Telangana

Mahbubnagar

CC/08/118

M. Srinivasa Reddy S/o Bucha Reddy O/c Agriculture - Complainant(s)

Versus

InCharge Officer K.Bhashyam, The Oriental Insu. Co. Ltd.,Mahabubnagar. - Opp.Party(s)

Sri D. Shiva Kumar

26 Nov 2008

ORDER

BEFORE THE DISTRICT CONSUMER FORUM AT MAHABUBNAGAR

Wednesday, the 26^th day of November, 2008

 

                                                               Present:- Sri M.Rama Rao, B.A.,LL.B., President

     Sri P.Venkateshwara Rao, B.com., LL.B., Member

       Smt.B.Vijaya Kumari, M.Sc. B.Ed., C.C.P., Member

 

                                                                             C.C.NO. 118  Of   2008

 

Between:-

M. Srinivasa Reddy S/o Bucha Reddy, age: 35 years, Occ: Agriculture, R/o Mallareddypally village, Ippatoor Post, Nawabpet Mandal, Mahabubnagar.  

                                                                                              … Complainant.

And

The Oriental Insurance Company Limited, Rep. by its in charge officer, K. Bhashyam, Door No.2-1-9/4, Sai Teja Complex, Raichur Road, Mahabubnagar.  

                                                                                         … Opposite Party

 

 This C.C. coming on before us for final hearing on 12-11-2008,  in the presence of Sri D. Shiva Kumar, Advocate, Mahabubnagar for the complainant and the opposite party having been set exparte and having stoodover for consideration till this day, this Forum delivered the following:

O R D E R

 

 (Smt.B.Vijaya Kumari, Member)

 

1.        This is a complaint filed on behalf of the complainant under section 12 of Consumer Protection Act, 1986 seeking a direction to the opposite party to pay a sum of Rs.24,500/- under Universal Health Policy as medical and surgical expenses in the shape of claim amount to the complainant with future interest @ 18% p.a. from the date of the complaint till realization along with compensation of Rs.24,5000/- and   also costs of the complaint.

 

2.     The complaint averments are as follows:-  The complainant has taken policy with the opposite party on 29.3.2008 by paying the premium amount of Rs.248/- under the Universal Health Policy.  The said policy has been introduced for the welfare of the poor and backward people depending on financial status in the society.   After receiving the said premium amount, the opposite party has issued a certificate of insurance vide policy No.433190/47/2008/13443 and the duration of policy is for one year and the said policy is effective from 30.3.2008 to 29.3.2009.   As per terms of the said policy, the insurance coverage is for two persons i.e., the complainant and his wife namely M. Susheela.  Under the said policy the said two persons are entitled for reimbursement of the hospitalization expenses for medical/surgical treatment at any Nursing Home in India.  The complainant has renewed the previous policy vide 11784 as the present policy and as per the terms of the policy the complainant is entitled for the reimbursement of medical expenses.   The complainant’s wife has undergone Caesarian operation for the delivery on 17.7.2008 for which she was admitted in J.J. Hospital, Hyderabad on 13.7.2008 and discharged from the hospital on 24.7.2008.   Totally she was in hospital for a period of 11 days for the treatment of operation.  During the said treatment she has paid an amount of Rs.24,500/- towards medical and surgical expenses.  The said information has been given to OP as on the date of operation itself.  After intimation, OP has issued claim form with regard to claim of the amount.  Later on 28.7.2008 the complainant submitted all the required documents i.e., medical bills, copy of certificate of insurance, copy of discharge summary of J.J. Hospital, copy of  Ration Card and copy of Bank A/c along with claim form for the claim amount of Rs.24,500/- and after receiving the same, OP has endorsed to the complainant.  As per the policy conditions, if the policy holder has renewed his policy for the second year consecutively, he will be entitled to claim the medical and surgical expenses.  After receipt of the documents the officer incharge has replied to wait for a period of one month time.  After completion of the said period, the complainant further approached to the office and OP did not respond and behaved in unhealthy manner to evade the payment.  Even after receipt of the documents the insurance office authorities have not bounded on their policy and deliberately failed to pay the sum of Rs.24,500/- to the complainant.   Later by demanding the same, the complainant got issued a legal notice on 4.9.2008 to OP and the same was served on them and issued a letter by admitting the contents of notice and stated in their letter as “the claim is under investigation”.    Thus OP has entertained unfair trade practice in respect of payment of claim amount covered under the policy to the complainant.  OP has rendered defective services to the complainant in negligent manner for which the complainant has suffered with mental agony apart from the monetary loss, for which the complainant is entitled to claim compensation from OP.   Hence the complaint. 

 

3.     The opposite party remained exparte.
4.  The complainant filed his affidavit and got marked Exs.A-1 to A-11 on his behalf.

 

5. The point which falls for consideration is whether the complainant is   entitled to the reliefs as prayed for?

 

6.     The case of the complainant is that he has joined as a policy holder in OP’s insurance company on 29.3.2008 by paying the premium amount of Rs.248/- under the Universal Health Policy.   After receiving the premium amount, OP has issued policy certificate vide policy  No. 433190/47/2008/13443 with the insurance coverage for one year with effect from 30.3.2008 to 29.3.2009.  As per the terms, the policy holder and his wife are entitled for reimbursement of hospitalization expenses for medical or surgical treatment at any Nursing Home in India.      On 17.7.2008 that the complainant’s wife undergone Caesarian operation for the delivery in J.J. Hospital, Hyderabad.   She was admitted on 13.7.2008 and discharged from the hospital on 24.7.2008.   Totally she as in-patient was in hospital for 11 days to undergo surgery and medical treatment.  The complainant has paid an amount of Rs.24,500/- towards the medical and surgical expenses. After discharging his wife, the complainant submitted claim form with required documents to OP and that OP has endorsed the claim form with seal.   As per the policy conditions, if the policy holder has renewed his policy for the second year consecutively, he will be entitled to claim the medical and surgical expenses.   After receipt of the documents OP did not respond and that the office authorities have not bounded on their policy conditions and they have failed to pay the sum of Rs.24,500/- towards the medical and surgical expenses to the complainant.  Later, the complainant got issued legal notice on 4.9.2008 and the same was served to them and after OP issued a letter with the contents that the claim is under investigation.   The acts of OP are in negligent manner and that it proves the deficiency of service on their part.   Due to this act the complainant has been put to mental agony and monetary loss for which he is entitled for compensation.   

 

7.    The opposite party remained exparte.  The allegations in the complaint stand uncontradicted.  The complainant has adduced evidence in the form of affidavit and got marked Exs.A-1 to A-11.   In the complaint, the complainant has taken a plea that as per policy conditions the complainant and his wife are entitled for reimbursement of medical and surgical expenses at any Nursing Home in India.   In the complaint, the complainant has stated that his wife has undergone Caesarian operation for the delivery on 17.7.2008 in J.J. Hospital, Hyderabad and she was discharged on 24.7.2008.  After her discharge, the complainant has submitted all the required documents along with claim form to claim the medical expenses for Rs.24,500/- from OP.  The complainant alleged that OP did not respond even after receiving the required documents and they have not bounded their policy conditions, which amounts to deficiency of service on the part of OP.   Due to this act the complainant suffered with mental agony and monetary loss for which the complainant is entitled to claim compensation from OP.   

 

8.      On perusal of above exhibits it is clear that the complainant is an insured person and the policy was issued by OP at their branch office, Mahabubnagar vide policy No. 433190/47/2008/13443 and that the policy is in force for a period of one year with effect from 30.3.2008 to 29.3.2009.   As per the terms of the policy, the complainant and his wife are entitled for the reimbursement of medical expenses.     As per Ex.A-3 i.e., Universal Health Insurance Policy vide policy  No. 433190/47/2008/13443, the insurance covered under the policy is “Subject to conditions, clauses, warranties and endorsements”.   As per Ex.A-3 the complainant obtained policy from OP by paying Rs.240/- on 28.3.2008 and it was in force for a period of one year i.e., 30.3.2008 to 29.3.2009.   As per the terms of the policy, the policy holder is entitled to claim upto Rs.30,000/- for hospitalization expenses as an in-patient at any hospital in India.  As per the policy conditions, the complainant and his wife are covered under the Universal Health Insurance Policy and they are eligible persons to claim the medical expenses.  As per Ex.A-4, Discharge Summary, the complainant’s wife undergone operation in J.J. Hospital, Hyderabad on 24.7.2008.  Totally she was as in-patient in hospital for 11 days to undergo surgery and medical treatment.  As per Exs.A-5 and A-6 the complainant has paid an amount of Rs.24,500/- towards the medical and surgical expenses.  As per Ex.A-2 the complainant submitted the claim form to the OP.  As per Ex.A-10, letter issued by OP, the claim is under investigation.  As per Ex.A-9 the complainant got issued legal notice on 4.9.2008.    The OP remained exparte.   Till today there is no response and they did not file any material to show the terms and conditions of the policy and also OP did not print any terms and conditions on the policy certificate.  In such circumstances, the allegations in the complaint stand uncontradicted.   The complainant has adduced evidence in the form of affidavit.    Ex.A-2 to A-6 corroborate with the version of the complainant which reveals that the complainant is successful in proving his case to the effect that OP has not rendered proper services to the complainant.  The same amounts to deficiency of service on the part of OP.  Hence OP is liable to pay Rs.24,500/- towards the medical expenses to the complainant. We therefore hold that the complainant is entitled to claim the amount of Rs.24,500/- towards the medical and surgical expenses and Rs.500/- towards the costs of the proceedings.   The complainant is entitled to interest @ 6% p.a. from the date of complaint. 

 

9.   In the result, the complaint is partly allowed.  The OP is directed to pay Rs.24,500/- along with interest @ 6% p.a. from the date of complaint towards the medical expenses under the policy conditions and Rs.500/- towards the costs of the proceedings to the complainant within one month from the date of receipt of this order.   The rest of the claims of the complainant are disallowed. 

 

        Typed to dictation, corrected and pronounced by us in the open Forum on this the 26th day of November, 2008.           

 

        

 MEMBER                                MEMBER                              PRESIDENT 

     Appendix of evidence

       Witness examined

 

For complainant: Nil                                                    For opposite party:  Nil

Exhibits marked for Complainant:-

 

Ex.A-1:        Original endorsed application, dt.28.7.2008.

Ex.A-2:        Copy of Policy Claim Form.

Ex.A-3:        Copy of Certificate of Insurance, dt.28.3.2008.

Ex.A-4:        Copy of Discharge Summary, dt.24.7.2008.

Ex.A-5:        Copy of total bill, dt.24.7.2008.

Ex.A-6:        Copies of bills (8) from 17.7.2008 to 20.7.2008.

Ex.A-7:        Copy of Legal Notice, dt.4.9.2008.

Ex.A-8:        Original Postal Receipt.

Ex.A-9:        Served Acknowledgement Card.

Ex.A-10:      Reply letter issued by OP, dt.5.9.2008.

Ex.A-11:      Copy of Household Card.

 

Exhibits marked for OP:-

   

      - Nil-

 

 By the Forum:

     - Nil-

                                                                                                                                                                                                                            PRESIDENT

Copy to:-

1. Sri D. Shiva Kumar, Advocate, Mahabubnagar for the complainant.
2. The Oriental Insurance Company Limited, Rep. by its in charge officer, K. Bhashyam, Door No.2-1-9/4, Sai Teja Complex, Raichur Road, Mahabubnagar.