This C.C coming on before us for final hearing, on 4-12-2008 in the presence of Smt. K.Kavitha Rani, Advocate for Complainant , and opposite party No-1 served and called absent, and of Sri.K.Ravindranath, Advocate for the opposite party No- 2 and of Sri.G.Sita Rama Rao, Advocate for opposite party No-3 ; upon perusing the material papers on record; upon hearing arguments, and having stood over for consideration, this Forum passed the following:-
ORDER
(Per Sri.K.V.Kaladhar, Member )
1. This complaint is filed under section 12(1) of the Consumer Protection Act, 1986 .
2. The brief facts of the complaint are that the complainant joined in the scheme under F.H.A.U vide policy No.050400/48/05/00551, UHID No.FHAU 0000105628, by paying required amount to the opposite party No-1 through the opposite party No-2 for the period from 30-6-2005 to 29-6-2006(F). Accordingly the opposite party No-2 had issued the relevant document. The opposite party No-2 obtained the policy from the opposite party No-3.
3. That on 13-10-2005 the complainant, Vanama Swetha joined in Sri Ram Kidney
Centre, Wyra Road, Khammam for the problem of stones in the Kidney and after removal of stones she was discharged on 16-10-2005. That while undergoing treatment in the said Hospital on 15-10-2005, the complainant sent a letter to the opposite party by informing about joining of her at Sri Ram Kidney Centre, Khammam and requested to send the claim forms. That after discharge, the complainant had sent all the relevant documents to the opposite party to settle the claim. That on 16-11-2005 the opposite party had sent a letter stating that they appointed a TPA to administer the Medi-claim Policy UHC and received the claim documents for the Hospitalisation of Vanama Swetha and requested the complainant to send original detailed discharge summary. As per the said letter, the complainant had sent the entire medical record to the opposite party. But the opposite party No-1 did not settle the claim and rejected the claim of the complainant and had sent a letter on 29-12-2005 stating therein that his medical team is of the opinion that the claim does not fall under the purview of the policy for the reason of the present hospitalization is for the management of an ailment, which is related to a pre existing condition clause 4.1, and by making that allegation, the claim of the complainant was rejected. Immediately on 30-1-2006 the complainant addressed a letter to the opposite party No-2 requesting him to consider and settle her claim as early as possible and also mentioned that as per the enclosed letter from M/s.Sri Ram Kidney Centre, it was not pre-existing ailment. The opposite party No-1 did not give any reply. Hence this complaint. It is prayed that the Hon’ble Forum may be pleased to direct the opposite parties to settle the claim of the complainant under the policy No.50400/48/5/00551 issued by the opposite party and to award compensation of Rs.10,000/- for causing mental agony and pain and to award costs of the complaint for Rs.2,000/- or to grant any other relief or reliefs.
3. The complainant filed the following documents:
ExA1: Policy issued by opposite parties for the period 28-6-04 to 8-6-05 and the same was renewed on 30-6-05 to 29-6-06 vide policy No.050400/48/04/00551. Ex A2:Discharge summary, Sri Ram Kidney Centre, Khammam of the complainant date of admission was on 14-10-05 and date of discharge on 16-10-05.Ex A3: A letter issued by the complainant to opposite party No-1, dated 15-10-2005.Ex A4: A letter addressed by opposite party No-1 to the father of the complainant, dated 16-11-2005.Ex A5: A letter issued to father of the complainant by opposite party dated29-12-2005. Ex A6: A letter issued by the father of the complainant to opposite party No-1, dated 31-1-2006.
4. The opposite party No-2 filed the following counter:
The settlement of claim is the sole responsibility of opposite party No-3 and this opposite party provides Advisory service only to the customers. This opposite party will receive the premium amount from the policy holder for the scheme of “AROGYADAN’ and it will be remitted to the United India Insurance Company. AB- Arogyadan is Medi claim Insurance Coverage under floater policy for a family of 1+ 3 consisting of policy Holder spouse, two dependent children. The policy issued for a family of 1+3 with a single sum insured and any one member or all the members put together can avail hospitalization benefits during the policy period for the sum insured selected. All the policy holders will be given an option whether they require services of TPA or not, if yes they have to specify the name of T.P.A. in the proposal form. In case of Hospitalization the policy Holder have to intimate in advance to TPA about Hospitalization in which case they guide the policy holder in all respects.
Exclusions: All diseases/injuries which are pre-existing when the cover incepts for the first time. For the purpose of applying this condition the date of inception of the initial medi-claim policy taken from any of the Indian Insurance Company shall be taken provided the renewals have been continuous and without any break. However this exclusion will be deleted after three consecutive continuous claims free policy years, provided there was no hospitalization for the pre-existing ailment during these three years of Insurance. The Insurance Company shall not be liable to make any payment under this policy to all disease/injuries which are pre-existing when the cover incepts for the first time.
5. The complainant is not entitled to claim the policy amount as it gives under the purview of exclusions. Hence it is prays to dismiss the complaint with exemplary costs.
6. The opposite party No-2 filed chief affidavit and also written arguments.
7. The summons of this Forum served to opposite party No-1 on 22-12-2006 itself but opposite party No-1 did not file any counter. The complainant filed I.A.No.604/07 to implead opposite party No-3 as party to these proceedings and the said I.A. is allowed on 21-11-2007 by this Forum.
8. The complainant filed neat copy on 4-2-08 and this Forum issued notice opposite party No-3 and the said notice was served on 3-3-08. Since then this case underwent several adjournments but opposite party No-3 did not file any counter.
9. The point for consideration is whether the complainant is entitled to the claim as prayed for?
10. It is the contention of the complainant that she joined in this scheme under F.H.A.U vide policy No. 050400/48/04/00551 for the period 28-6-04 to 8-6-05 and the same policy was renewed for one more period i.e., from 30-6-05 to 29-6-06 vide policyNo.050400/48/05/00551. To prove her contentions she filed the Xerox copies of the said policy vide Ex A1. As per Ex A1 it is proved that the complainant joined in the policy run by opposite parties for two continuous years. That on 13-10-2005 the complainant had joined in Sri.Ram Kidney Centre, Wyra Road, Khammam for the problem of stones in the Kidney and after removal of stones she was discharged on 16-10-2005. To prove this contention the complainant filed Ex A2 which is the discharge summary as per Ex A2 she under went treatment at Sri Ram Kidney Centre for removal of stones. As per Ex A3 dated 15-10-2005 the father of the complainant informed the same stating that her daughter V.Swetha joined in the hospital of Sri Ram Kidney Centre for treatment of Kidney stones. As per Ex A4 it is revealed that opposite parties sent a letter to the father of the complainant dated 16-11-2005 stating to submit all the original documents pertaining to treatment of complainant.
11. As per the averments of the counter of opposite party No-2 the complainant is not entitled to the sum assured as per exclusion clause 4.1 she was suffering with pre existing disease. To substantiate their case the opposite parties did not file any document to show that the complainant was suffering with pre existing disease. In the absence of any documentary proof it cannot presumed or assumed that the complainant was suffering with pre existing disease. More over the complainant renewed her medi-claim policy two consecutive years, as per the documents filed by the complainant.
12. Hence, we are of opinion that the complainant is entitled to the sum assured under the policy No.050400/48/05/00551 issued by the opposite parties. As per the averments of counter we are of opinion that opposite party No-2 has received the premium from the complainant and paid to the opposite party No-3 which is the Insurance Policy. Hence opposite party No-2 is nothing to do with this policy and there is no deficiency of service against opposite party No-2.
13. Hence, we direct the opposite party No-1 &3 to pay the sum assured with 9% interest under policy No.050400/48/05/0051 from the date of complaint i.e., 30-10-06 till the date of realization and also pay an amount of Rs.1,000/- on damages for causing mental agony and pain and also to pay an amount of Rs.1,000/- towards costs of this litigation. This C.C. is dismissed against opposite party No-2. Accordingly this CC is allowed.
Dictated to the Stenographer, Corrected and pronounced by us, in this Forum on this 11th day of December, 2008.
President Member Member
District Consumers Forum, Khammam
APPENDIX OF EVIDENCE
WITNESS EXAMINED FOR
Complainant Opposite parties
Nil Nil
DOCUMENTS MARKED FOR
Complainant
ExA1: Policy issued by opposite parties for the period 28-6-04 to 8-6-05 and the same was renewed on 30-6-05 to 29-6-06 vide policy No.050400/48/04/00551.
Ex A2:Discharge summary, Sri Ram Kidney Centre, Khammam of the complainant date of admission was on 14-10-05 and date of discharge on 16-10-05.
Ex A3: A letter issued by the complainant to opposite party No-1, dated 15-10-2005.
Ex A4: A letter addressed by opposite party No-1 to the father of the complainant, dated 16-11-2005.
Ex A5: A letter issued to father of the complainant by opposite party dated29-12-2005. Ex A6: A letter issued by the father of the complainant to opposite party No-1,
dated 31-1-2006.
Opposite parties
Nil
President Member Member
District Consumers Forum, Khammam
