Date of filing: 22-07-2013.
Date of disposal: 01-11-2013.
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM - II:
VIJAYAWADA, KRISHNA DISTRICT
Present: Sri A. M. L. Narasimha Rao, B.Sc., B. L., President
Smt N. Tripura Sundari, B. Com., B. L., Member
Sri S. Sreeram, B.Com., B.A., B.L., Member
Friday, the 1st day of November, 2013
C.C.No.139 of 2013
Between:
Smt Kalidindi Sakuntala, W/o Kalidindi Appala Raju, Hindu, Aged about 66 years, Housewife, R/o.D.No.8-2, Plot No.G-8, Rajasri Towers, Kamayyathopu, Vijayawada – 520007, Krishna District.
... Complainant
And
1. Branch Manager, M/s Star Health and Allied Insurance Co., Ltd., Branch Office, D.No.40-1/1-17, Adarsh Nagar, Opp: Chennupati Petorl Bunk Road, Moghalrajpuram, Vijayawada – 10.
2. Chief Authorized Signatory, M/s Star Health and Allied Insurance Co., Ltd., Corporate Office, 1, New Tank Street, Valluvar Kottam High Road, Nungumbakkam, Chennai – 600034, Tamilnadu Street.
. … Opposite Parties.
This complaint is coming before for final hearing on 30-10-2013 in the presence of Sri B. Raghava Rao, advocate for complainant, Sri N. Sridhar, advocate for opposite parties, and having stood over for consideration till this day, the Forum doth order the following:
ORDER:
(Delivered by Hon’ble Member Sri S. Sreeram)
This complaint is filed by complainant under Section 12 of Consumer Protection Act, 1986 directing the opposite parties to pay Rs.21,888/- together with interest at 18% p.a. from the date of filing the complaint till realization, to pay Rs.20,080/- towards expenses incurred by the complainant, to pay Rs.20,000/- towards expenses for approaching Ombudsman and opposite parties.
1. The brief averments of the complaint are as follows:
The complainant who is a senior citizen took Senior Citizens Red Carpet Insurance Policy from the 1st opposite party in the year 2011 for an assured sum of Rs.1,00,000/- on payment of premium and the same is renewed in the year 2012 and the policy Number is P/131211/01/202/004973 and valid from 18-2-2012 to 17-2-2013 and the same was again renewed. It is further averred that all of a sudden the complainant lost her left eye vision and took treatment in LV Parasad Eye Insitute, Hyderabad and before taking treatment, the complainant informed the same to the opposite parties and spent Rs.32,087/- towards operation and medicines in addition to traveling, boarding and lodging charges of Rs.20,080/-. Later the complainant approached the opposite parties 1 and 2 for reimbursement of Rs.32,087/-, but in vain. The complainant approached the Insurance Ombudsman and while the matter is pending, the opposite parties 1 and 2 sent a DD for Rs.14,674/- on 17-11-2012 towards full and final settlement and the complainant received the same under protest. Later the Insurance Ombudsman passed order on 20-6-2013 with a direction to the opposite parties to pay Rs.5,600/- for short settled amount without any delay. It is further averred that though the opposite parties are liable to reimburse the entire amount, paid only Rs.14,674/- by violating the terms and conditions of policy. Hence the complainant is constrained to file the present complaint.
2. After registering the complaint, notices were sent to the opposite parties, Opposite parties filed vakalat, since the opposite parties have not filed versions no further steps are needed.
3. The complainant filed his affidavit and got marked Ex.A1 to A20. None is examined on behalf of opposite parties.
4. Heard complainant and perused the record and written arguments filed by the complainant.
5. Now the point that arises for consideration in this complaint are:
- Whether there is any deficiency in service on the part of the opposite parties 1 and 2 in not settling the claim of complainant?
- If so is the complainant entitled for the reliefs as prayed for?
6. Point No.1: The admitted facts are that the complainant obtained the Senior Citizens Red Carpet Insurance Policy bearing No. P/131211/01/202/004973 from the 1st opposite party and renewed the same in the year 2012 and 2013 by paying requisite premiums and the same is in force. Ex.A17 to A19 disclose the same. The other admitted facts are that the complainant got treatment to her left eye as the vision become poor, at L.V. Prasad Eye Institute, Hyderabad on 18-4-2012, which is evident from Ex.A2 and spent Rs.28,000/- which is evident from bill under Ex.A1. Thereafter the complainant approached the opposite parties 1 and 2 for reimbursement of an amount of Rs.32,087/- (i.e. Rs.28,000/- towards medicines etc., Rs.3,413/- towards pre hospitalization expenses and Rs.674/- towards post hospitalization expenses). But the opposite parties repudiated the claim under Ex.A3 on the ground that the complainant is not an inpatient and that she was admitted in the hospital on 18-4-2012 and discharged on the same day and that she was not in the hospital for 24 hours and as such violated the condition of policy. Aggrieved by the same, the complainant made lot of correspondence with the opposite parties, which is evident from Ex.A4 to A8. Finally the complainant approached the Insurance Ombudsman, Hyderabad for redressal of her grievance. While so, the opposite parties 1 and 2 sent a letter dt.12-11-2012 to the complainant stating that they have considered the claim and settled the same by applying 50% co-pay for pre existing disease and sent a D.D for Rs.14,674/- and the complainant received the same under protest. Subsequently the Insurance Ombudsman passed an order on 20-6-2013 in Complaint No.I.O(HYD)G-11-16-253/2012-2013 directing the opposite parties to pay another sum of Rs.5,600/- by applying exclusion clause No.5 of policy and by holding that the disease of complainant is not a preexisting disease.
7. Now the main grievance of the complainant is that the ground of repudiation by the opposite parties that the complainant is not an inpatient as she discharged on the same day is not valid and that the complainant has not suffered with any preexisting disease. Admittedly as seen from the record, in the first instance, the opposite parties repudiated the claim on the ground that the complainant was discharged on the same day and subsequently took a plea before Ombudsman that the complainant suffered with preexisting disease. As stated above, the Hon’ble Insurance Ombudsman has held that the complainant was not suffered with any preexisting disease and ordered to pay the balance amount. As such there is no need to discuss the said ground for repudiation. So far as the other ground is concerned i.e. the complainant not stayed at hospital for 24 hours, as seen from record, the opposite parties totally repudiated the claim in the first instance. But after the complainant approached the Ombudsman, they considered the claim and settled an amount of Rs.14,674/- and sent D.D for the same. In this regard, the contention of complainant is that, in the present days there is no need to stay in the hospital for 24 hours in view of sophisticated equipment and that the repudiation of claim on the said ground is not plausible and the opposite parties are liable to pay Rs.32,087/-. In support of her contention, she filed Ex.2 certificate issued by Asst.Director, Patient Care Service, LV Prasad Eye Institute, Hyderabad wherein it is clearly mentioned that surgery was done under day care procedure and as per the procedure, 24 hours admission is not required.
8. A perusal of record discloses that, though the opposite parties 1 and 2 received the notices in the present complaint since the opposite parties has not filed versions. Therefore, the claim of the complainant is deemed to be admitted by the opposite parties 1 and 2. Exs. A1 to A20 remained unquestioned and unchallenged. Accordingly the complainant proved her case. Unless the opposite parties 1 and 2 put forth their version by stating the grounds for their repudiation and about the co-pay clauses and about non payment of pre hospitalization expenses etc., it is very hard to ascertain whether the opposite parties acted deligently in repudiating the claim. As they admitted the claim of complainant to some extent and as they failed to put forth their version, will have to decide on the basis of the material placed by the complainant. According to Ex.A1, the total claim is for Rs.32,087/-. It includes the operation charges of Rs.28,000/-, prehospitalization expenses and posthospitalization expenses. According to Clause 5 of exclusion noted in Ex.A20, 30% of the expenses are not payable in all cases. So the complainant was entitled to 70% of operation charges, which comes to Rs.19,600/- towards operation charges. The opposite party has allowed Rs.674/- as posthospitalization expenses. It is infact more than for relevant items noted in Ex.A1. So we may allow it. Then the amount payable comes to Rs.20,274/-. The opposite parties initially paid Rs.14,674/- on 12.11.2012 and later paid Rs.5,600/- on 11.7.2013 i.e., after just before this complaint was filed. Thus the opposite parties has paid entire amount of Rs.20,674/-. However since the payment of Rs.5,600/-from 12.11.2012 to 11.7.2013 at a reasonable rate of interest 9% p.a. We may also allow nominal costs as the opposite party had deposited the amount of Rs.5,600/- after the Ombudsman had given order. We asses the costs at Rs.500/-.
9. In the result, the complaint is allowed partly and the opposite parties 1 and 2 are directed to pay Rs.336/- (Rupees three hundred and thirty six only) to the complainant towards interest and costs of Rs.500/-. The other claims of complaint are hereby dismissed. Time for compliance is one month from the date of receipt of this order.
Type written by Steno N. Hazarathaiah, corrected by me and pronounced by us in the open Forum, this the 1st day of November, 2013.
PRESIDENT MEMBER MEMBER
Appendix of evidence
Witnesses examined
On behalf of the complainant: On behalf of opposite parties:
Smt Kalidindi Sakuntala (by affidavit) None.
PW-1
Documents marked
On behalf of the complainant:
Ex.A1 Photocopy of claim form.
Ex.A2 21-05-2012 Copy of medical report issued by LV Prasad Eye Institute.
Ex.A3 30.03.2012 Photocopy of status of intimation letter.
Ex.A4 18.05.2012 Copy of claim/final notice by Ops.
Ex.A5 Postal acknowledgement.
Ex.A6 06.07.2012 Copy of complaint by policy holder.
Ex.A7 Postal acknowledgement.
Ex.A8 26.07.2012 Photocopy of letter issued by OP to complainant.
Ex.A9 16.08.2012 Photocopy of petition filed by complainant to OP.
Ex.A10 Postal acknowledgement.
Ex.A11 04.09.2012 Photocopy of complaint by complainant to insurance ombudsman.
Ex.A12 Postal acknowledgement.
Ex.A13 12.11.2012 Copy of letter issued by OP to complainant and DD.
Ex.A14 19.11.2012 Photocopy of underprotest letter.
Ex.A15 19.11.2012 Photocopy of underprotest letter.
Ex.A16 24.06.2013 Photocopy of letter issued by ombudsman to complainant.
Ex.A17 Senior citizens red carpet insurance policy copy.
Ex.A18 Senior citizens red carpet insurance policy copy.
Ex.A19 Senior citizens red carpet insurance policy copy.
Ex.A20 Star Senior citizens red carpet insurance policy copy.
On behalf of opposite parties: NIL
PRESIDENT
