BEFORE THE DISTRICT FORUM: KURNOOL
Present: Sri. T.Sundara Ramaiah, B.Com B.L., President
And
Sri. M.Krishna Reddy, M.Sc., M.Phil., Male Member
And
Smt. S.Nazeerunnisa, B.A., B.L., Lady Member
Monday the 23rd day of January, 2012
C.C.No.70/2011
Between:
S.Rami Reddy, S/o S.Venkata Reddy, Manager,District Co-operative Central Bank,
Resident of Flat No.205,Brindavan Pride,Near Brain and Heart Hospital,
Kurnool - 518 002.
…Complainant
-Vs-
1. Divisional Manager, Oriental Insurance Company Limited,
H.No.40/383, Bhupal Complex,Kurnool - 518 001.
2. General Manager, District Co-operative Central Bank,
H.No.46-1-C,Opp- Eye Hospital, Kurnool - 518 002.
...Opposite ParTies
This complaint is coming on this day for orders in the presence of Sri P.Siva Sudarshan, Advocate for complainant and Sri L.Hari Hara Natha Reddy, Advocate for opposite party No.1 and Sri K.Rama Krishna Rao, Advocate for opposite party No.2 and upon perusing the material papers on record, the Forum made the following.
ORDER
(As per Smt. S.Nazeerunnisa, Lady Member) C.C. No. 70/2011
1. This complaint is filed under section 11 and 12 of C. P. Act, 1986 praying to direct the opposite party No.1:-
- To pay the policy amount of Rs.55,329/- with interest @ 24% per annum from the date of operation to till the date of realization along with benefits;
- To grant a sum of Rs.20,000/- towards mental agony;
- To grant the cost of the complaint;
- To grant any other relief as the Honourable Forum deems fit and proper in the circumstance of the case.
2. The case of the complainant in brief is as under:- The complainant took Universal Health Scheme policy form opposite party No.1 through opposite party No.2 for the period from 28-07-2009 to 27-07-2010. The complainants wife is also covered under the said policy bearing No.433100/47/2010/3199. Opposite party No.2 is the employer of the complainant. The complainants wife took treatment in Fernandea Hospital, Hyderabad as in patient from 14-07-2010 to 17-07-2010 for abdominal histercotmy operation. The complainant incurred a sum of Rs.55,329/- towards medical expenses. After discharge from the hospital the complainant submitted the claim to opposite party No.1 through opposite party No.2. Opposite party No.1 repudiated the claim with unethical reason. Hence the complaint.
3. Opposite party No.1 filed written version stating that the complaint is not maintainable. It is admitted that the complainant took Universal Health Insurance Policy. It is admitted that the policy covers risk of the wife of the complainant. The policy was issued subjects to the terms and conditions. The wife of the complainant took treatment for Hysterctomy within one year. Therefore the expenses incurred by the complainant for Hysterctomy treatment need not be paid by the opposite party No.1. The complainant is not entitled for any amount.
Opposite party No.2 filed written version stating that there is no deficiency of service on its part. The repudiation of the claim by opposite party No.1 is illegally and unjust. The complaint is liable to be dismissed.
4. On behalf of the complainant Ex.A1 to A5 are marked and sworn affidavit of the complainant is filed. On behalf of the opposite parties Ex.B1 to B3 are marked and sworn affidavits of the opposite parties 1 and 2 are filed.
5. Both sides filed written arguments.
6. Now the points that arise for consideration are:
- Whether there is deficiency of service on the part of Opposite Parties?
- Whether the complainant is entitled for the reliefs as prayed for?
- To what relief?
7. POINTS i and ii:- Admittedly the complainant is the employee in opposite party No.2 bank. He obtained Ex.B1 Universal Health Insurance policy bearing No.433100/47/2010/3199 from opposite party No.1 through opposite party No.2. The period of the policy is from 28-07-2009 to 27-07-2010. The policy covers the risk of the wife of the complainant. It is the case of the complainant that his wife took treatment for Hysterctomy at Fernandus Hospital, Hyderabad from 14-07-2010 to 17-07-2010 and that he incurred an amount of Rs.55,329/- for treatment and expenses. The main contention of the opposite party No.1 is that the complainant is not entitled for any amount as his wife took treatment for Hysterctomy within one year of the policy. As seen from Ex.B1 it is very clear that it was issued subject certain terms and conditions. Ex.B2 contains the terms and conditions of the Universal Health Insurance Policy. As per condition No.4.3 of the policy the company is not liable to pay expenses incurred on treatment of disease such as Hysterctomy during the first year of the operation of the policy. Admittedly in the present case the wife of the complainant during the first year of the operation of the policy took treatment in Fernandus Hospital, Hyderabad for Hysterctomy. Therefore opposite party No.1 cannot be held liable for the amount incurred by the complainant for treatment of his wife for Hysterctomy during the first year of the service. It is submitted by the learned counsel appearing for the complainant that the terms and conditions of the policy were not supplied to the complainant at the time of taking the policy. Admittedly the opposite party No.2 obtained the policy from opposite party No.1 for the benefits of the complainant we don’t believe that opposite party No.2 without knowing the terms and conditions of the policy obtained Ex.B1 policy in favour of the complainant. As per conditions of policy the expenses incurred for Hysterctomy need not be paid by opposite party No.1. The opposite party No.1 rightly repudiated the claim.
8. The learned counsel appearing for the complainant cited a decision repudiated in I (2011) CPJ 25 (NC) where in the National Commission held that imposition of restriction in exclusion clause in policy was a unilateral action and no document placed to justify corporation’s action. The facts of the present case are entirely different from the facts of the case cited above. The contention of the complainant that he obtained the policy without knowing the terms and conditions of the policy cannot be believed. No deficiency of service is found on the part of the opposite parties. The complainant is not entitled for any reliefs.
9. In the result, the complaint is dismissed without costs.
Dictated to the stenographer, transcribed by her, corrected and pronounced by us in the open bench on this the 23rd day of January, 2012.
Sd/- Sd/- Sd/-
MALE MEMBER PRESIDENT LADY MEMBER
APPENDIX OF EVIDENCE
Witnesses Examined
For the complainant : Nil For the opposite parties : Nill
List of exhibits marked for the complainant:-
Ex.A1 Letter issued by opposite party No.1 to opposite party No.2
dated 18-08-2010.
Ex.A2. Office copy of Letter issued by complainant to
opposite party No.1 dated 24-07-2010.
Ex.A3 Photo copy of Universal Health Insurance Claim Form
dated 14-07-2010.
Ex.A4 Photo copy of Case Summary issued by Fernandez Hospital
Private Limited, Hyderabad dated 14-07-2010.
Ex.A5 Photo copy of Universal Health Insurance Policy
No.433100/47/2010/3199.
List of exhibits marked for the opposite parties:-
Ex.B1 Universal Health Insurance Policy
No.433100/47/2010/3199.
Ex.B2 Universal Health Insurance Policy terms and conditions.
Ex.B3 Photo copy of Repudiation Letter dated 18-08-2010.
Sd/- Sd/- Sd/-
MALE MEMBER PRESIDENT LADY MEMBER
// Certified free copy communicated under Rule 4 (10) of the A.P.S.C.D.R.C. Rules, 1987//
Copy to:-
Complainant and Opposite parties :
Copy was made ready on :
Copy was dispatched on :
