Date of filing:       26.02.201

                                                             Date of Disposal:  17.04.2015

                                 BEFORE THE DISTRICT CONSUMER FORUM-II, EAST GODAVARI

                                                              DISTRICT AT RAJAHMUNDRY

                                   PRESENT:  Sri B.Vinay Kumar, B.Sc., B.L., PRESIDENT

                                                      Smt H.V. Ramana, B.Com., L.L.M., MEMBER.

                  Sri A. Madhusudana Rao, M.Com., B.L., MEMBER          

                                                         CONSUMER COMPLAINT No.9 /2013

                                                               Friday, the 17^th day of April, 2015

Between:-

1)  Posimsetti Anandrao, S/o.late Subbarao, 28 years,

      Hindu, Software Engineering employee,

      BA Continuum Private Limited, native of Pasarlapudi

      Badava village, Mamidikuduru Mandal, East Godavari Dist. 

2)  Smt.Posimsetti Satyavathi, W/o.late Subbarao, 50 years,

      Pasarlapudi Badava village, Mamidikuduru Mandal,

      East Godavari Dist.                                                                      …   Complainants

                                                And

1)  K.V. Ramana Kumar, M.S. (Ortho),

      Sai Leela Orthopedic Hospital, Yerramilli Street,

      Amalapuram.

2)  Dedicated Health Care Services TPA (India) Private Ltd.,

      Rep. by its authorized signatory, Cambata Building,

      RWS Theatre, Andheri Building, East Wing, 2^nd Floor,

      42, Maharshi Kare Road, Church Gate, Mumbai.

3)  United India Insurance Company Limited,

      Represented by its Branch Manager, Noida.                                …   Opposite parties

This case is coming on 31.03.2015 for final hearing before this Forum and upon perusing the complaint, and other material papers on hand and upon hearing the arguments of Sri B. Sitaramaih, Advocate for the complainants and Sri B.N. Prasad, Advocate for the opposite party No.1;  the opposite party No.2 having been set exparte and Sri B. Ramesh, Advocate for the opposite party No.3, and having stood over for consideration till this day, this Forum has pronounced the following.

O R D E R

(Per Smt. H.V. Ramana, Lady Member)

This is a complaint filed by the complainants under section.12 of the Consumer Protection Act, 1986 to direct the 1^st opposite party to pay an amount of Rs.1,41,500/- with interest @ 18% p.a. from 4.8.2012, the date of operation conducted on the 1^st complainant till the date of payment; award compensation of Rs.1,00,000/- towards mental agony and hardship and award costs of the complaint.

2.         The case of the complainant is that the 1^st complainant has obtained Medi claim policy No.222200/48/11/41/00001275 covering the mediclaim to his parents vide DHS ID No.MO 221195975.  The 2^nd complainant, who is the mother of the 1^st complainant approached the 1^st opposite party as she was suffering from acute pain in the hip joints.  The 1^st opposite party checked her and suggested to undergo joint replacement surgery for the right leg.  The 2^nd complainant admitted in the hospital of the 1^st opposite party on 1.8.2012 as inpatient as I.P.No.56/12.  The operation was conducted on 4.8.2012 and she was discharged on 18.8.2012. Even after the discharge from the hospital, he has been treated as outpatient and she took medicines as per the prescription of the 1^st opposite party.  The 1^st opposite party collected an amount of Rs.1,41,500/- towards fee, medicines etc.  The 1^st complainant submitted claim for reimbursement along with all the relevant bills.  The 2^nd opposite party repudiated the claim on 4.12.2012 on the ground that the hospital of the 1^st opposite party as only ten beds and the registration certificate is not valid for the current year.  After repudiation of the claim, the complainants got issued a registered legal notice to the 1^st opposite party dt.18.12.2012.  The 1^st opposite party received the notice and did not give any reply.  Hence, the complaint.

3.         The 1^st opposite party filed written version and denied all the allegations made in the complaint. It is submitted that this opposite party i.e. Dr. K.V. Ramana Kumar has obtained his Degree of M.S. (Ortho) from Nizams Institute of Medical Sciences, Hyderabad, the university of excellence.  It is recognized by the Medical Council of India which is highest National Authority of recognition of medical (Graduate and Post Graduate) degrees.  This opposite party established Orthopedic Hospital at Amalapuram in the year 1995 and is regularly conducting so many surgeries of highest nature and his clients who are having insurance coverage and getting medical reimbursement of expenses without any objections from any authority till today.  It is submitted that the complainants showed the policy copy for which the 1^st opposite party gave consent for doing surgery are incorrect.  It is in between the patient and the opposite parties 2 and 3 only.  The 1^st opposite party is nothing to do with the policy.  The operation was done successfully and there is no complaint from the complainants regarding the surgery.  The complainants contacted the 1^st opposite party after issuance of legal notice for which the 1^st opposite party replied that reimbursement is in between the complainants and the opposite parties 2 and 3.  It is submitted that this opposite party is running 10 bedded hospital since 1995 and the registration came into force since 2007.  The 1^st opposite party submitted all the documents and paid the prescribed fee to the District Registration Authority, Kakinada long long ago, consequently the team of inspectors from the D.R.A. have inspected their hospital and given satisfactory report on 30.7.2012.  The 1^st opposite party is nothing to do with the insurance coverage, it is in between the complainants and the 2^nd and 3^rd opposite parties.  Hence, there is no deficiency of service on the part of this opposite party and the complaint is liable to be dismissed with exemplary costs.

4.         The 3^rd opposite party filed written version.  This opposite party submit that the 1^st complainant is a software engineering employee of BA Continuum Private Limited is denied because there is no such supporting documents filed in this case.  It is submitted that this opposite party denied that the 1^st complainant through his employer obtained Mediclaim policy as employee No.20046723 covering the medical claims of his parents vide DHS ID No.MO221195975 from this 3^rd opposite party.  It is submitted that the complainants neither filed any document about repudiation made by this 3^rd opposite party except repudiation made by the 2^nd opposite party.  The complainants not filed any policy with terms and conditions issued by the 3^rd opposite party. It is true that the 2^nd opposite party rightly repudiated the claim because “the 1^st opposite party has only ten beds and its registration certificate is not valid for the current year” and as such question of deficiency of service does not arise.  It is submitted that the complainants must go through the contents of the policy under contract of insurance if any valid insurance policy is in existence and they ought to have verify whether the 1^st opposite party hospital has sufficient infrastructure with inpatient beds and satisfied the conditions of the policy or not.  It is irrelevant that the 1^st opposite party has gone through the policy and assured that the surgical treatment in his hospital is within the four corners of the conditions of the policy and the complainants hypothetically believed that the expenses of the surgical treatment could be claimed under the policy is not correct.  Hence, there is no deficiency of service on the part of this opposite party and the complaint is liable to be dismissed.

5.         Proof affidavit of 1^st complainant filed and Exs.A1 to A7 have been marked on behalf of the complainants. Proof affidavits of 1^st & 3^rd opposite parties. Exs.B1 to B6 have been marked on behalf of the 1^st & 3^rd opposite parties. Complainants filed their written arguments and the 1^st & 3^rd opposite parties filed their written arguments.

6.         Heard both sides.      

7.         The points that arise for consideration are:

      1) Whether there is any deficiency in service on the part of the opposit parties?

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

      3) To what relief?

8.         Admitted facts in this case are that the 1^st complainant’s employer obtained medi-claim policy (group) through the 2^nd opposite party from the 3^rd opposite party vide Ex.A1 and Ex.B2.  The 1^st complainant’s mother underwent an orthopedic surgery in the 1^st opposite party’s hospital at Amalapuram. The 1^st complainant submitted that he has taken paternal medi-claim insurance policy with the 2^nd & 3^rd opposite parties for medical treatment of his parents. He submitted that he contacted the 1^st opposite party and showed the medi-claim policy. After going through the policy, the 1^st opposite party said that the surgery has to be done to the 2^nd complainant is within the terms and conditions of the policy. He further submitted that he admitted the 2^nd complainant in the hospital of the 1^st opposite party for surgery on 1.8.2012 and the operation was conducted on 4.8.2012. The 2^nd complainant was in the hospital till 18.8.2012 and incurred an amount of Rs.1,41,500/- towards fees and medical expenses vide Ex.A2 and the same was communicated the 2^nd opposite party and repudiated the claim on the ground that the hospital of the 1^st opposite party was having only 10 beds and the registration certificate is not valid for the current year vide Ex.A3. Therefore, the complainants got issued a legal notice to the 1^st opposite party vide Ex.A4. The 1^st opposite party received the same and acknowledged vide Ex.A6 and kept quiet.

            The 1^st opposite party submitted that he obtained his degree of M.S. (Ortho) from Nizam Institute of Medical Sciences, Hyderabad and his degree recognized by the Medical Council of India, which is the highest national authority of recognition of medical. He established Orthopedic Hospital at Amalapuram in the year 1995 and conducting so many surgeries and his patients who are having insurance coverage are getting medical reimbursement of expenses without any objection from any authority till today. The complainant has to obtain pre-authorization approval from the insurance company prior to the surgery. He has not filed any insurance policy and suppressed the fact. He further submitted that his hospital was registered under A.P. Allopathic Private Medical Care Act. The date of application registration is 3.6.2012 and they have given a registered number is 130 dt.3.6.2012 and paid Rs.3,750/- as fees through demand draft vide Ex.A4 and the said hospital was inspected by the District Registration Authority vide Ex.B3. This opposite party also filed certificate of registration vide Ex.B6 in which it is mentioned that the Sai Leela Orthopedic Hospital, Amalapuram with 10 beds and the same was in force for 5 years i.e., from 30.7.2012 valid up to 29.7.2017. The 3^rd opposite party filed the inspection report vide Ex.B1 and group health insurance policy vide Ex.B2.    

9.  POINT Nos.1 & 2:-  The main contention of the 1^st opposite party is that the  1^st complainant failed to produce the copy of the policy and other related documents with regard to the medical insurance. The 3^rd opposite party contended that under point No.4 of exclusion clause “The Company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of:

(i)    As per Point No.4.4 of Exclusions clause: “During the first four years of the

     operation of the policy, the expenses related to treatment of joint Replacement    

    due to Degenerative condition and age-related Osteoarthritis & Osteoporosis

    are not payable”.

                        But as per the discharge summary, the 2^nd complainant is “Middle aged;

                 moderately well built lady suffering from severe agonizing pain both hips

                 – ® side more, unable to walk or sleep due to the pain since 8 months.

                 Diagnosed to be having B/L Avascular necrosis of the HIP joint with

                 secondary osteoarthritis”.

            (ii) As per point 5.5 of Conditions clause of the policy: “The Company shall

                 not be liable to make any payment under this policy in respect of any claim if

                 such claim be in any manner fraudulent”.

            The 3^rd opposite party also submitted that the 2^nd opposite party rightly repudiated the claim because the 1^st opposite party’s hospital has only 10 beds and its registration certificate is not valid for the current year and the said hospital was not having sufficient infrastructure with inpatient beds and further submitted that point No.4.4 of Exclusions clause: i.e. “During the first four years of the operation of the policy, the expenses related to treatment of joint Replacment due to Degenerative Condition and age-related Osteoarthritis & Osteoporosis are not payable.  Clause 2.1.(a) Hospital means: It has been registered as a hospital with the local authorities and as per 2.1.(b) it should have at least 15 inpatient beds.

10.       After perusing the material on record, it is observed that the 2^nd opposite party wrote a letter to the 1^st complainant vide Ex.A3 and stated that the claim is inadmissible that the Sai Leela Orthopedic Hospital has only 10 beds and the registration certificate is not valid for the current year. As per Ex.A7 and B6, it is observed that the said hospital was registered on 30.7.2012 and the said registration is in force for a period of 5 years.           In the said certificate, it is also mentioned that Sai Leela Orthopedic Hospital, Amalapuram with 10 beds. As per Ex.B2 issued by the 3^rd opposite party to the 2^nd opposite party in which it is mentioned that,

2.1 N.B. 1. In class ‘C’ towns condition 2.1. b(i) in respect of number of beds to

                   be reduced to 10.

As per the above, the 1^st opposite party’s hospital comes within the purview of the said clause.

            The 2^nd opposite party in their repudiation letter, only mentioned with regard to the registration and number of beds of the 1^st opposite party.  But, as per our observation and the material on record, the 1^st opposite party’s hospital is a registered one on the date of operation and also it having 10 beds. The 2^nd opposite party or its team of doctors never said the other allegations made by the 3^rd opposite party.  Therefore, the repudiation of the claim of the complainant is not valid and it amounts to deficiency in service on the part of the 2^nd & 3^rd opposite parties and they are jointly and severally liable to pay the claim amount to the complainants. The claim against the 1^st opposite party is dismissed as there is no deficiency in service on his part.    

11.  POINT No.3:  In the result, the complaint is allowed directing the 2^nd & 3^rd opposite parties to pay Rs.1,41,500/- with interest @ 9% p.a. from the date of repudiation i.e. 04.12.2012 till realization and pay Rs.2,000/- towards costs of this complaint.  Time for compliance is two months from the date of this order.

      Typed to dictation, corrected and pronounced by us on this the 17^th day of April, 2015.

       Sd/-                                                                  Sd/-                                                   Sd/-

     MEMBER                                                        MEMBER                                  PRESIDENT

APPENDIX OF EVIDENCE

                                                                     WITNESSES EXAMINED

FOR COMPLAINANTS: None                                                         FOR OPPOSITE PARTIES: None

DOCUMENTS MARKED

FOR COMPLAINANTS:

Ex.A1    DHS identity card given to the 1^st complainant.

Ex.A2    Medical bills.

Ex.A3    Letter of repudiation of claim given by the 2^nd and 3^rd opposite parties.

Ex.A4    O/c of the notice issued by the 2^nd complainant to the 1^st opposite party.

Ex.A5    Postal receipt for issuance of the notice.

Ex.A6    Postal acknowledgement of the 1^st opposite party.

Ex.A7    RTI letter from District Medical and Health Officer(FAC), Kakinada to             

              B. Sitaramaiah.

FOR 1^st & 3^rd OPPOSITE PARTIES:             

Ex.B1    Inspection Report.

Ex.B2    Health Insurance Policy – Group, Policy No.222200/48/11/41/00001275 issued

  by United India Insurance Co. Ltd.  

Ex.B3    copy of proceedings of the District Medical & Health Officer, E.G., Kakinada.

Ex.B4    Letter dt.17.7.2014 from Vijaya Bank, Amalapuram to the 1^st opposite party.

Ex.B5    O.P. issued by the 1^st opposite party.

Ex.B6    Certificate of Registration of Allopathic Private Medical Care Establishments

  issued by District Registering Authority & District Medical & Health Officer,

  Kakinada, E.G. Dist.

         Sd/-                                                                Sd/-                                               Sd/-

     MEMBER                                                        MEMBER                                 PRESIDENT.