Zone, Whitefield,

Bangalore – 560066.       

 

                  

Date when order copies were issued: