Andhra Pradesh

Visakhapatnam-II

CC/144/2010

P.V. Satyanarayana - Complainant(s)

Versus

ICICI Lombard General Insurance Company Limited - Opp.Party(s)

G. Subhadra Devi

24 Jan 2015

ORDER

Reg.of the Complaint:12-04-2010

                                                                                                                                 Date of Order:24-01-2015 BEFORE THE DISTRICT CONSUMERS FORUM-II

AT VISAKHAPATNAM

                   Present:

1.Sri H.ANANDHA RAO, M.A., L.L.B.,

       President

2.Sri C.V.RAO, M.A., B.L.,

                                             Male Member

3.Smt.K.SAROJA, M.A., B.L.,

       Lady Member

 

 

SATURDAY, THE 24^TH DAY OF JANUARY, 2015

CONSUMER CASE NO.144/2010

 

BETWEEN:

 

P.V.SATYANARAYANA S/O SATYANARAYANA MURTHY,

HINDU, AGED 49 YEARS, R/AT FLAT NO.11, PRINCE APARTMENTS,

BALAJINAGAR, NEAR SIRIPURAMM IDBI BANK, VISAKHAPATNAM.

…COMPLAINANT

AND:

1.ICICI LOMBARD GENERAL INSURANCE  COMPANY LTD.,

REP. BY ITS MANAGING DIRECTOR, ZENITH HOUSE,

KESAVARAO KHADE MARG, MAHALAKSHMI, MUMBAI-400 034.

2. ICICI LOMBARD GENERAL INSURANCE  COMPANY LTD.,

OPP BATA SHOWROOM, DWARAKNAGAR VISAKHAPATNAM-16.

3. TTK HEALTH CARE TPA PVT. LTD.,

REP. BY ITS MANAGING DIRECTO, 2^ND FLOOR,

ANMOL PALANI, G.N.CHETTY ROAD  T.NAGAR, CHENNAI.

OPPOSITE PARTIES

 

This case coming on 07-01-2011 for final hearing before us in the presence of SMT SUBHADRA DEVI, Advocate for the Complainant and of SRI D.SIVA PRASAD Advocate for the Opposite Parties 1 & 2  and 3^rd Opposite Party, being exparte and having stood over till this date for consideration, this Forum made the following.

 

ORDER

(As per the Honourable President on behalf of the Bench)

1.       The case of the Complaint in brief is that the 1^st Opposite Party is the Insurance Company, providing heath and general insurance to the public in collaboration with the 3^rd OP and 2^nd OP is the Branch Office of the 1^st OP and the complainant herein is having a savings bank account in ICICI Bank and the 1^st and 2^nd OPs acquired his address and lured in obtaining a policy. Accordingly, he had taken a health care Policy vide Policy No.4034/HIR/03448847/00/000 for the period from 11-04-2008 to midnight of 10-04-2009 for which, he paid a premium of Rs.18,197/- to the OPs and they issued a policy in his name. As per the terms of the policy, the expenses of any inpatient treatment for both the complainant as well as his spouse will be reimbursed by the OPs being insurers and as per the terms of the policy, the OPs are liable to pay the entire medical expenses.

2.       That in the month of December, 2009, his wife P.V.Surya Kumari has developed a problem of irregular bleeding and on the advice of Doctors, she was admitted in a hospital for surgery and the same was intimated to 3^rd OP and after receiving due reference from 3^rd OP, she was admitted in Krishna IVF Clinic, Krishna Nagar, Visakhapatnam on 3-12-2009. On 4-12-2009, a surgery was conducted and finally discharged on 7-12-2009 as a result of which, he incurred a sum of Rs.36,438/-  as per the terms of the policy, the OPs are bound to refund the entire the expenditure incurred by him.

3.       That the staff of the Krishna IVF Clinic, Krishna Nagar, while referring the case details to 3^rd OP, had mistakenly mentioned that his wife was suffering with disease for the past 4 years  instead of mentioning as 4 months. The 3^rd OP on 6-9-2009 issued a letter to the said clinic denying the claim of his wife stating the diseased pre-existing insurance policy. Realizing the mistake committed by the aforesaid hospital,  Dr.V.Sita Rama Raju of the said clinic has issued a letter on 7-12-2009, admitting the mistake and also forwarded the OP sheet which shows his wife has been suffering with the disease for 4 months prior to 3-12-2009. However, the OP did not respond and not refund the expenditure incurred by him. Thereupon, he got issued a notice,  demanding them to pay the amount but there was no response. Hence, this complaint.

4.       The case of the Opposite Parties denying the allegations  of the complaint, is that this Forum has no jurisdiction since the complainant is not a consumer. However, they admitted the OP2 Insurance Company, carrying the insurance business as well as introduced various welfare schemes in order to protect the interests of the individual persons and the family members scheme is Medi-Claim Policy. The 3^rd OP is the agent of the of 1^st OP, the OP3 used to process the claims as per the terms and conditions of the policy as well as the medical norms as OP3 having expert package of doctors by further admitting  that the complainant obtained medical claim policy which is valid for 1 year and that they are not aware about the wife of the complainant treatment in the above referred hospital and in order to ascertain the true state of affairs, the 3^rd OP provided the claim form to the complainant and requesting the complainant to resubmit the same and the compliant submitted the same with relevant documents, claiming an amount of Rs.15,950/- towards the alleged treatment but not an amount of Rs.36,438/- even after the bill filed by the complainant, the complainant paid only an amount of Rs.15,950/-.

5.       That the wife of the complainant had the disease since 4 years but not 4 months prior to her admission in the hospital as alleged in the complaint further said it was his preexisting one. Even prior to the first policy and as per the policy conditions, the claim of the complainant is not at all admissible. As the complainant obtained the said policy by suppressing the truth and known facts to them. As per the letter of repudiation dated 6-12-2009 as per the policy conditions, the claim of the complainant is not at all admissible. The letter of repudiation is forged and the same was issued as per the express terms and conditions, it is exclusion of the policy. Hence, there is no deficiency of service on their part.

6.       That after repudiation of the claim of the complainant, he obtained letter from OP on 7-12-2009 in order to claim the amount from them in wrongful manner, alleging that his wife suffering with the said disease only from 4 months prior to admission into the hospital. As the proceedings before this forum only summary proceedings in nature and as he is completely disputing the letter of repudiation, therefore, this forum has no jurisdiction to determine the claim.

7.       The prove the case of the complainant, he filed Evidence Affidavit and got marked Exhibits A1 to A12 and the OPs 1 & 2 filed Evidence Affidavit and got marked Exhibits B1 and B2.

8.       Exhibit A1 is the Insurance Policy dated 11-04-2008, Exhibit A2 is the Discharge Bill of complainant’s wife issued by Krishna IVF, dated 08-12-2009, Exhibit A3 is the receipts issued by Doctors towards fee dated 07-12-2009, Exhibit A4 is the Medical bills, Exhibit A5 is the letter addressed by 3^rd OP to Krishna IVF Clinic dated 06-12-2009, Exhibit A6 is the letter addressed by Krishna IVF clinic to 3^rd OP along with OP sheet dated 07-12-2009, Exhibit A7 is the Registered Lawyer’s Notice  issued by Complainant to OPs dated 8-1-2010, Exhibit A8 is the Postal acknowledgement from 1^st OP dated 11-01-2010, Exhibit A9 is the Postal Acknowledgement from 2^nd OP dated 08-01-200, Exhibit A10 is the Postal Acknowledgement from 3^rd OP dated 13-02-2010, Exhibit A11 is the insurance premium with health card, Exhibit A12 is the  Medical Certificate issued by Doctor in favour of P.V.Surya Kumari.

9.       Exhibit B1 is the Policy Bond dated 30-03-2008 and Exhibit B2 is the Brochure.

10.     Both parties filed their respective Written arguments.

11.     Heard both sides.

12.     In view of the respective contentions raised by either side, the point that would arise for determination in this case is;

Whether there is any deficiency of service on the part of the OPs and the complainant is entitled to any reliefs asked for?

13.     Now the point for consideration is, whether the wife of the complainant was suffering with the disease, referred supra, since 4 years as contended by the OP or from the last 4 months prior to her admission in the hospital as contended by the complainant is to be seen.

14.     It is a fact that the complainant obtained Medi-Claim Policy and his wife of joined in Krishna Hospital Visakhapatnam for treatment after discharge, the complainant requested the OPs with relevant documents in respect of the claim of expenses in the Hospital incurred by his wife for treatment and when they failed to pay as per the terms and conditions of the policy, they issued Lawyer Notice vide Exhibit A7.  As per medical records submitted by the complainant, the wife of the complainant is suffering with the disease since 4 years prior to joining in the hospital which resulted repudiation of the claim. Subsequently vide Exhibit A12, the Hospital Authorities informed the wife of the complainant admitted in their hospital on 03-12-2009 and discharged on 7-12-2009 which was issued on 10-11-2014. Thus, it is clear the record available with the OPs at the time of claiming amounts under Medi-claim policy, the wife of the complainant is suffering with the disease since 4 years but not 4 months prior to her admission in the hospital. Thus as per record, the suffering of disease by the complainant’s wife is preexisting one even prior to the 1^st year policy, which resulted. The claim of the complainant was not admitted by the OPs.

15.     It is the duty of the complainant to prove his case that his wife is not suffering with the said disease since 4 years and only suffering from the last 4 months prior to her admission in IVR Krishna Hospital. He has not filed  the respective evidence affidavits or documents prove this case. Exhibit A2 filed by him shows that his wife was admitted on 4-12-2009 and discharged on 7-12-2009. That does not mean to say that she was suffering with disease  since 4 months of her admission in the hospital. Exhibit A12 certificate issued by medical officer dated 10-12-2014 reveals that the wife of the complainant is suffering with the dieses from the last 4 months but his evidence affidavit is not filed. Further the said certificate was issued in the year 2014.  In the absence of any proof thereto, it can be held that the disease with which the complainant is suffering, is pre-existing one as rightly contended by the counsel for the OPs. Since, the complainant claim is not admissible, the OPs rightly repudiated the claim as there is no deficiency of service on their part. For these reasons, the claim of the complainant is liable to be dismissed.

16.   In this result, this complaint is dismissed, no costs.

Dictated to the Stenographer, transcribed by him, corrected and pronounced by us in the open Forum, on this the 24^th day of January, 2015.

Sd/-                                                       Sd/-                                                         Sd/-

LADY MEMBER                                    M.MEMBER                                                    PRESIDENT

 

APPENDIX OF EVIDENCE

Exhibits Marked for the Complainant:

Exhibits	Date	Description	Remarks
A-1	30-03-2008	Insurance Policy	Photocopy
A-2	08-12-2009	Discharge Bill of complainant’s wife issued by Krishna IVF	Photocopy
A-3	07-12-2009	Receipts issued by Doctors towards fee	Photocopy
A-4	-	Medical bills	Photocopy
A-5	06-12-2009	Letter addressed by 3rd OP to Krishna IVF Clinic	Photocopy
A-6	07-12-2009	Letter addressed by Krishna IVF clinic to 3rd OP along with OP sheet	Photocopy
A-7	08-01-2010	Registered Lawyer’s Notice  issued by Complainant to OPs	Office copy
A-8	11-01-2010	Postal acknowledgement from 1st OP	Original
A-9	08-01-2010	Postal acknowledgement from 2nd OP	Original
A-10	13-02-2010	Postal acknowledgement	Original
A-11		Insurance Premium With Health Card	Photocopy
A-12	10-11-2014	Medical Certificate issued by Doctor in favour of P.V.Surya Kumari.	Original

 

Exhibits Marked for the OPs

Exhibits	Date	Description	Remarks
B-1	30-03-2008	Policy Bond.	Photocopy
B-2	-	Brochure	Original

 

Sd/-                                          Sd/-                                                                 Sd/-

LADY MEMBER                                 M.MEMBER                                                 PRESIDENT