KADAPA YSR DISTRICT
PRESENT SMT. K. SIREESHA, B.L., PRESIDENT FAC
SRI M.V.R. SHARMA, MEMBER.
Friday, 4th July 2014
CONSUMER COMPLAINT No. 79/ 2013
M. Sreenivasulu, S/o M. Krishna Murthy,
Aged about 47 years, R/at D.No. 18/467,
B.K.M. Street, Kadapa. Complainant.
Vs.
1) Bank of Baroda, Rep. by its Manager, C.B. Road,
Opp. Little flowers School, Chittoor – 517 001.
2) Bank of Baroda, Rep. by its Manager,
Near 7 Roads, Kadapa.
3) The National Insurance Co. Ltd., Rep. by its
Regional Manager, Regd. Office. 3, Middleton Street,
Post B ox No. 9229, Kolkata – 700071.
4) The National Insurance Co. Ltd., Rep. by its
Branch Manager, 2nd floor, 10-3-74, PVN Complex,
Sheshapeeran Street, Chittoor – 517 001.
5) The National Insurance Co. Ltd., Rep. by its
Branch Manager, Near Kotireddy Womens College,
Kadapa.
6) The Heritage Health TPA Ltd., Rep by its
Regional Manager, R.O. 510, 5th floor,
Babukhan Estate, Basheerbagh, Hyderabad – 5. Respondents.
This complaint coming on this day for final hearing on 25-6-2014 in the presence of Sri G. Trivikram Singh and V. Satish Kumar, Advocates for complainant and Sri P. Goutam Kumar, Advocate for R2 & R5 and R1, R3, R4 and R6 called absent and set exparte on 20-3-2014 and upon perusing the material papers on record, the Forum made the following:-
O R D E R
(Per Smt. K. Sireesha, President FAC),
1. Complaint filed under section 12 of C.P. Act 1986.
2. The brief facts of the complaint are as follows:- The complainant is deposit holder in the bank of R1, R2 is a branch of R1. The R1 bank has tie-up with R3 Insurance Company for the sake of health policy to its deposit holders. R4 and R5 are the branch offices of R3. In turn the R3 has tie-up with 3rd party i.e. R6 to provide insurance to the customers of R1 & R2. Accordingly the R3 got issued a group insurance policy in favour bearing No. 552201/41/11/85/00000342 for a period of one year staring from 19-12-2011 to 18-12-2012 in favour of under the name and style “Baroda Health Policy” as for the terms and conditions complainant of the policy in case of hospitalization the R3 to R6 are liable to indemnify the expenses incurred by the complainant.
3. While so, on 26-9-2012 the complainant admitted in Padmachandra Super Speciality Hospital on the complaint of severe pain in left hip since two months. The doctors at Padmachandra Super Speciality Hospital, Kurnool diagnosed the problem of complainant as vascular necrosis left hip and conducted surgery of total left hip replacement on 01-10-2012. The complainant has incurred Rs. 3,94,191/- towards his medical treatment and for hospitalization charges. After the discharge, the complainant contacted with respondents and submitted all original medical bills, discharge summary and all other relevant documents with claim form on 22-11-2012. After receipt of claim form the complainant, the R3 and R4 have forwarded the same to R6. After the lapse of several months the respondents did not prefer to settle the claim of complainant. On that the complainant got issued a legal notice dt. 5-3-2013 to the respondents calling upon them to settle his genuine claim. But there was no response from them.
4. To his utter surprise the complainant has received a letter dt. 16-2-2013 from R6 calling upon him to submit original documents and bills. The complainant was puzzled after reading the letter. Even though the complainant submitted all required original documents he was asked to submit the documents once again. With great patience the complainant submitted reply to the R6 including other bills. Though the R6 received all required documents in original from the complainant, he had not taken any steps for settlement of mediclaim. He has been dragging the matter on one or other pretext. Being the holder of medi claim policy the complainant is entitled to claim the medical expenses incurred by him for his treatment. The respondents are liable to indemnify to the complainant. The services of respondents are deficient in nature they are liable to pay the entire expenses incurred by the complainant towards his hospitalization charges under the above medi claim policy. The acts of the respondents lead to mental agony and physical strain to the complainant. The respondents are liable to pay the compensation to the complainant for causing mental agony and physical strain. Hence, this complaint.
5. The Hon’ble forum has jurisdiction to entertain the present complaint as the respondents have branch office within the jurisdiction of the Hon’ble forum and cause of action arose on 19-12-2011 when the complainant obtained health insurance from the respondents and when he was hospitalized and incurred huge amounts towards his treatment and when the respondents did not settle his claim within the jurisdiction of the Hon’ble forum at Kadapa. A fee of Rs. 200/- is paid by way of I.P.O.
6. Therefore, it is prayed that the Hon’ble forum may be pleased to allow the complaint and pass orders in favour of the complainant and directing the respondents (a) to pay the amount of Rs. 3,94,191/- towards hospitalization charges incurred by the complainant together with 24$ interest from the date of making the claim till the date of realization, (b) to pay compensation of Rs. 1,00,000/- for causing physical strain and mental agony and (c) to pay Rs. 3,000/- towards the cost of the complaint and other reliefs as the Hon’ble Forum deems fit and proper in the circumstances of the case.
7. The counter filed by R2. The allegations in the complaint made by the complainant against this respondent are neither just nor maintainable either in law or on facts of the case.
8. The complainant is put to strict proof of all the allegations mentioned in the complaint which are not expressly and specifically admitted herein by this respondent.
9. It is submitted that the allegation in para – 1 of the complaint that the complainant is the deposit holder bearing S.B. Account No. 323201000007900 in the bank of R1 and R2 is one of the branch of Bank of Baroda at Kadapa is true. It is also true that this respondent bank has tie-up with the R3 Insurance Co. for the sake of health policy to its deposit holders and that the R4 and R5 are the Branch offices of the R3. The further allegation in the same para that the R3 has tie-up with 3rd party i.e. R6 to provide insurance to the customers of R1 and R2 is also true. The other allegations in the same para that the complainant took group insurance policy issued by R3 bank bearing Policy No. 552201/48/11/8500000342 valid from 19-12-2011 to 18-12-2012 under the name of Baroda Health Policy is also true, but the sum assured in the policy for total family members consisting of complainant, his wife and two children for a sum of Rs. 3,00,000/-.
10. It is submitted that all the other allegations mentioned in para – 2 & 3 have to be strictly proved by the complainant with all documentary evidence.
11. This respondent humbly submits that the complainant has submitted his claim form on 22-11-2012 to this respondent and the same is forwarded to R4, who in turn send the same to R6 for settlement of the claim.
12. It is humbly submitted that in all aspects this respondent is hereby adopting the counter filed on behalf of the R5, in the interest of justice and equity. This respondent, therefore, prays that the Hon’ble forum be pleased to dismiss the complaint of the complainant with exemplary costs against this respondent, in the interest of justice.
13. The counter filed by R5, The allegations in the complaint made by the complainant against this respondent are neither just nor maintainable either in law or on facts of the case.
14. The complainant is put to strict proof of all the allegations mentioned in the complaint which are not expressly and specifically admitted herein by this respondent.
15. It is submitted that the allegation in para – 1 of the complaint that the complainant is the deposit holder in the bank of R1 and R2 is the branch of R1 is to be strictly proved by the complainant. The further allegations of R1 bank has tie-up with R3 Insurance Company for the sake of health policy to its deposit holders. The R4 and R5 are the branch offices of R3 is true. The allegations in the same para that the R3 has tie-up with 3rd party i.e. R6 to provide insurance to the customers of R1 and R2 is also true. The other allegation in the same para that the complainant took group insurance policy issued by R3 bank bearing No. 552201/48/11/8500000342 valid from 19-12-2011 to 18-12-2012 under the name of Baroda Health Policy is also true, but the sum assured in the policy for total family members consisting of complainant, his wife and two children for a sum of Rs. 3,00,000/-.
16. It is submitted that it is pertinent to note that this policy issued by the R1 covering the risk of the group i.e. family members of the complainant consisting of complainant, his wife and two children for a sum assured i.e. Rs. 3,00,000/-. As per terms of the policy which is clearly mentioned in the policy that the benefit for pre-existing disease will accrue only after the completion of 36 months. Hence, this policy took by the complainant and that he is not entitled for any coverage of pre-existing diseases. It is submitted that according to the exclusionary clause 4 (1) of policy conditions the insurance coverage of pre-existing disease accrued only after expiry of three years from the date of inception of the policy provided if the insured keeps payment regularly. In the present case the disease of complainant is pre-existing and it is not a sudden disease. The maximum sum payable to insurer in case of disease within the ambit of policy would be Rs. 50,000/- only and it may range higher in case of coverage of insurance for entire family. As per condition 5 (1) of the policy in the event of any misrepresentation, mis-description or non-disclosure of any material fact the policy shall be void and all the premiums paid herein shall be forfeited to the company.
17. It is submitted that the complainant is having an account with Bank of Baroda i.e. R1 at Chottoor. It is true that he is having coverage of medi claim with the conditions prescribed in the policy. It is submitted that the policy has been issued by R6 in association with this respondent i.e. National Insurance Company.
18. The complainant submitted a claim stating that he underwent a surgery of left hip which planted at Padma Chandra Super Speciality Hospital, Kurnool. The surgery conducted upon the complainant was said to be Vascular Necrosis left hip and submitted certain papers for settlement of his claim. But he has not submitted all the records which include hospitalization bills, pre hospitalization medical history and the invoice for implants and first consultation papers with investigation reports as per clause 5 (3) (4) of conditions of policy. But he has not chosen to submit the said records enabling the insurer to settle the claim. Hence, reminders dt. 28-11-2012, 16-2-2013 and 25-2-2013 were issued to him by clearly mentioning the documents required for settlement of claim in serial number. However, he got issued a notice through his advocate and attempted to avoid the submission of documents. The R6 has also issued a reply to the said notice. The complainant is well educated man and he knows terms and conditions of the policy and also its implications. The complainant has also sent a letter dt. 10-4-2013 acknowledging the reply notice dt. 30-3-2013.
19. It is submitted that there must be premedical history before undergoing surgery in Padmachandra Super Speciality Hospital, Kurnool and implantation of hip will not be a sudden result of ailment. In the first instance there must be conservative treatment for the said ailment and it consists of 5 stages and the implantation will be done at 5th stage and the implantation will be done at 5th stage which is final stage required long duration. Hence, the complainant has to submit the premedical history. The hospital has to purchase the implants under proper invoice and there must be proof of implantation as this type of operations is rear operations in this type of hospital. Mere certificate or unauthorized documents will not give right to the complainant to claim that he underwent certain surgery.
20. It is submitted that the complainant cannot file the complaint claiming the amount according to his vhims and fancies. It is false to say that the complainant has incurred an amount of Rs. 3,94,191/- towards his medical treatment and for hospitalization charges. It is also false to say that the complainant has submitted all the documents required and the insurer failed to settle the claim and that the matter has been dragged. The services of the respondents are insufficient in nature. In any event asking the complainant to produce the documents leally for settlement of the claim cannot be styled as deficiency in service. In fact the complainant is avoiding to submit the documents as his claim is false and without basis. The complainant was informed to produce the documents required for settlement of the claim by the insurer. As he failed to submit the same after giving reasonable opportunity the claim was repudiated. The repudiation by speaking order will not amount to deficiency of service. The settlement of claim must be basing on all the documents required and in shortfall would entitle the company to repudiate the claim as the insurance companies are dealing with public money. They are the trustees of public money and they cannot disburse the amount without proof of claim. The repudiation by the company is bonafide and by applying the mind. Hence, the same cannot be challenged before this Hon’ble authority.
21. All the allegations in the complaint which are not specifically denied are all false and invented. Suffice it to say that the complainant has to prove his case on his own documents and absolutely no documents is forthcoming to show the alleged claim is genuine.
22. The respondent, therefore, prays that the Hon’ble authority be pleased to dismiss the complaint of the complainant with exemplary costs against this respondent in the interest of justice.
23. On the basis of the above pleadings the following points are settled for determination.
- Whether the complainant is eligible for compensation as prayed by the complainant?
- Whether there is negligence or deficiency of service on the part of the Respondents?
- To what relief?
24. On behalf of the complainant Ex. A1 to A6 were marked and on behalf of the respondents Ex. B1 to B7 were marked.
25. Point Nos. 1 & 2. It is an admitted fact that the complaint is the deposit holder in R1’s bank had tie-up with R3 Insurance Company for the sake of health policy to its deposit holders. R4 and R5 are the branch offices of R3. R3 tie-up with 3rd party i.e. R6 to provide insurance to the customers of R1 & R2. As per Ex. B1 issued by R3 is a group insurance bearing No. 552201/41/11/85/00000342 for a period of one year commences from 19-12-2011 to 18-12-2012 in the name and style “Baroda Health Policy”. As per terms and conditions of the policy in case of hospitalization of the complainant the R3 & R6 are liable to indemnify the expenses incurred by the complainant. Ex. B1 is policy bond issued by R3. Ex. A1 clearly shows that the complainant had health policy with R3, who was tie-up with R6. Ex. A2 and B1 are same. Ex. B3 clearly shows that the complainant was admitted at Padmachandra Super Speciality Hospital and underwent surgery of total left hip replacement on 01-10-2012. Ex. A4 clearly shows that the complainant had incurred expenses to a tune of Rs. 3,94,191/-. After surgery the complainant had send all relevant documents for settlement of the claim to R3 & R4. The complainant had send the claim form along with documents for settlement of the claim. The health policy of the complainant under the name and style of “Baroda Health Policy” is for a sum of Rs. 3,00,000/- as per Ex. A2, B1 and counter of R2. As per counter of R2 it is very clear that the complainant had submitted the claim form on 22-11-2012 and the same claim form was forwarded to R4, who in turn send it to the R6 for settlement of the claim.
26. Ex. B2 was issued by R6 for additional documents from the complainant. Ex. B2, B3 and B4 are all one and same. Ex. A5 and B5 are same, which is a legal notice issued by the complainant to R1, R4 and R6 for settlement of his claim. As per counter of R5 they says that it is a pre-existing disease and the hip implantation needs 5th stages and the last 5th stage is the implantation surgery. The R5 is not clear that what are the remaining four stages of the treatment are?, Sometimes the ailments will be very severe in nature and they will occur suddenly in chronic stage which definitely needs implantation or replacement. Nobody will go for implantation and replacement or surgeries for the sake of claiming medi-claim or any insurance policies. Now a days the doctors are not finding why the diseases are in chronic stage. Nobody will say, when the human being can get severe diseases. There is no guarantee for the life. There is no age limitation to get diseases. Here the respondents did not disclosed the stages of the hip implantation, when the implantation of hip requires five stages, it is the burden of the respondents to prove the five stages. The insurance companies are trustees of public monies only, they are not giving their own money. The R5 in his counter requested the complainant for invoice of implants which were implanted in his left hip. No hospital will issue the invoice of the instruments which they import from the companies. There is no meaning in asking for invoice of implants by the respondents. In the above circumstances it is very clear that there is deficiency of service on the part of the respondents 1 to 6. As the policy was inforce at the time of surgery of the complainant. It is bounded duty of the respondents to settle the claim of the complainant. The respondents are utterly failed to discharge their duties. It amounts to deficiency of service on the part of the respondents 1 to 6. At the same time the complainant is eligible for compensation as prayed by him.
27. Point No. 3 In the result, the complaint is allowed, directing the respondents 1 to 6 jointly and severally liable to pay Rs. 3,00,000/- the sum assured under medi-claim policy (Rupees three lakhs only) to the complainant, to pay Rs. 20,000/- (Rupees twenty thousand only) towards physical strain and mental agony and Rs. 3,000/-(Rupees three thousand only) towards cost of the complaint, within 45 days of date of receipt of orders.
Dictated to the Stenographer, transcribed by him, corrected and pronounced by us in the open Forum, this the 4th July 2014
MEMBER PRESIDENT FAC
APPENDIX OF EVIDENCE
Witnesses examined.
For Complainant NIL For Respondents : NIL
Exhibits marked for Complainant : -
Ex. A1 Attested copy of insurance card issued by the respondents.
Ex. A2 Attested copy of insurance policy issued by R3.
Ex. A3 Attested copy of discharge summary dt. 6-10-2012 issued by Padma
Chandra Super Speciality Hospital, Kurnool.
Ex. A4 Attested copy of discharge bill for Rs. 3,94,191/- issued by Padma
Chandra Super Speciality Hospital, Kurnool.
Ex. A5 Legal notice dt. 5-3-2013 issued by the complainant to the
respondents 3 in number and 3 postal receipts and 2 postal Ack.cards. A6 Letter dt. 16-2-2013 issued by the R6 to the complainant.
Exhibits marked for Respondents: -
Ex. B1 Policy copy bearing No. 552201/48/11/8500000342 issued by the R3
along with terms and conditions.
Ex. B2 Reminder dt. 28-11-2012.
Ex. B3 Reminder dt. 16-2-2013.
Ex. B4 Final reminder dt. 25-2-2013.
Ex. B5 Copy of legal notice issued by the Advocate for the complainant.
Ex. B6 Reply notice dt. 30-3-2012 issued by the R6 to the Advocate for the
complainant.
Ex. B7 Letter dt. 10-4-2013 sent by the complainant.
MEMBER PRESIDENT FAC
Copy to :-
- Sri G. Trivikram Singh and Sri V. Satish Kumar, Advocate for complainant.
- Sri P. Goutham Kumar, Advocate for R2 & R5.
- Bank of Baroda, Rep. by its Manager, C.B. Road,
Opp. Little flowers School, Chittoor – 517 001.
- The National Insurance Co. Ltd., Rep. by its Regional Manager, Regd. Office. 3, Middleton Street, Post B ox No. 9229, Kolkata – 700071.
5. The National Insurance Co. Ltd., Rep. by its Branch Manager, 2nd floor, 10-3-74, PVN Complex,
Sheshapeeran Street, Chittoor – 517 001.
6. The Heritage Health TPA Ltd., Rep by its Regional Manager, R.O. 510, 5th floor, Babukhan Estate, Basheerbagh, Hyd.-5
B.V.P.
